Rosacea fulminans is a severe skin disease of the face that is characterized by the sudden onset of papules, pustules, and nodules. Pregnancy is considered a potential trigger. Serious complications can develop in pregnant women if the disease is not diagnosed and treated early. We report a new case of rosacea fulminans in a pregnant woman and analyze the epidemiologic and therapeutic characteristics and severe complications reported in this group of patients.

An otherwise healthy 20-year-old woman who was 14 weeks pregnant came to the clinic with an extensive outbreak of pustules on an erythematous–edematous base, with no comedones. The lesions were located on the cheeks and forehead (Fig. 1) and accompanied by low-grade fever. No acneiform lesions were observed at other sites. The patient denied having taken new medication and recent exposure to sunlight. Bacterial culture of the pustules was negative, and no significant laboratory abnormalities were recorded.

Figure 1.

Extensive pustules over an erythematous base mainly affecting the cheeks and forehead.

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Histology (Fig. 2) revealed reactive epidermal hyperplasia, with a collection of intracorneal neutrophils and infundibular dilatation of the hair follicle. The dermis was remarkable for the presence of vascular ectasia and a lymphohistiocytic infiltrate. An abundance of Demodex folliculorum was also observed. Together with the symptoms, these findings were compatible with rosacea fulminans. The patient was given erythromycin 500mg/8h for 3 weeks in combination with topical metronidazole and hydrocortisone. Topical metronidazole was subsequently maintained for 3 months, leading to almost complete resolution of the lesions.

Figure 2.

Reactive epidermal hyperplasia with collection of intracorneal neutrophils. The dermis is remarkable for the presence of a lymphohistiocytic infiltrate and vascular ectasia, together with figures suggestive of Demodex folliculorum (arrows) (hematoxylin–eosin, ×20).

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To date, we have identified 21 cases of rosacea fulminans during pregnancy (Table 1).1–13 The median age was 31 years (range, 20–38 years), and most patients were diagnosed during the first trimester (43%) owing to the appearance of lesions a few weeks earlier. In 32% of cases, the patient reported a history of rosacea before becoming pregnant. Oral antibiotics were the most widely prescribed option (95%), with macrolides being the first choice in 68% of patients. Almost one-third of patients (32%) also received systemic corticosteroids that were subsequently tapered, and 18% required isotretinoin after labor owing to lack of response to their previous treatment. Topical treatment was administered in 68% of cases, mainly with metronidazole, clindamycin, and erythromycin. The severe complications reported include a case of fetal demise owing to the adverse effects of corticosteroids (secondary adrenal insufficiency),5 induced abortion owing to major anxiety-depression syndrome,8 and a case of bilateral corneal perforation requiring a corneal transplant.9 There are no reports of recurrence in subsequent pregnancies.

Rosacea fulminans is a severe facial dermatosis of uncertain origin. Hormonal changes during pregnancy could be a trigger. Very extended lesions have been reported in pregnant women, as have profound and irreversible eye involvement9 and a psychiatric condition triggered by the onset of lesions.8 Given the degree of involvement of rosacea fulminans, systemic treatment is often necessary. However, commonly used drugs, such as retinoids and tetracyclines, are contraindicated during pregnancy. Therefore, oral macrolides such as erythromycin and azithromycin are the safest and most effective option in this situation. More evidence is available for erythromycin, although findings for the effectiveness of azithromycin in rosacea are favorable, showing a more comfortable dosing regimen and fewer adverse effects.10 Topical antibiotics should also be added owing to their anti-inflammatory effects. Systemic corticosteroids may prove to be necessary, although they can cause delayed intrauterine growth, gestational diabetes, and hypertension, as well as secondary adrenal insufficiency, which can lead to fetal demise.5,8

Considering the cases reviewed, we propose the following therapeutic approach: first-line therapy with oral macrolides combined with topical clindamycin or metronidazole, and second-line therapy with addition of topical and systemic corticosteroids (doses up to 0.5mg/kg/d).

In conclusion, rosacea fulminans is a severe skin disease that can develop during pregnancy. Affected patients should be diagnosed early to avoid progression to extended lesions. Thus, we can decrease the possibility of potentially severe complications by reducing the need for treatment with systemic corticosteroids.