Rosacea or lupus rash

Rosacea Review – Newsletter of the National Rosacea Society

While the facial effects of rosacea and lupus may sometimes be confused, the presence of eye symptoms may point definitely to rosacea, as it almost never occurs in lupus flares.

“The presence of ocular involvement can be very helpful in differentiating active lupus from active rosacea,” said Dr. Guy Webster, associate professor of dermatology at Jefferson Medical College.

The two disorders may have a similar appearance. Like rosacea, lupus sufferers often have redness across the central portion of the face, often in a butterfly pattern. Although both rashes can be smooth in texture, especially in early rosacea, the presence of bumps and pimples, which rarely occur in a lupus flare, may help differentiate the two diseases.

Moreover, unlike lupus, as many as 50 percent of rosacea patients may also have ocular signs. Visually, an eye affected by rosacea often appears simply to be watery or bloodshot. Patients may feel a gritty or foreign-body sensation in the eye, or have a dry, burning or stinging sensation.

Inflammation of the eye or eyelid, called blepharitis, is also very common in rosacea, Dr. Webster said.

Is This Rosacea or Do I Have Something Else?

Rosacea acne and redness can mimic other skin problems, but there are ways to distinguish this condition from others.

You may think you have acne, but red bumps on the face could be a sign of a different skin condition. Alamy

A red bump or pus-filled pimple may seem like run-of-the-mill acne, but sometimes it’s a sign of another skin condition. So if you have acne along with redness, you might be wondering if you have rosacea.

What Does Rosacea Look Like?

Rosacea, sometimes called acne rosacea, is a chronic inflammatory disease of the skin. Those affected tend to blush, or flush, more easily than others.

Rosacea can be mild or severe. Over time, the redness can spread from the cheeks and nose to the chin and forehead. (1) Rosacea can also cause thickening or enlargement of the skin around the nose.

Rosacea is most common in people with fair skin, particularly those of Celtic or Scandinavian descent. (2) It also occurs in other skin types, but it’s less noticeable in people with darker skin. In fact, rosacea can be underdiagnosed or flat-out missed in every other ethnicity, says Erum Ilyas, MD, a board-certified dermatologist based in the Philadelphia area.

“I routinely have patients of color who have seen numerous other doctors, but have had their diagnosis missed simply because their skin type didn’t show the classic ‘rosy cheeks,’” continues Dr. Ilyas.

Approximately half of all people with rosacea also develop eye problems or ocular rosacea. (3) “This is a form of rosacea that affects the eyes, and it occurs in about 50 to 70 percent of patients with rosacea,” notes Ilyas. “It may or may not be associated with rosacea of the skin.”

Symptoms of ocular rosacea include chronic tearing and eye dryness, a gritty sensation in the eye, flaking at the base of the eyelashes (called blepharitis), and recurring sties. (4)

People with rosacea typically have sensitive skin and can’t tolerate a variety of skin products. What’s more, rosacea often worsens with certain environmental triggers, including temperature extremes and sun exposure.

Other triggers include emotional stress and certain foods and drinks, such as red wine and spicy dishes. (3)

The exact cause of rosacea is unknown, but scientists do know that the blood vessels within the skin of people with rosacea are unstable and more reactive than those who don’t have the condition. (2,3)

Also, Demodex mites — microscopic organisms that normally inhabit hair follicles in low numbers — appear to be more numerous in those with rosacea, explains Anna D. Guanche, MD, a board-certified dermatologist based in Calabasas, California. (2) On average, these patients have more Demodex mites per pore, adds Dr. Guanche. This may contribute to the red bumps of rosacea.

Skin Conditions That Can Resemble Rosacea

Several other conditions can produce the skin redness and acne-like bumps of rosacea, including the following:


Acne develops when small pores in your skin become clogged with oil and dead skin cells. Symptoms can vary from person-to-person, but may include red lumps or spots, tiny white bumps, and dark spots with open pores. (5)

Acne typically occurs in younger people, triggered by hormone fluctuations that cause excess oil secretion. But older people can get zits, too. In fact, some women develop problems with acne in middle age. (5) The telltale sign that distinguishes acne from rosacea is the presence of whiteheads or blackheads, called comedones. Though acne and rosacea can be present at the same time, only acne is associated with comedones.

