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Ask a Dermatologist Free: Rosacea Differentials

Dear Doctor

Hi, I have pedant red patchy cheeks but no pimples or other symptoms of Rosacea

It’s persistent  I’m only 22 and have had this for as long as I remember but it’s getting harder to cover up.

My doctor says it’s Rosacea but I can’t find any other pictures or symptoms that match mine.

I just wanted  a second opinion. Kind regards.

ask a dermatologist free

Dear Patient

The differential diagnoses for rosacea include:

1. Systemic lupus erythematosus (SLE)

SLE is a condition which mimics rosacea because it causes facial erythema (redness) around the malar (cheek) area. This SLE malar rash has papules (small swellings) and it is often photosensitive. There may also be other symptoms of SLE  like mouth sores and hematuria (blood stained urine). Lab tests done for SLE reveal:

a. Antinuclear antibodies (ANA) positive

b. Anti-Ro antibodies positive

c. Anti-double-stranded dexoyribonucleic acid (anti-dsDNA) antibodies positive

These tests are negative for rosacea.


2. Seborrheic dermatitis

Seborrheic dermatitis can also cause facial redness. But it is associated with a yellow, greasy scale in the nasolabial folds, eyebrows, ears and scalp.

I do not see a scale on the photo and therefore I think this is unlikely to be seborrheic dermatitis.


3. Acne vulgaris

Acne vulgaris is characterized by the presence of comedones (black head and white heads) which are absent in rosacea. Telangiectasia, flushing and eye symptoms are not seen in acne.

I do not see comedones on the picture and therefore I think this is unlikely to be acne vulgaris.

acne vulgaris

4. Perioral dermatitis

Perioral dermatitis can also cause redness on the face associated with pinpoint papules and pustules. But they are usually concentrated around the mouth though they can also affect the perinasal (around the nose) and periorbial regions (around the eyes). Telangiectasia and flushing are absent. It is treated by stopping the application of steroids on the face and applying antibiotics like metronidazole or erythromycin.

The area around your mouth that I can see does not have any lesions and therefore I think this is unlikely to be perioral dermatitis.


5. Contact dermatitis

Contact dermatitis can also cause redness on the face on the areas where the irritating substance is being applied. There is often some scaling, papules and vesicles (fluid filled swellings).

If you are applying anything to the cheek areas I would advise you to stop applying it for atleast 2 weeks to see if the symptoms resolve. In addition, patch testing may also  help identify the specific contact allergens.


6. Carcinoid syndrome

Carcinoid syndrome is another condition which can cause facial redness. It also causes facial flushing which does not have a trigger unlike that of rosacea. Diarrhea and other systemic symptoms may also be present. Lab tests reveal high 24 hour urinary 5 HIAA levels.



Your symptoms are suggestive of rosacea and I suggest you follow the recommendations in this article.

You can also discuss with your doctor the possibility of doing the SLE and Carcinoid syndrome tests if you have other associated symptoms.

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