Pseudolymphomatous Folliculitis Presenting as Multiple Facial Papules: A Diagnostic and Therapeutic Challenge.

A 31-year-old woman with 2-year progressive papules and 6-year multiple tumours had facial, palmar and plantar papules as well as mucosal cobblestone-like lesions, with trichilemmoma confirmed histopathologically. Genetic testing detected a heterozygous PTEN p.Arg233Ter variant, leading to the diagnosis of Cowden syndrome, a rare multisystem disorder associated with malignancy risk and benign hamartomatous overgrowths.

A three-year-old boy presented with asymptomatic facial papules. Biopsy revealed dermal histiocyte proliferation. Based on clinical and histological findings, benign cephalic histiocytosis - a rare, self-limiting condition of infancy - was diagnosed. Recognition is key due to overlap with more serious histiocytic disorders such as Langerhans cell histiocytosis.

Rosacea is a chronic skin disorder causing facial erythema, telangiectasias, papules, and pustules. Guidelines recommend sub-antimicrobial doses, such as doxycycline 40 mg. If symptoms persist, evaluating the efficacy and safety of sub-antimicrobial minocycline may expand therapeutic options. The present systematic review and meta-analysis evaluates DFD-29 as a low-dose tetracycline alternative to treat rosacea. Our analysis included data from three RCTs sourced from PubMed, Embase, and Cochrane databases to compare the Investigator's Global Assessment (IGA) success, reduction in inflammatory lesion counts, treatment-emergent adverse events (TEAEs), and serious adverse events (SAEs) in patients using DFD-29 versus modified-release doxycycline. Statistical analyses were conducted using RStudio. In pooled analysis of 643 patients, DFD-29 significantly increased the likelihood of achieving a successful IGA score compared to doxycycline (OR 2.51; 95% CI 1.80 to 3.49; p < 0.001; I2 = 0%). The DFD-29 40 mg group had significantly greater reductions in IGA scores compared to the 20 mg group (p = 0.0210). The DFD-29 40 mg group also exhibited a higher reduction in inflammatory lesion counts than doxycycline (MD -4.56; 95% CI -6.18 to -2.93; p < 0.001), whereas the 20 mg group did not show significant results. There were no significant differences in TEAEs across groups (OR 0.96; 95% CI 0.55 to 1.66; p = 0.87; I2 = 0%), with only one SEA (atrial fibrillation) was reported with DFD-29. Our meta-analysis showed that DFD-29 at 40 mg daily, is a superior and well-tolerated alternative to modified-release doxycycline for moderate-to-severe rosacea.

The pathogenesis of Lichen Planus (LP) and its variants, despite many investigative efforts, remains incompletely understood. The occurrence of the disease in siblings suggests a potential role for both genetic and shared environmental factors. Here, three Iranian siblings—one male and two females—who presented with various clinical forms of LP were introduced. Case No. 1 exhibited bilateral facial pigmentation and was diagnosed with Lichen Planus Pigmentosus (LPPigm). Case No. 2 presented with facial pigmentation accompanied by facial papules and was diagnosed with LPPigm and Lichen Planopilaris (LPP). Case No.3 had frontotemporal hairline recession and eyebrow sparsening and was diagnosed with Frontal Fibrosing Alopecia (FFA). Histopathological examination confirmed the diagnoses in all three patients. Patients were treated with an individualized plan that included sunscreen use, potent topical corticosteroids, topical pimecrolimus, minoxidil, and systemic finasteride. To our knowledge, no other family in the literature has been reported to have such a wide range of LP variants. This series underscores the need for further research into genetic and environmental factors contributing to the development of LP and its variants.

Rosacea is a chronic inflammatory skin condition characterized by facial erythema, flushing, telangiectasias, papules, and pustules. Its pathophysiology involves a multifactorial interplay of genetic, immune, microbial, and neurovascular factors contributing to inflammation and vascular dysregulation. Environmental and lifestyle triggers are important contributors to disease exacerbation. In this review, we highlight 4 major modifiable triggers-UV radiation exposure, temperature fluctuation, skin care practices, and diet-and their roles in rosacea pathogenesis and management. Lifestyle modifications targeting these triggers combined with topical, oral, and/or laser therapies can improve disease control. A holistic, patient-specific approach to treatment that involves education on environmental influences and tailored management strategies is essential.