Lupus is another skin condition that can be mistaken for rosacea. This chronic autoimmune disease causes inflammation in different parts of the body, including the skin. (6)

Inflammation results from the immune system attacking healthy cells and tissues. One distinct symptom of lupus is a red, facial rash. This rash can cover both cheeks and usually has a butterfly shape. (7)

Along with rosy cheeks, the rash can cover the bridge of the nose. But while a rosacea rash may look like lupus, the difference is that a lupus rash doesn’t have red bumps that are typical of rosacea, although the rash can be raised. (8)

Other symptoms that may accompany a lupus rash include fever, fatigue, joint pain and stiffness, headache, dry eyes, and shortness of breath.

Seborrheic Dermatitis

This skin condition is often found on the scalp, causing red patches and dandruff. It can also develop on other parts of the body, including the face and the nose, so it’s sometimes mistaken for rosacea. There is, however, a way to tell these conditions apart. (9,10)

In addition to redness, seborrheic dermatitis can cause flaking in the brows, the lower forehead between the eyebrows, in the creases around the nose, and sometimes the chin. (10)

If you have seborrheic dermatitis, you won’t have red, swollen bumps or pus-filled pimples that are typical with rosacea. (9)

Keep in mind that it is possible to have seborrheic dermatitis and rosacea at the same time. (10)

Seeing a Dermatologist for Diagnosis and Care

If you think you have rosacea, don’t ignore symptoms. While rosacea can’t be cured, treatment can help you manage symptoms and reduce flares. (3)

Seeing a dermatologist makes sense, first to get the right diagnosis and second to get the appropriate care.

There isn’t a specific medical test to diagnose rosacea. Your doctor will examine your skin and eyes, ask about your medical history, and you’ll likely undergo tests to rule out skin conditions with similar symptoms. (11)

Although there are over-the-counter options for treating rosacea, topical and oral prescription medication might do a better job with improving the physical symptoms.

Early diagnosis and treatment is key to stopping the progression of this chronic disease, says Ilyas. If left untreated, facial redness can worsen or become more persistent. But if caught early, rosacea can be controlled. (11)

Becoming aware of — and avoiding — any strong triggers can also keep breakouts and redness under control. (3)

Because rosacea is a chronic condition, redness can return at different points in your life. For this reason, you’ll need to follow up with your doctor periodically to keep skin care on course.

What is a malar rash?

Share on PinterestA malar rash occurs on the cheeks and bridge of the nose.

Causes of the malar rash include:

  • autoimmune diseases, such as lupus
  • bacterial infections, such as Lyme disease
  • inflammatory skin disorders, such as rosacea
  • vitamin deficiencies, such as pellagra
  • genetic disorders, such as Bloom syndrome
  • sensitivity to ultraviolet rays in sunlight

Lupus or SLE

Lupus is a chronic autoimmune condition where a person’s immune system attacks healthy tissue. It is also known as systemic lupus erythematosus or SLE.

Lupus results in inflammation of joints, skin, and other organs. While there is no cure, treatment can improve some of the symptoms.

Around half of all people diagnosed with lupus will develop a malar rash as a symptom. One study recorded a prevalence of 61 percent.


This common skin condition affects 16 million Americans and 415 million people worldwide. It is characterized by:

  • redness of the skin
  • flushing
  • hard or pus-filled pimples

Seborrheic dermatitis

Seborrheic dermatitis is a common inflammatory disease of the skin characterized by greasy or dry scales usually on the scalp, hairline, and face, although it can affect many other areas of the body.

When someone has dandruff, they have a mild form of seborrheic dermatitis.


Cellulitis is a type of bacterial infection that affects the deeper skin layers plus the layer of fat that is stored directly under the skin.

Lyme disease

This is caused by a tick bite, which then transmits bacteria into the body. Other symptoms may include:

  • joint pain
  • stiffness
  • severe headaches
  • dizziness


This is a condition involving inflammation of the muscles, connective tissues, and skin. Unlike SLE, the associated rash impacts the folds of skin that run from either side of the nose to the corners of the mouth.


