Not all facial dermatoses in systemic lupus erythematosus represent cutaneous lupus

Rosacea and cutaneous lupus erythematosus share overlapping clinical features, posing a diagnostic challenge in individuals with systemic lupus erythematosus. Misinterpretation of new facial lesions may lead to inappropriate escalation of immunosuppressive therapy. We report a 47-year-old woman with longstanding systemic lupus erythematosus, under belimumab, hydroxychloroquine, and methotrexate, who developed a progressive facial dermatosis over 5 months. The eruption was initially suspected to represent cutaneous lupus, prompting consideration of intensifying treatment. Dermatological evaluation revealed multiple erythematous papules and plaques with a hyperkeratotic appearance, associated with pustules on the frontal, periorbital, and malar regions, with sparing of the nasolabial fold. Laboratory studies showed no evidence of systemic activity, and histopathology was consistent with papulopustular rosacea. The patient was treated with isotretinoin and a short course of systemic corticosteroids, achieving complete resolution while maintaining her baseline immunomodulatory regimen. This case underscores the need for careful differential diagnosis to avoid unnecessary therapeutic escalation and to ensure appropriate, targeted management.