Tuberous sclerosis is a rare autosomal dominant genetic disorder caused by mutations in tumor suppressor genes (TSC1/2), leading to hamartomas in multiple organs. Renal angiomyolipomas are often asymptomatic but can cause mass effects or bleeding if they enlarge, requiring treatment. A 29-year-old woman presented with severe left flank pain, an abdominal mass, and facial papules. Imaging revealed a large, 18.3 × 13 × 11.5 cm mass in the lower pole of the left kidney, which was fat-poor, a smaller lesion on the opposite kidney, pulmonary cysts, and osteoblastic bone lesions, all indicating tuberous sclerosis-associated lymphangioleiomyomatosis. A left nephrectomy was performed, and she recovered well. Histology confirmed a renal angiomyolipoma with chronic inflammation. This case underscores the importance of nephrectomy for managing large angiomyolipomas to alleviate symptoms and improve quality of life. Managing such patients requires a multidisciplinary approach, including imaging and genetic testing, with ongoing care and surveillance to achieve better outcomes.

Background:Rosacea is a chronic inflammatory skin disorder, particularly challenging in moderate-to-severe cases, characterized by symptoms such as facial papules, pustules, erythema, flushing, and telangiectasia, which severely impact quality of life. Although oral doxycycline is a primary treatment, its efficacy against erythema is limited, necessitating the exploration of combination therapies. Intradermal botulinum toxin type A (BTX) has shown promise in managing facial erythema and flushing, but its combined use with doxycycline has not been evaluated.Objectives:This study aims to evaluate the effectiveness and safety of combining oral doxycycline with intradermal BTX (combination therapy) versus doxycycline with normal saline (monotherapy) in treating moderate-to-severe rosacea.Methods:A randomized, controlled trial was conducted with 46 participants aged 18 and older, diagnosed with moderate-to-severe rosacea. Participants were randomized to receive either combination therapy (doxycycline and BTX) or monotherapy (doxycycline and normal saline) for three months. Efficacy was assessed using the Clinician Erythema Assessment (CEA), Global Flushing Severity Score (GFSS), Investigator Global Assessment (IGA), telangiectasia degree, and Dermatology Life Quality Index (DLQI). Safety evaluations included monitoring adverse reactions.Results:Both groups showed significant reductions in CEA scores from baseline, with combination therapy demonstrating greater improvement (P < 0.001). Combination therapy also significantly reduced GFSS and IGA scores compared to monotherapy (P < 0.05). No significant changes were observed in the degree of telangiectasia. DLQI scores improved significantly in both groups, with greater reductions in the combination therapy group (P < 0.05). Common adverse events, including injection site pain, erythema, and oedema, were tolerable and comparable between groups.Conclusion:The combination of oral doxycycline and intradermal BTX is more effective than doxycycline monotherapy in reducing erythema, flushing, and inflammatory lesions in moderate-to-severe rosacea, with a comparable safety profile. This combination therapy offers a promising approach for comprehensive management of rosacea symptoms.

Rosacea is a common, chronic, inflammatory disease of the skin, which predominantly (but not exclusively) affects the centrofacial region. Clinical features may include transient or persistent facial erythema, recurrent flushing, telangiectasia, papules, pustules, phymatous changes, and ocular disturbances. These can lead to significant physical and psychological burden and discomfort, which adversely affects a patient's quality of life (QoL). While current guidelines provide recommendations on treatment initiation and modification, there is a lack of information for long-term management and maintenance. The Rosacea-Expert Advice on Combined and Holistic approaches (REACH) group is an international group of experienced dermatologists, brought together to address these shortcomings. This paper summarizes discussions from three REACH Global Scientific Committee (GSC) meetings, with the objective to simplify the rosacea management pathway and ensure that healthcare professionals are aware of rosacea triggers, pathogenesis, risk factors, comorbidities, chronicity, patient satisfaction, monitoring, and treatment options. The REACH GSC developed a rosacea management pathway as a backbone for this publication-to advise on each step, including pitfalls to avoid, patient discussions to conduct, tools and guidelines to employ, and clinical factors to consider. Being able to discern all the clinical features of rosacea specific to each patient is imperative, from recognizing overriding signs and symptoms to understanding potential comorbidities and assessing impact on QoL. Clear and sensitive communication regarding these elements, and what outcomes are achievable, will help to optimize therapeutic management and foster a sense of patient empowerment and disease control. For patients, being able to engage in their own long-term care of symptoms, signs, and flares is critical. Deepening the understanding of the condition as a chronic, yet eminently manageable one, will help empower patients with rosacea and their dermatologists alike. The REACH GSC project was initiated and funded by Galderma.