When someone eats a diet that is extremely low in niacin, one of the B vitamins, it can lead to Pellagra.

This condition causes a range of symptoms that affect the skin, central nervous system, gastrointestinal system, and mucous membranes, such as the lining of the mouth. These symptoms can include pain and swelling.

Bloom syndrome

Bloom syndrome, which is also called Bloom-Torre-Machacek syndrome, is an inherited disorder that is characterized by short stature and elevated rates of most cancers.

Among other symptoms, it causes a malar rash and skin eruptions on other areas of the body.


Homocystinuria is a genetic disorder where the body is unable to process the amino acid methionine, leading to harmful levels of this and the chemical homocysteine in the blood and urine.

The condition can also result in vision problems, skeletal abnormalities, and intellectual disability.


Erysipelas is a skin infection caused by Streptococcus bacteria. It results in acute skin inflammation. This is a rare cause, but it may also affect the ears and the face.


Sunburn or sensitivity to sunlight may cause a malar rash, and it may worsen one if it already exists.

The biological agent belimumab was approved as an add-on therapy in SLE by NICE in 2016,9 but is reserved for patients with more severe disease and those unresponsive to standard treatment.

One recent placebo study suggests that the monoclonal antibody ustekinumab may be of value in treating patients with SLE,10 though its place in the management of the condition remains to be seen.


According to recently introduced guidelines, Janine has mild SLE (malar rash, mouth ulcers and arthralgia).11 Initial management should include topical or oral corticosteroids (prednisolone up to 20mg daily), for 14 days to induce remission. She should also take hydroxychloroquine (6.5mg/kg/day) provided that she has normal renal and liver function.

There is good evidence that the malar rash can be significantly improved with HCQ after 3-4 months. Moreover, there is some evidence that HCQ reduces overall disease activities with reduced rates of flares and delayed time to renal damage.11 Janine also needs to use sun protection and should be advised about the use of sun-protective clothing. Though non-steroidal anti-inflammatory drugs (NSAIDs) can increase the risk of renal failure in patients with SLE, they can be used cautiously in patients to manage pain where paracetamol has been ineffective. Janine should have blood tests every one to three months during active disease and this can be reduced to 6 or 12 monthly once the disease is stable.

Monitoring is important, since between 20-75% of those with SLE will develop lupus nephritis, which leads to end-stage kidney disease in 10-17% of patients after 10 years.12

Despite the available interventions, patients in the UK with SLE will, on average, die 25 years earlier than the mean age for men and women.

Rod Tucker: Pharmacist with a special interest in dermatology

Further reading:

You’re the doctor: A photo-case study challenge

Butterfly rash vs Rosacea?

A MyLupusTeam Member said:

If it is on your face upper cheek area. I feel like it is different for everyone like all the symptoms are. It sometimes feels like a hard scab and like you have a mud mask on where your face is stiff. Sometimes it stings or burns. For me it is the same exact pattern even time. It comes on after overexerting myself or a lot of heat. If you have lupus and have a rash across your upper cheek area and bridge on nose area, it is your butterfly in my opinion. They like to say you have rosacea when they are not definite they want to “categorize you as lupus” The real reason it takes so long to diagnose is because the diagnose is so that they can have more accurate data on the drugs they give to us. Every diagnose the doctor is responsible for their patient affecting this data, that is why we are left waiting and in the dark. Obviously it discredits them if they keep diagnosing the wrong diseases and because so many of these overlap they want to identify you with the most dominant one as your primary and then make the others secondary. So if they felt that your sjogrens was more diagnosable than your lupus at this time they would say it is rosacea.

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Lupus pictures and symptoms

The immune system’s attack can affect many different body parts and systems. As a result, lupus can cause a wide variety of symptoms that may be different from person to person.

The symptoms of lupus may appear or get worse during flares. Once a flare is over, a person may have mild or no symptoms for weeks, months, or even years.

A person with lupus may notice some of the following symptoms.

