Lupus vs. Rosacea

Rosacea vs. Lupus: What’s the Difference?

Rosacea vs. Lupus: What’s the Difference?

If you have a red rash on your face, google might tell you it could be either rosacea or lupus. There is confusion around how these two diseases are different, however, there are some distinctions that set the two diseases apart.

What is rosacea?

Rosacea is an inflammatory skin disease that presents as vibrant red flushing on the cheeks, nose, chin, eyes, and forehead.

Signs and symptoms

This skin condition typically follows a flare-up—remission cycle where it can be triggered by things such as UV sunlight exposure or alcohol or spicy foods. This disease also ranges from mild to severe, with the treatment goal to reduce symptoms and stop the progression of the disease to a more severe form.

There are four subtypes of rosacea, each of which presents different symptoms.

Erythematotelangiectatic rosacea (ETR)

This subtype is characterized by flushing, persistent redness (erythema), and possible broken blood vessels on the surface of the skin—sometimes referred to as spider veins or telangiectasias.

Symptoms include:

  • Flushing
  • Erythema (persistent)
  • Telangiectasias/spider veins
  • Irritated skin
  • Burning or stinging pain
  • Edema
  • Rough skin
  • Scaly skin

Papulopustular rosacea

This subtype is often referred to as adult acne and presents as papules and/or pustules (forms of pimples) on the central part of the face including the cheeks and nose.

Symptoms include:

  • Erythema (persistent)
  • Papules
  • Pustules
  • Burning and stinging pain

Phymatous rosacea

This subtype most commonly presents as an enlargement of the nose (rhinophyma) from nodular growths and skin thickening, often seen in older men. However, it can also be seen as enlargements of the chin, cheeks, or forehead.

Symptoms include:

  • Thickening of the skin
  • Irregular-shaped nodules growing on the skin surface
  • Enlargement of the nose, chin, cheek, or forehead
  • Patulous (large) follicles
  • Telangiectasia

Ocular rosacea

This subtype is the most dangerous, as left untreated ocular rosacea can cause permanent damage to your vision. Approximately 50% of people with cutaneous (facial) rosacea will develop ocular rosacea.

Symptoms include:

  • Bloodshot eyes
  • Watery eyes
  • Dry eyes
  • Itchy eyes
  • Sensitivity to light
  • Burning or stinging pain
  • Blurred vision
  • Telangiectasias on eyelids
  • Erythema on the lids and around the eyes
  • Frequent conjunctivitis
  • Styes
  • Vision loss

Causes

The cause of rosacea is unknown, but current research suggests that the underlying cause involves a combination of genetic factors, a malfunctioning immune system—which leads to high levels of inflammation and vasodilation in the facial skin and environmental factors such as food triggers, UV exposure, gut-microbiome health, and related diseases.

What is lupus?

Lupus is an autoimmune disorder, which means all symptoms experienced by patients are the result of the body’s natural immune system misreading healthy tissue as foreign and attacking it. This attack results in tissue damage and inflammation, which presents many mild and severe symptoms.

Signs and symptoms

This disease also follows a flare-up/remission cycle where patients experience periods where their symptoms flare-up, due to environmental triggers, and then go back into remission, where their symptoms reduce.

Lupus can be divided into two categories, which present different symptoms.

Cutaneous lupus erythematosus

This form of lupus specifically involves the skin and most commonly presents as a bright red rash. These rashes can form all over the body including the face.

Many lupus patients develop this rash, and it is often found to be one of the first symptoms or a key symptom leading to a lupus diagnosis. It is often more associated with a mild form of the disease, with some patients having no other symptoms related to lupus.

The rash that develops on the face, called a malar rash, is commonly called a butterfly rash because it looks like a butterfly over the nose and cheeks.

Symptoms include:

  • Facial rash (malar rash), spanning the nose and cheeks, in a shape of a butterfly
  • Red rash on other body parts including neck, chest, arms, and torso
  • Photosensitivity
  • Oral ulcers

Systemic lupus erythematosus

This form of lupus refers to a more severe form of the disease. Lupus is a continuum, where symptoms can be mild—like a rash—but can progress to be life-threatening.

Severe lupus involves systemic damage involving many vital organs including the heart, lungs, and kidneys as well as body systems including the nervous system, gastrointestinal tract, blood, and muscle.

Mild symptoms include:

  • Rash on body or face
  • Fatigue
  • Muscle weakness
  • Hair loss
  • Joint pain
  • Weight loss
  • Loss of appetite
  • Photosensitivity
  • Oral ulcers
  • Dry eyes

Severe symptoms include:

  • Chest pain
  • Shortness of breath
  • Damage to the heart
  • Heart failure
  • Reduced kidney function
  • Kidney failure
  • Abdominal pain
  • Nausea and vomiting
  • Diarrhea
  • Headaches
  • Dizziness
  • Seizures
  • Vision problems
  • Changes in personality
  • Depression
  • Anemia
  • Low immunity
  • Arthritis
  • Osteoporosis

Causes 

The cause of lupus is unknown but is thought to be a combination of genetic predisposition, immune system intolerance, hormonal factors, and exposure to environmental factors such as UV exposure or certain medications. This means someone with a family history of lupus may develop the disease due to a trigger such as a virus.