Lupus miliaris disseminatus faciei (LMDF) is a chronic, self-limiting inflammatory skin disease of unknown etiology that can lead to disfiguring scars. A 51-year-old male presented with a 1-month history of facial papules and eyebrow exfoliation. Skin biopsy confirmed that this case was LMDF. After the diagnosis was confirmed, the patient was treated with oral doxycycline (100 mg) and prednisone (12 mg) once daily. Follow-up at 1 month showed significant improvement in facial rash and regrowth of both eyebrows. This report describes an atypical case of LMDF complicated by eyebrow loss, providing insights into the rarity and pathogenesis of this condition.

Abstract Introduction/Objective Extramedullary involvement by myeloid precursor cells - known as myeloid sarcoma -is a well-recognized manifestation of myeloid neoplasms, typically resulting from leukemic cells migrating through circulation and infiltrating peripheral tissues. In contrast, histiocytic lesions associated with myeloid neoplasms are rare and have been less extensively explored. The WHO reports a 3-15% prevalence of mature myeloid neoplasms in patients with Erdheim-Chester Disease (ECD), a rare non-Langerhans cell histiocytosis. Histiocytic neoplasms—including Langerhans cell histiocytosis and ECD—are frequently driven by activating mutations in the mitogen-activated protein kinase (MAPK) signaling pathway, most commonly involving BRAF, NRAS, KRAS, or MAP2K1. These mutations are thought to promote clonal proliferation and survival of histiocytic-lineage cells. Emerging evidence suggests at least a subset of histiocytic proliferations may arise from a shared hematopoietic progenitor clone, supporting a clonal relationship with underlying myeloid malignancies. A recent study further strengthened this link by identifying shared mutations—most commonly ASXL1, TET2, and SRSF2—between cutaneous histiocytic-dendritic lesions and underlying myeloid neoplasms. Here, we present a novel case of non-Langerhans cell histiocytic lesions arising after allogeneic hematopoietic stem cell transplantation (HSCT) in a patient with acute myeloid leukemia (AML), demonstrating overlapping cytogenetic and molecular features that support a clonal relationship. Methods/Case Report A 64-year-old male with no significant medical history presented with febrile neutropenia. Bone marrow biopsy revealed 35% blasts with an immunophenotype consistent with AML. Cytogenetic studies showed trisomy 8, and next-generation sequencing (NGS) detected ASXL1, DNMT3A (x2), and IDH2 mutations -meeting criteria for AML with myelodysplasia-related changes. The patient was treated with decitabine and venetoclax. Follow-up bone marrow biopsies demonstrated morphologic remission of AML; however, persistent dyserythropoiesis, ring sideroblasts, atypical megakaryocytic hyperplasia, and continued evidence of trisomy 8 were noted. He subsequently underwent allogeneic HSCT. Post-transplant marrow evaluation revealed complete remission with normal cytogenetics, resolution of dysplasia, and no detectable mutations on myeloid NGS panel. Six months post-transplant, the patient developed facial papules and mucosal lesions involving the oral cavity and trachea. Biopsy revealed xanthogranulomatous inflammation characterized by foamy macrophages and multinucleated giant cells. Immunohistochemistry was positive for CD68, CD163, and cyclin D1, and negative for Langerin, CD1a, S100, ALK, and BRAF V600E. Recurrence of these lesions, including new lung nodules, prompted repeat biopsies which confirmed similar non-Langerhans cell histiocytic lesions. Ancillary testing demonstrated the same cytogenetic and mutational profile as the original AML with one additional finding -a CDKN1B mutation. Results NA Conclusion Following allogeneic hematopoietic stem cell transplantation (HSCT), the patient developed cutaneous, mucosal, and pulmonary non-Langerhans cell histiocytic lesions that shared cytogenetic and molecular features with the original AML. A CDKN1B mutation was also identified, along with aberrant cyclin D1 expression within the histiocytic proliferation. CDKN1B is not typically associated with histiocytic neoplasms -which more commonly harbor MAPK pathway mutations (e.g., BRAF, NRAS, KRAS, MAP2K1) -all of which were absent in this case. These findings further support the possibility of clonal evolution or transdifferentiation from a common progenitor shared with the antecedent myeloid malignancy. While this case exhibits clinical and histologic features reminiscent of Erdheim-Chester disease, the absence of MAPK pathway mutations is unusual. The molecular profile is more consistent with a clonal histiocytic proliferation arising from a myeloid progenitor. Furthermore, although non-Langerhans cell histiocytic lesions have been described in the setting of MDS, MPNs, and overlap syndromes, to our knowledge, this is the first reported case arising post-transplant in AML. The presence of an ASXL1 mutation in both the AML and the histiocytic lesion is notable, as this gene is recurrently mutated in previously reported cases of clonal histiocytic-dendritic proliferations arising from myeloid neoplasms.