Butterfly rash

Many people with lupus experience a red or purplish rash that extends from the bridge of the nose over to the cheeks in a shape that resembles that of a butterfly.

The rash may be smooth, or it may have a scaly or bumpy texture. It can look like a sunburn.

The medical term for this type of rash is a malar rash. Other conditions can cause a malar rash, however, so this symptom alone is not enough to indicate lupus. Other conditions that cause a malar rash include:

  • rosacea
  • cellulitis
  • erysipelas, a type of cellulitis
  • sunburn

In some cases, a doctor may treat the malar rash with prescription creams or ointments. These medications may include steroids to minimize inflammation. In other cases, a doctor may prescribe medicines that help stop immune system activity.

Sores or red patches on the skin

Lupus can cause two main types of lesion or sore:

  • Discoid lupus lesions, which are thick and disk-shaped. They often appear on the scalp or face and can cause permanent scarring. They may be red and scaly, but they do not cause pain or itching.
  • Subacute cutaneous lesions, which may look like patches of scaly skin or ring-shaped sores. They usually appear on areas of skin that get exposure to the sun, such as the arms, shoulders, and neck. They do not cause scarring.

Both types of lesion are photosensitive, which means that they are highly sensitive to sunlight.

People who have these types of lesion should avoid being out in the sunlight as much as possible, use sunscreen, wear sun-protective clothing, and limit or avoid exposure to fluorescent light.

Hair loss

Share on PinterestHair loss is a possible symptom of lupus.

Lupus can cause the hair to get thinner or fall out, either in patches or all over. Many different factors lead to hair loss in people with lupus, including:

  • Discoid lupus sores on the scalp or other areas can cause hair to fall out temporarily. If the sores produce a scar, hair loss can be permanent in that area.
  • Severe lupus can cause temporary hair loss if there is inflammation of the skin. The hair usually grows back when a person takes medication to manage the symptoms.
  • Some medications that treat lupus can cause hair loss. For example, some steroids and immunosuppressants can cause the hair to become brittle and break, leading to hair loss.

Joint swelling and pain

One of the most common symptoms of lupus is joint problems. Lupus may cause swollen, tender, stiff, or warm joints.

These issues usually affect the extremities, including the fingers, toes, wrists, knees, and ankles. Although lupus is not a type of arthritis, the inflammation that it causes can result in symptoms of arthritis.

Sun sensitivity

A person with lupus may have photosensitivity, which is a sensitivity to ultraviolet (UV) light. They may notice that they get sunburned more easily than other people.

The sun can also trigger the development of skin lesions, such as a butterfly rash or discoid lupus.

Cold, blue, or pale hands or feet

Some people with lupus experience Raynaud’s phenomenon, which affects the blood vessels in the fingers, toes, hands, or feet.

Raynaud’s phenomenon makes the blood vessels in the extremities constrict, which turns the extremities blue or pale, as well as causing tingling, numbness, and pain.

A person may notice this reaction when they are in cold temperatures or under stress.

A person may be able to manage their Raynaud’s symptoms by avoiding cold temperatures, dressing warmly in gloves, socks, and boots, and using stress management techniques, such as meditation and relaxation.

Dry, red, or irritated eyes and vision problems

Lupus can affect the eyes and the area around the eyes in several ways:

  • The retina may have an inadequate blood supply, leading to vision loss.
  • Discoid lupus lesions can appear on the eyelids.
  • The tear glands may not produce enough tears, leading to dry eyes.
  • The outer layer of the eye may become inflamed and red, which is an effect called scleritis.

Additional symptoms

Other possible symptoms of lupus include:

  • chest pain when taking a deep breath
  • headaches
  • severe fatigue
  • fever
  • anemia (low red blood cell count or low blood volume)
  • weak muscles or reduced strength
  • carpal tunnel syndrome
  • tendonitis (irritation of a tendon)
  • kidney problems
  • heart problems
  • confusion

Red Skin & Rashes Are Not Always the Result of Rosacea

Rosacea is sometimes confused with other conditions because its signs and symptoms can appear so similar, and a professional diagnosis is essential. To make matters worse, patients often suffer from more than one skin disorder at once, and an NRS survey found that 77 percent of rosacea patients had been diagnosed with other skin conditions as well. Here are some of the most common disorders mistaken for rosacea.


