Mixed diagnoses – 10 cases (7 of 11)

He has rosacea, a common facial rash affecting the face of men and women in middle-life. Early rosacea presents with prolonged flushing (eg with heat, embarrassment, change of temperature, spicy food, alcohol). Inflammatory rosacea results in persistent erythema, papules and pustules on the cheeks, chin and mid-forehead. Telangiectasia is usual. The cause of rosacea is unknown; gastrointestinal infections, hormones, Demodex mites and climatic factors have been blamed.

Ocular rosacea is common particularly blepharitis and conjunctival hyperaemia and less frequently iritis, episcleritis and superficial punctate keratopathy. Rarely, corneal neovascularization, scarring and perforation occur.

The majority of cases respond well to treatment, which may be required at least intermittently long term. Management may include:

• Sun protection and avoidance of stimuli likely to precipitate flushing
• Oral tetracycline at an initial dose of 500mg bd for one to three months, then tapering off, repeated if necessary
• Topical metronidazole gel used alone or in combination with oral therapy
• Oral metronidazole, cotrimoxazole or isotretinoin if resistant to standard treatment
• Clonidine to reduce flushing
• Ablation of telangiectatic vessels using vascular laser (eg pulse dye, Krypton- Argon, KTP or copper bromide systems) or flashlamp.