This just published paper is confirm that belief that the granulomatous forms of rosacea are not genuine subtypes in the same ways as the 4 well-know subtypes: ER, PP, PHY and OC (my abbreviations). A one-line summary of this paper is that a group of patients who had tests to show that they had granulomatous rosacea did not have any of the symptoms normally associated with rosacea.

In the early 2000’s, the NRS convened an expert panel to create a Standard Classification of Rosacea (SCoR, again my abbr.). Their classification system split rosacea into 4 main sub-types. Their aim was to create an “investigational instrument is intended to set the stage for a better understanding of rosacea and its subtypes among researchers and practitioners by fostering communication and facilitating the development of a research-based classification system.”

The Standard Classification does recognise a variant: Granulomatous Rosacea ;

Granulomatous rosacea is characterized by hard, yellow, brown, or red cutaneous papules or nodules that may be severe and lead to scarring. These lesions tend to be less inflammatory than papules and pustules and sit upon relatively normal-appearing skin. They can vary in size among patients but are monomorphic in each individual patient, and typically appear on the cheeks and periorificial areas. Granulomatous rosacea may occur in locations other than those in which the phymas are observed. The presence of other rosacea signs is not needed for a diagnosis of the granulomatous rosacea variant.

So this paper is further confirming the classification system created by the expert panel. Whilst the panel does recognise that revisions to the SCoR might be necessary as the pathogenesis and subtypes become clearer, we should carefully analyse calls within the rosacea community for more subtypes to be created without due proof. I’m thinking here of calls to create types for neuropathic and demodectic forms of rosacea. Bring on the proof and show the NRS Panel, and see where we get – they are ready and waiting to revise their classification system.

Granulomatous rosacea., Am J Dermatopathol. 2008 Feb;30(1):6-9, Sánchez JL, Berlingeri-Ramos AC, Dueño DV

Rosacea is classified into four clinical subtypes, namely erythematotelangiectatic, papulopustular, phymatous, and ocular. There is also a granulomatous variant, which is recognized in the rosacea spectrum. The objective of this study is to take a closer look at the different histopathologic patterns and cellular compositions seen in granulomatous rosacea and their correlation to the clinical presentation. Facial biopsies from patients previously identified with a clinical diagnosis consistent with rosacea, and who demonstrated a granulomatous infiltrate upon histopathologic examination, were reviewed and the results were correlated to the clinical presentation.

Four distinct histopathologic granulomatous patterns were identified, namely nodular, perifollicular, diffuse, and a combined perifollicular and nodular patterns. The clinical presentation varied greatly among patients and failed to correlate to the microscopic findings.

The varied clinical features seen in our study favors the theory that granulomatous rosacea is not a clinical subtype of rosacea per se, but a distinct histological variant, which can be found in most of its clinical spectrum.

Related Articles

• RRF: Standard Classification of Rosacea
• RRF: Standard Grading System for Rosacea