Some of the most common signs of rosacea — bumps and pimples — are also the most common cause of confusion about the skin condition. Acne covers a broad range of symptoms that occur when pores on the skin become clogged with oil and dead skin cells. Acne may appear as whiteheads, blackheads, pimples, small red bumps, and painful cysts. The bumps (papules) and pimples (pustules) of Subtype 2 (papulopustular) rosacea are often mistaken for acne, and the historical term “acne rosacea” reflects an early but now-disproven belief that the two conditions are related. The blackheads of acne do not occur with rosacea. The two conditions further differ in that acne is most common in teens, while rosacea generally occurs later in life. Also, acne can appear on the shoulders, neck, back and chest in addition to the face, but rosacea usually only affects the face.


The term dermatitis refers to itchy, red, or swollen skin caused by inflammation or irritation. The rash can begin to ooze, crust and flake if untreated. Unlike rosacea, which includes a specific collection of symptoms, dermatitis is a more general term that is often a symptom of other conditions. There are many different types of dermatitis, but the two most commonly confused with rosacea are seborrheic dermatitis and eczema.

Eczema is a type of dermatitis which can occur anywhere on the body. Caused by inflammation, eczema makes skin dry, itchy, red and cracked. It appears most commonly on the hands, neck, face, legs, and skin creases. It afflicts those of all ages, including infants (see photo).

Seborrheic dermatitis may be one of the most common skin conditions to occur at the same time as rosacea. It is a chronic inflammatory skin disorder, generally confined to areas where sebaceous (oil) glands are most prominent, including the face. Scaling and redness are the two dominant characteristics, and may be accompanied by a burning sensation. The most common sites on the face include the creases around the nose, the forehead, the inner eyebrows and the external ear canal. The upper eyelids and eyelid margins may be involved.


When psoriasis appears on the face, it may look similar to rosacea. Caused by an overproduction of skin cells, psoriasis is a common and chronic disease. Symptoms include red patches, silvery scales, dryness, itching, burning, thick nails and stiff joints. Unlike rosacea’s four subtypes, there are more than eight types of psoriasis depending on the location and extent of symptoms, and treatment options for psoriasis vary greatly. When psoriasis occurs on the face, it may appear similar to rosacea, but treatment options for psoriasis vary greatly. Psoriasis can be treated with topical steroids, retinoids, and sun exposure, among other things. In contrast, steroid creams and sun exposure can contribute to rosacea flare-ups.


Though it might not seem to belong on this list of primarily skin conditions, lupus erythematosus is sometimes mistaken for rosacea because of the butterfly-shaped rash it can cause on the cheeks and nose. Lupus is an inflammatory disease that can affect joints, kidneys, blood cells, the brain, heart, lungs and skin. Symptoms include fever, joint pain, chest pain, headache, facial rash, skin lesions and dry eyes. Because lupus is a more widespread disease that affects multiple systems of the body, blood and urine tests, chest x-rays, and kidney and liver assessments may be conducted to assess the condition and determine appropriate medical therapy and care.

Lena Dunham Is Seriously Bummed She Suddenly Has Rosacea at 31. Here’s Why That Happens

Lena Dunham has never cared much what other people say or write about her body, her weight, or her looks. But this week, the actress revealed that she’s dealing with a new issue that actually made her extremely self-conscious and upset: At age 31, she suddenly developed rosacea.

“ few weeks ago, a course of steroids to treat a massive flare of joint pain and instability led to rosacea’s appearing overnight,” Dunham wrote Tuesday on Lenny Letter, “making me look like a scary Victorian doll, two perfect pink circles painted on her porcelain face.” (Along with endometriosis, the actress has an autoimmune disease that causes chronic pain and fatigue, she explained.)

Then, after wearing makeup for a long and sweaty shoot, Dunham wrote that she washed her face “to reveal that the rosacea had become hundreds of tiny pimple-blisters that covered me from forehead to neck.” She described feeling a mixture of terror, rage, and sadness at that moment, and wrote that “my face burned, but not as badly as my pride.”

