Introduction: Rosacea is a centrofacial dermatosis with numerous triggers, leading to neurovascular dysregulation. Phymatous rosacea results from sebaceous hyperplasia and fibrosis, clinically presenting as irregular hypertrophy of the affected area. Medical therapies, such as photoprotection, anti-inflammatory antibiotics, and retinoids, provide suboptimal benefits in cases of phymatous rosacea. This limitation necessitates the use of surgical modalities like ablative lasers, electrosurgery, or plastic reconstruction for effective treatment. Here, we report a case of phymatous rosacea with multiple phymas over the nose, eyelids, forehead, chin, ears, and cheeks, creating a lion-like facial appearance (leonine facies) due to diffuse facial nodularity. The condition was clinically confounded with leprosy, leishmaniasis, lymphoma, and scleromyxedema. Additionally, the zygophyma (cheek) presented as a giant pedunculated tumor, which is rarely reported. It was mistaken for a soft tissue tumor, posing a diagnostic challenge. Plastic surgical excision and reconstruction proved therapeutic, and microscopic examination played a pivotal role in solving the diagnostic enigma. Case Presentation: A young male farmer with recurrent photo-exacerbated centrofacial lesions, clinically diagnosed as rosacea, later developed diffuse facial nodularity resembling leonine facies. The appearance of a progressively enlarging, globose, pedunculated tumor on his right cheek further complicated the diagnosis. Although phymatous rosacea was the leading clinical suspicion, histological analysis was deemed necessary to distinguish the combination of leonine facies and the pendulous mass from other serious conditions. Leprosy, leishmaniasis, lymphoma, and scleromyxedema are among the many causes of leonine facies, while soft tissue tumors like lipoma, fibroma, and neurofibroma can present with pedunculated morphology. The pendulous mass was surgically excised and sent for microscopic analysis, which confirmed the diagnosis of granulomatous rosacea. Cold knife excision was preferred over lasers and radiosurgery to preserve tissue architecture for histological analysis. Continued medical therapy and photoprotection contributed to further clinical regression. Conclusions: Pedunculated phymatous rosacea, mimicking a soft tissue tumor, requires histopathological distinction from more serious conditions. Cold knife plastic surgery, which preserves tissue architecture for histopathological studies, should be the recommended surgical treatment in such cases. Additionally, avoiding triggers and adhering to medical therapy are essential for better aesthetic outcomes.
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