In the Chair: Pediatric Papulopustular Rosacea

Rosacea is a disease of adults. That statement is accurate in the vast majority of cases. But when an 8-year-old presents with a 3-year history of recurrent facial pustules, burning sensation, and a father with a history of rosacea, the question is not whether pediatric rosacea exists (it does) but whether it is being considered early enough in the differential diagnosis.^1,2

This patient saw 12 dermatologists before receiving a working diagnosis of rosacea. Prior treatments included therapies directed at acne, eczema, psoriasis, and allergic disease, none of which produced sustained improvement. The eventual diagnosis was supported by clinical pattern recognition and histopathologic findings after biopsy was obtained at the family’s request.

This case presents 3 clinical decision points in the evaluation and management of a chronic pediatric papulopustular eruption. At each stage, the distinguishing features are subtle but clinically decisive.

THE PATIENT

An 8-year-old boy presented with a 3-year history of recurrent facial eruption localized to the central face, involving the cheeks, nose, and chin. Lesions began as small erythematous papules and evolved into multiple inflamed pustules with intermittent flares and partial remissions, though never complete resolution.

There was no truncal involvement and no clinically evident telangiectasia. The eruption was associated with a burning sensation rather than pruritus. Symptoms worsened with heat exposure and swimming. Topical corticosteroids provided transient improvement, while benzoyl peroxide and isotretinoin were ineffective.

The patient also reported intermittent cough with mucus production, which was evaluated separately and managed symptomatically.

The child was otherwise healthy, with no systemic symptoms. There was no relevant exposure history. Family history was notable for a father diagnosed with rosacea beginning in childhood.

On examination, erythematous papules and pustules were present on the central face without comedones, crusting, ulceration, or scarring. The remainder of the physical examination was normal.

CLINICAL DECISION POINT 1 — Building the Differential

An 8-year-old with a chronic centrofacial papulopustular eruption, burning sensation, heat-triggered flares, absence of comedones, and partial response to topical corticosteroids presents a diagnostic challenge.

📋 WHAT WOULD YOU DO?

CLINICAL DECISION POINT 2—The Role of Biopsy

After multiple evaluations without a definitive diagnosis, a skin biopsy was performed at the family’s request.

CLINICAL DECISION POINT 3 — Management

A clinical diagnosis of papulopustular rosacea was made based on morphology, distribution, chronicity, and supportive biopsy findings.

CLINICAL TAKEAWAY: Pediatric Rosacea

• Pediatric rosacea is rare but documented, most often presenting as papulopustular disease
• Absence of comedones is a key feature distinguishing it from acne vulgaris
• Heat, sun exposure, and environmental triggers are consistent features across age groups
• Family history may increase clinical suspicion but is not diagnostic
• Diagnosis remains clinical; biopsy may provide supportive findings in atypical cases but is not required
• First-line therapy in children is topical (metronidazole, azelaic acid, ivermectin) with avoidance of unnecessary systemic therapy

THE TAKEAWAY

This patient developed symptoms at age 5 and spent 3 years undergoing multiple evaluations and treatments before a unifying diagnosis was made. The distinguishing clinical features were present early: centrofacial distribution, papulopustular morphology without comedones, burning sensation, heat sensitivity, and a relevant family history.

The delay in diagnosis reflects not a lack of data, but a low index of suspicion for pediatric rosacea.

When papulopustular facial eruptions persist despite acne-directed therapy, the key question is not which acne regimen to escalate — but whether acne is the correct diagnosis at all.

References

1. Sharaf R, Assaf T, Ghanem UI, Alhameed HA, Adwan R. Pustular rosacea in an 8-year-old patient: a rare presentation of pediatric rosacea. Case Rep Dermatol Med. 2026;2026:6001322. Published 2026 Apr 27. doi:10.1155/crdm/6001322
2. Woo YR, Kim HS. Deciphering childhood rosacea: a comprehensive review. J Clin Med. 2024;13(4):1126. Published 2024 Feb 16. doi:10.3390/jcm13041126
3. Nguyen C, Kuceki G, Birdsall M, Sahni DR, Sahni VN, Hull CM. Rosacea: practical guidance and challenges for clinical management. Clin Cosmet Investig Dermatol. 2024;17:175-190. Published 2024 Jan 23. doi:10.2147/CCID.S391705