Systemic administration of Neochamaejasmin B inhibits mast cell activation to reduce inflammation in a rosacea mouse model by targeting MRGPRX2.

Hamartomas are benign, tumor-like malformations composed of an abnormal mixture of tissue elements normally found at the site of origin but arranged in a disorganized fashion. Rhabdomyomatous Mesenchymal Hamartoma (RMH) is a rare subtype, first described in 1986, characterized by a haphazard proliferation of mature skeletal muscle fibers admixed with other mesenchymal and adnexal elements within the dermis and subcutis. RMH most commonly presents as a congenital, solitary, dome-shaped papule or nodule in the midline head and neck region of infants and young children, though cases in older children and adults, as well as in atypical locations, have been reported. We present the case of a 2-month-old female with a congenital midline nasal lesion that enlarged proportionally with growth. Physical examination revealed a firm, dome-shaped papule on the inferior columella. MRI and MRA excluded intracranial extension. Surgical excision at 14 months demonstrated haphazardly arranged skeletal muscle bundles within the dermis, interspersed with hair follicles and adipocytes with desmin positivity and SMA negativity on immunohistochemistry, confirming the diagnosis of RMH. Surgical excision remains curative with no reported recurrences or malignant transformation. This case highlights the importance of considering RMH in the differential diagnosis of midline facial papules in infants and demonstrates the value of clinicopathologic correlation and imaging to guide management.

Rosacea is a chronic inflammatory skin disorder characterized by facial erythema, papules, pustules, and telangiectasia, affecting approximately 5.5% of the global population. Current treatments, primarily topical and oral antibiotics and anti-inflammatories, often show limited efficacy and may cause undesirable side effects, prompting the need for alternative therapies. Cannabidiol (CBD), a non-psychoactive component of Cannabis sativa, has shown promise as a therapeutic agent for rosacea due to its anti-inflammatory, antioxidant, and anti-apoptotic properties. CBD interacts with the endocannabinoid system, which plays a crucial role in cutaneous homeostasis. This study evaluated the efficacy of CBD, both alone and in combination with metronidazole (MET), in reducing inflammation and modulating immune responses in a rosacea-like mouse model. Our results demonstrated that both CBD and MET significantly inhibited redness, epidermal thickness, and mast cell infiltration, with their combination being more effective. Mechanistic analyses revealed that the therapeutic effect of CBD is associated with the suppression of key inflammatory regulators in the MAPK signaling pathway, particularly the ERK, JNK, and p38 pathways. CBD treatment also led to a significant reduction in pro- inflammatory cytokines and chemokines, indicating immune modulation. These findings suggest that CBD, especially in combination with MET, may represent a novel therapeutic option for rosacea and offer a scientific basis for its clinical application in managing inflammatory skin conditions. [BMB Reports 2025; 58(8): 357-363].

Background. Rosacea is a chronic inflammatory skin disorder that manifests as persistent facial redness, papules, and pustules on the background of telangiectasia. Diagnosing it is often challenging because its symptoms overlap with skin conditions like seborrheic dermatitis and acne. Accurate diagnosis is important for effective management. Aims. This review aims to assess the role of dermoscopy as a non-invasive diagnostic tool in improving the accuracy of rosacea diagnosis and its subtypes. Materials and Methods. The review focuses on the characteristic follicular and vascular features detectable through dermoscopy and identifies key dermoscopic features of rosacea, such as polygonal vessels, follicular plugging, and Demodex mites. These findings were assessed in the context of differentiating between the various subtypes of rosacea, including papulopustular, erythematotelangiectatic, phymatous, and granulomatous. Results. The review revealed that dermoscopy significantly enhances the diagnostic precision of rosacea by revealing specific vascular and follicular patterns that are otherwise difficult to detect through clinical observation alone—furthermore, dermoscopy aids in classifying rosacea into its specific subtypes. This improved diagnostic accuracy can lead to better clinical outcomes and more effective treatment monitoring for patients with rosacea.

