*3.1.2 Granulomatous rosacea*

Granulomatous rosacea is a distinct variant of rosacea. Lewandowsky described the "rosacea-like tuberculid" as having a clinical appearance similar to that of a papular form of rosacea; however, it appeared as yellow-brown "apple-jelly" nodules on diascopy and as tuberculoid granulomas on histologic examination [63]. Later it was noted that granulomas can be seen in typical rosacea [64]. Thus rosacea may be manifested by a clinical and a histologic spectrum that includes granuloma formation in some patients [65]. Lesions are persistent, firm, and non-tender; red to brown papule or nodule arises primarily on otherwise normal appearing skin around the mouth and eyes and on the cheeks [66] (**Figure 13**). Granulomatous rosacea often does not present facial erythema, is not limited to facial convexities, often has periocular lesions, and shows an asymmetrical distribution [67]. Some studies have demonstrated that patients with this variant present clinically with monomorphic yellow-brown and red papules or nodules situated predominantly over the cheeks and periorificial areas [68, 69]. Although clinical correlation is important, the diagnosis of GR is dependent upon the histopathologic finding of a granulomatous infiltrate [70, 71].
