Diagnosis
Consistent flushing in children may be a sign of vasomotor instability and early rosacea. These children may blush more frequently and with greater intensity for longer periods than their peers exposed to the same stimuli.24 Thus, blushing in the early stage of rosacea may be an accentuation of the body's normal physiologic response system. A diagnosis of pediatric rosacea beyond the initial stage should be considered when a healthy child has acuminate papules and small pustules of the face, especially if there also exists flushing, telangiectasias, or a family history of rosacea.14
Differential Diagnosis
The earliest form of rosacea, facial blushing, may be difficult to distinguish from flushing due to other causes. Blushing due to emotions such as embarrassment or anger and to exercise-induced flushing are both appropriate reactions to such stimuli, whereas blushing in the first stage of rosacea may be an exaggeration of this phenomenon.2 The main pathway for thermoregulatory and emotional flushing is the cervical sympathetic outflow tract.25 Gustatory blushing, as occurs with consumption of spicy foods, is mediated by autonomic neurons via a branch of the trigeminal nerve.2 Sweating often occurs in conjunction with the aforementioned causes of flushing, but it is rarely associated with rosacea flushing. Thus, sweating may be helpful in reaching a diagnosis; however, exceptions exist.2 Frey syndrome (auriculotemporal syndrome), which is characterized by warmth and sweating in the malar region caused by aberrant autonomic fiber connections after damage in the parotid region, may mimic the early stage of rosacea.
The intermediate stage of pediatric rosacea may be confused with other papulopustular disorders such as acne vulgaris, perioral dermatitis, and lupus erythematosus (Table). Careful attention to symptoms, distribution of facial lesions, and potential biopsy results are warranted to distinguish between the conditions. Steroid rosacea and perioral dermatitis may be variants of rosacea or completely separate conditions.9,26
Please refer to the PDF to view the table
Perioral dermatitis is a rosacealike dermatitis characterized by erythematous papules and pustules usually confined to the perioral region, though the perinasal and periocular areas may be involved.27 A granulomatous perioral dermatitis with tiny, closely spaced, flesh-colored papules in the perioral, perinasal, and periorbital areas was described in children aged 3 to 11 years.28 All cases had spontaneous resolution of symptoms regardless of treatment. The patients did not exhibit flushing or telangiectasias.28
The classic butterfly rash, consisting of erythema and telangiectasia of the malar region and associated with systemic lupus erythematosus, also can be confused with rosacea. Histopathologic examination and direct immunofluorescence of the lesion may help to differentiate lupus from rosacea.14
Laboratory Diagnosis
There is no specific histologic change unique to rosacea.12 The most common findings are telangiectasia, edema, elastosis, a variable amount of superficial and deep perivascular lymphohistiocytic inflammatory infiltrate loosely arranged around the hair follicles, and especially architectural disruption of the upper dermis.12,28 Depending on the variant of rosacea, there may be an exaggeration of one or more histopathologic signs.12 For example, granulomatous rosacea may contain collections of granulomas with multinucleated giant cells.28
Treatment
Treatment is gradual and largely determined by the clinical type of rosacea. Children with early or intermediate stages of rosacea are encouraged to avoid their individual local triggers to prevent flares. Topical corticosteroids, especially fluorinated medications, should be discouraged, because even low-potency steroids, including over-the-counter preparations and hydrocortisone 1%, have been shown to cause worsening of the condition.8
Traditional therapy for rosacea includes topical and systemic antibiotics, topical metronidazole, and topical retinoids. Oral tetracycline can be used for adolescents in doses similar to those prescribed for adults. It should not be used in children younger than approximately 9 years17 because it is known to cause dental staining and to be deposited in the skeletal system where it can cause temporary depression in bone growth.29,30 Azithromycin or a low dose of doxycycline can be used with good results.31,32 For younger children, oral erythromycin is safe and effective to eliminate the erythema, papules, and pustules of rosacea.32 Topical erythromycin and clindamycin have been used with varying results. Azelaic acid and isotretinoin also may be effective.33 Topical metronidazole 0.75% gel has proven effective in clinical trials.34,35 A combination of systemic antibiotics and topical treatment may lead to a substantial reduction in inflammatory lesions, erythema, and the size and diameter of telangiectatic vessels.32
Eyelid hygiene and erythromycin or bacitracin ointment, to improve meibomian gland function, are appropriate initial treatments for the ocular manifestations of childhood rosacea.17,36 A low dose of steroid drops can manage significant irritation when needed. Systemic therapy with tetracycline or other oral pharmaceuticals used to treat the face also may work for ocular symptoms.17