Abstract Frontal fibrosing alopecia (FFA) is a scarring alopecia, predominantly affecting postmenopausal White women, with male cases being rare and under-reported. It is considered a variant of lichen planopilaris, likely driven by a type IV hypersensitivity reaction. While its pathogenesis remains unclear, genetic, hormonal and environmental factors have been implicated. Here, we present two unusual cases of FFA in male patients. The first patient was a 51-year-old White man who developed scarring alopecia of the frontal hair margin 6 weeks after receiving his first COVID-19 vaccination, with further progression following the second dose. Examination revealed perifollicular erythema, scaling, frontal hairline recession and facial papules. Histopathology confirmed scarring alopecia with perifollicular fibroblasts and fibrotic replacement of follicles. Treatment with topical corticosteroids, lymecycline, doxycycline and hydroxychloroquine led to partial stabilization, although significant psychological distress persisted. His son concurrently developed oral lichen planus after COVID-19 vaccination, suggesting a possible immune-mediated response. Our second patient is a 44-year-old South Asian man who presented with a progressive facial rash with burning sensation, which was previously misdiagnosed as sun sensitivity. Examination revealed prominent monomorphic facial papules with hyperpigmentation. Further examination revealed perifollicular inflammation and frontal hair margin retraction. Scalp biopsy showed perifollicular fibrosis and a marked reduction in follicular density, confirming FFA. Histology from facial papules showed epidermal pigmentation without melanocytic proliferation. His presentation of extensive facial papules was notably severe, raising questions about their pathogenesis and optimal management strategies. FFA remains an under-recognized cause of scarring alopecia in men, with an estimated prevalence of only 1–2% in reported cases. We are beginning to see FFA cross clinical boundaries, including possible vaccine-related immune triggers and a pronounced facial papular phenotype, especially in men. In 2023 a genome-wide association study also identified two genes associated with male FFA, which were different from genes implicated in women. These cases highlight the potential for further research into possible environmental and genetic triggers and novel treatment approaches.

Rosacea is a chronic inflammatory disease characterized by facial skin lesions, including flushing, persistent erythema, papules, telangiectasia, and phymatous changes, affecting 5.5% of the world's population. Rosacea causes disfigurement and emotional ramifications and affects quality of life. The pathophysiology of this disease has yet to be understood, and new therapies are necessary. Photobiomodulation has been used to treat dermatological diseases and various conditions, such as inflammatory processes and pain relief. Thus, this study aimed to review studies on PBM for rosacea treatment, summarizing the radiation sources and subject features and reporting the main results. Scientific articles were accessed by PubMed, using keywords related to rosacea and photobiomodulation. Data on irradiation conditions, patient features, experimental models, and results obtained were assessed. The data analysis allowed to list the conditions for applying photobiomodulation that could lead to therapeutic effects, safety, and efficacy in treating the rosacea. Based on clinical and experimental studies accessed, photobiomodulation could decrease rosacea hallmarks and symptoms by decreasing of pro-inflammatory factor expression, inflammatory infiltration and immune cells, and promoting extracellular matrix remodeling. However, due to few studies available on the application of photobiomodulation in the treatment of rosacea, studies based on experimental and clinical models are necessary to better understand the mechanisms of action of this therapy, efficacy, and validation in the treatment of rosacea.