Lupus symptoms can also be caused by medications used to treat hypertension and high blood pressure. This is called drug-induced lupus and is caused by a disruption in the immune system caused by the drugs. Symptoms worsen the longer someone is on the medicine but stop after the medicine is stopped.

What is the difference?

While both rosacea and lupus can present with a bright red rash over the cheeks and nose, there are distinct differences between the two diseases when symptoms are more closely examined.

Rosacea is an inflammatory skin disease whereas lupus is an autoimmune disease. Rosacea is a condition that only affects the skin on the face whereas lupus can cause damage to organs and body systems all over the body, and in severe cases, be life-threatening.

Diagnosis

As they are separate diseases with different symptoms, rosacea, and lupus have distinctly different diagnostic criteria.

Rosacea diagnostic criteria

The criteria for rosacea is split into diagnostic, major, and secondary criteria. These criteria are measured by physical examination. A diagnosis is based on the presence of one diagnostic criteria or two major criteria.

Diagnostic criteria:

  • Fixed erythema present on central third of the face (not presenting as a butterfly-shaped rash)
  • Phymatous changes

Major criteria

  • Flushing
  • Papules and/or pustules
  • Telangiectasias
  • Ocular symptoms

Secondary criteria

  • Burning and/or stinging
  • Edema
  • Dryness
  • Ocular symptoms

Lupus diagnostic criteria

There are 11 criteria for the diagnosis of lupus. To make a diagnosis at least 4 criteria must be present. Diagnosis of lupus involves biochemical tests to gain a better understanding of what is happening inside the body.

Criteria include:

  • Malar rash
  • Discoid rash
  • Photosensitivity
  • Oral ulcers
  • Arthritis
  • Serositis
  • Renal disorder
  • Neurological disorder
  • Hematologic disorder
  • Immunologic disorder
  • Antinuclear antibody

There is a risk that a patient with a mild case of lupus, who is presenting with a malar rash may be misdiagnosed as someone experiencing erythema as a symptom of rosacea. This could have serious effects on the patient’s long-term health as untreated cutaneous lupus can progress to systemic lupus, which can be life-threatening.

Treatment

As these two diseases have different underlying causes, they require different treatments.

Treatment for rosacea

There are multiple subtypes of rosacea that all require different treatments. A patient can experience more than one type of rosacea at a time so will need a combination of treatments.

Treatments include:

  • Avoiding environmental and lifestyle triggers such as sun exposure, alcohol, exercise, hot drinks, and trigger foods
  • Removing irritating products from skincare routines
  • Topical medications i.e. antibiotics, steroids
  • Oral medications i.e. antibiotics
  • Surgical therapy (for phymatous)
  • Antibiotics applied to eyelashes (ocular rosacea)
  • Ocular surgery (ocular rosacea)

Treatment for lupus

Treatment for lupus is very varied depending on the severity of symptoms experienced by the patient.

The treatment of cutaneous lupus erythematosus involves preventing and reducing symptoms.

Treatments include:

  • Reducing UV exposure
  • Education on the use of sunscreen. Specifically natural sunscreens such as zinc instead of chemical sunscreens.
  • Topical medications including corticosteroid creams
  • Antimalarial drugs
  • Oral medications

Takeaway

There are multiple similarities between rosacea and lupus. Specifically, they can both present a bright red flush or rash over the cheeks and nose, which is sensitive to UV exposure. However, the two diseases are very different in how they develop and how they affect patients.

Rosacea is an inflammatory skin disease and lupus is a potentially life-threatening autoimmune disease. Because of these differences, the two diseases have different underlying causes, different symptoms, different diagnostic criteria, and different forms of treatment.

Brandon Kirsch
brandon.kirsch@clearifirx.com

Brandon Kirsch, MD, FAAD, is a board-certified dermatologist specializing in clinical drug development and medical innovation. He is the founder of Kirsch Dermatology in Naples, Florida and is also the Chief of Dermatology at the Naples Community Hospital. Kirsch Dermatology Website Dr. Kirsch started his career as a lawyer and holds law degrees from the University of Western Ontario (LL.B.) and Georgetown (LL.M. Securities and Financial Regulation). Dr. Kirsch completed his pre-medical studies at the University of Pennsylvania, medical school at Brown University, internship at the Mayo Clinic (Florida) and dermatology residency at the University of North Carolina. In partnership with the Mayo Clinic, he filed to patent a novel topical composition for the treatment of skin hyperpigmentation that he co-developed and also oversaw a successful pilot study of the formulation. Dr. Kirsch has experience with therapeutic drug development programs from pre-clinical to Phase 3 studies. He is licensed to practice medicine in California, Colorado, Florida, and North Carolina and law in New York and Ontario.



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