Dunham’s right: A skin condition like rosacea—which causes unusual flushing and sometimes pimple-like bumps to appear on the cheeks or other areas of the face—can be seriously embarrassing. But she should take some comfort in knowing that she’s not alone: According to government estimates, about 14 million people in the United States have rosacea.

But what exactly is rosacea—and is it common to develop it in adulthood, after years of clear, glowing skin? To learn more, Health spoke with Temitayo Ogunleye, MD, assistant professor of dermatology in the Perelman School of Medicine at the University of Pennsylvania. Here’s what she had to say.

RELATED: How to Care for Your Sensitive Skin

Rosacea can appear at any time

The exact cause of rosacea’s trademark redness and bumps hasn’t been established, but scientists do know it occurs when blood vessels beneath the skin dilate, and increased blood flow makes the skin appear flushed.

Rosacea is different from acne, however, and it’s common for it to appear in a person’s 20s or beyond. “I see patients in their 40s, 50s, 60s, 70s who develop it out of the blue,” says Dr. Ogunleye, who has not treated Dunham. “Usually it’s not something they’re are doing differently; it’s just something that begins on its own.”

The condition is most commonly diagnosed in fair-skinned people of European descent, Dr. Ogunleye adds, but it can occur in people of all ethnicities and all skin types. (It may just be less noticeable and under-diagnosed in people with darker skin tones.)

It can range from mild to severe

Dr. Ogunleye describes rosacea as a “spectrum of a condition.” Most often, redness appears on the cheeks, but it can also appear on the forehead, nose, chin. “Some people who have this ruddy complexion aren’t bothered by it,” she says. “They just accept that this is what their skin does, and they’re okay with it.”

Other people complain about easy flushing and blushing, which usually happens as a result of different triggers—including heat, cold air, sun exposure, hot foods, caffeine, or embarrassment. “And this isn’t normal flushing we’re talking about,” she says. “It’s flushing that lasts for 10 minutes or longer.”

Some people with rosacea may also develop acne-like bumps or blisters, while others—often middle-aged men—develop thickening of the skin around the nose. One type of the disease can also cause eye redness and dryness, as well.

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Medications—and avoiding triggers—may help

Rosacea is a chronic condition, and there’s no cure. But antibiotics—either oral or topical—may help reduce its symptoms, especially for people who have skin sensitivity or those pimple-like bumps. (Sounds like Dunham was experiencing both of those symptoms: She wrote that her face “felt like someone had given it a nice, slow sandpaper massage by candlelight.”)

“The flushing itself is actually the hardest part to treat,” says Dr. Ogunleye, “although topical antibiotics may take the redness down a little bit. Paying attention to your triggers, and learning to avoid them, can also help.

For people who are really bothered by their condition, doctors can also recommend topical creams and moisturizers that temporarily reduce redness, or laser treatments that can shrink the underlying blood vessels and last for several years. These options can be expensive, though—the laser treatments run several hundred dollars—and aren’t covered by insurance.

RELATED: The Best Moisturizers for Rosacea, According to Dermatologists

Medications can cause rosacea-like symptoms

Dunham wrote that she’s stocked up on “creams and potions,” along with “antibiotics and probiotics,” and that she doesn’t know what to expect going forward. But because her condition appears to be steroid-induced, it may only lasts as long as she’s on medication. (Of course, that could also be long-term, based on her other health issues.)

According to research cited by the National Rosacea Society, the use of corticosteroids can cause rosacea-like symptoms (including visible blood vessels, bumps, and pimples) that worsen with triggers such as stress, heat, or sun exposure. In these cases, stopping the medication can lead to skin improvement.

No matter what’s in store for Dunham’s skin, it seems that writing about it has helped her face her emotions around the issue. She also hopes it helps other young women “understand that nobody is immune from feeling bad about hateful attention.”

Dunham also seems determined to embrace her new condition, despite her initial reaction. “I love myself. I think I’m grand … I have a bunch of blister-pimples,” she wrote at the end of her essay. “All are true. All are fine. None are forever. I promise you.”

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