Background: Frontal fibrosing alopecia (FFA) is a primary cicatricial alopecia, initially described in postmenopausal women but increasingly reported in men. The male form remains under-recognized, often misdiagnosed as androgenetic alopecia (AGA) or alopecia areata (AA), particularly in the beard. Objective: This review aims to summarize the current literature on the epidemiology, clinical presentation, etiopathogenesis, diagnosis, and treatment of FFA in men. Epidemiology and Clinical Features: FFA in men typically presents at a younger age compared to women. Key features include frontal and temporal hairline recession, early involvement of the beard and sideburns, and a high prevalence of eyebrow alopecia (43-94.9%). Facial papules and body hair loss are more common in men than women. Occipital involvement varies widely across studies (8-45%). Clinical features like beard alopecia, often presenting as plaque or diffuse patterns, are highly suggestive of FFA in men but are not part of current diagnostic criteria. Etiopathogenesis: FFA is postulated to have an autoimmune basis influenced by genetic, hormonal, and environmental factors. Genetic studies have identified associations with HLA-B*07:02 and CYP1B1 loci. Environmental triggers include prolonged use of facial sunscreens and moisturizers, as demonstrated in case-control studies and meta-analyses. Diagnosis: Diagnosis is predominantly clinical, supported by trichoscopy and biopsy when needed, particularly in cases overlapping with AGA or AA. Unique presentations, such as beard alopecia and the "watch sign", highlight the importance of considering FFA in atypical male cases. Treatment: Current treatment protocols in men mirror those for women and focus on disease stabilization. Oral 5-ARi (dutasteride) combined with topical corticosteroids and calcineurin inhibitors form the first line. Additional treatments include intralesional corticosteroids, oral isotretinoin for facial papules, and minoxidil for associated AGA. Surgical hair transplantation remains controversial, requiring disease control and careful patient counselling. Conclusions: FFA in men presents with distinct clinical features and challenges in diagnosis, often overlapping with other alopecia. Further studies are needed to validate diagnostic criteria and evaluate treatment efficacy in this underrepresented population.

ABSTRACTBackgroundRosacea is a chronic inflammatory skin condition characterized by facial erythema, telangiectasia, and papules. Although clinical assessment is essential for diagnosis, objective criteria for evaluating severity are lacking. This study aimed to investigate the relationship between rosacea severity, disease duration, and associated microvascular changes through oral mucosal capillaroscopy.MethodsThis cross‐sectional case–control study included patients with rosacea and healthy controls. Oral capillaroscopy was performed to evaluate capillary morphology, analyzing parameters such as capillary arrangement (regular or irregular), presence of dot vessels, microhemorrhages, glomerular vessels, megacapillaries, tortuous vessels, areas of discoloration, and hyperkeratosis.ResultsA total of 100 patients diagnosed with rosacea and 100 healthy controls were included in the study. Oral capillaroscopic findings revealed significantly higher rates of family history of rosacea and tortuous capillaries in the patient group. Patients with microhemorrhages exhibited a longer disease duration. No significant differences in tortuous capillary positivity were found between the papulopustular and erythematotelangiectatic subtypes; however, phymatous rosacea demonstrated no positive findings. Additionally, moderate‐severity patients had lower rates of microhemorrhage positivity, whereas the presence of tortuous capillaries increased with severity.ConclusionOral mucosal capillaroscopy is a valuable tool for assessing microvascular damage in rosacea and may serve as a diagnostic and prognostic marker for effective management.

Background Rosacea is a skin condition characterised by persistent facial erythema, flushing, papules, pustules, and telangiectasia. Botulinum toxin A (BoNT-A) has been used to treat a variety of conditions, but its effectiveness in improving facial erythema in rosacea patients is uncertain. Objectives The aim of the study is to evaluate the effectiveness and determine the optimal dose of BoNT-A treatment for rosacea. Methods An online database search (Pubmed, Cochrane Library and Embase) was conducted on 30th June 2023 to identify studies that used intradermal injection of BoNT-A to treat facial erythema in rosacea patients and excluded studies in which BoNT-A was used for facial erythema due to other known medical condition such as menopause, drug or pregnancy. The primary outcome measure for this study was the improvement in erythema score as objectively assessed. A random effect model was used in the meta-analysis. Results Seven studies involving a total of 167 rosacea patients were included in the meta-analysis. Meta-analysis of two randomised controlled trials showed improvement of erythema on the third month after treatment standardized mean difference (SMD): 1.676, 95% confidence interval (CI): 2.278-1.074, I2: 35.76%). A separate analysis of seven single-armed treatment studies found significant improvement in erythema with intradermal injection of BoNT-A at one, two and three months after treatment (first month: SMD: 2.712, 95% CI: 4.1182-1.243; second month: SMD:2.213, 95% CI: 3.702-0.725; third month: SMD: 1.912, 95% CI: 2.882-0.941). Adverse events, including mild facial paralysis and injectional purpura, were reported in some studies. Limitation The limitations of this study include heterogeneity in study design and a small sample size. Conclusion Intradermal injection of BoNT-A may be an effective treatment for facial erythema in rosacea. Unwanted facial muscle paralysis was seen in different BoNT-A concentration but not noted when the dose was less than 0.02ml per site. Future studies particularly randomised trials are required to identify the volume of injection required to reduce the erythema.