Lupus miliaris disseminatus faciei: A Simon and Garfunkel playlist

By Warren R. Heymann, MD, FAAD
Oct. 1, 2025
Vol. 7, No. 39

William Tilbury Fox (1836-1879) was a brilliant dermatologist, the first in the United Kingdom to have a post in a teaching hospital. With Erasmus Wilson, he resurrected the prominence of British dermatology nearly half a century after the passing of Robert Willan and Thomas Bateman. He only used his middle name; he is most famous for describing impetigo contagiosa and dyshidrosis. (1)

The year before his death, Fox described what is now known as lupus miliaris disseminatus faciei (LMDF) in a Lancet publication titled “Disseminated follicular lupus (simulating acne).” (2) LMDF is an idiopathic granulomatous disease predominantly affecting facial skin, particularly the eyelids. Although the disorder shares overlapping features with rosacea and sarcoidosis, it is considered a disease sui generis. Most cases resolve spontaneously within several years but can leave potentially disfiguring scarring. There are approximately 200 cases of LMDF in the literature. Although initially considered a tuberculid, the etiology is obscure (3) — still crazy after all these years.

This commentary reviews the latest literature on LMDF. The body of the commentary uses the abstract from Nasimi et al., which is in italics. (4) Elaborations on the topic are interspersed throughout, written in standard font, and individually referenced. After reading this, residents should get this diagnosis right during their Kodachrome sessions — yes, they are still called that!

Background: Lupus miliaris disseminatus faciei (LMDF) is a granulomatous inflammatory disease often manifesting on the face as red, brown, or yellow papules. Lesions can cause scarring and disfigurement. There is no standard treatment due to a limited understanding of the etiology. All efforts to identify a pathogenic microbe (mycobacteria, Cutibacteria, Demodex) have been unsuccessful. Current thinking focuses on immunologically mediated damage to the hair follicle leading to subsequent rupture and provoking an allergic or foreign body granulomatous response to keratin, sebum, or microbial components in the dermis. (3) The immunopathogenesis of granuloma formation relies on Th1 cells producing interleukin (IL)-2 and interferon-gamma, with subsequent T-cell proliferation and macrophage activation. (5)

Method: This review examines the clinical and histopathological characteristics of 70 LMDF patients who were diagnosed from 2016 to 2022.

Results: The patients’ mean age was 32.43, with a majority being in their 20s and 30s. Females were more affected during the fourth decade and beyond. Pediatric LMDF has been reported in children, the youngest being a 10-year-old Chinese boy. (6) The average disease duration among patients was 7.2 months. All of them had facial involvement, mostly around the eyes and on the eyelids. LMDF infrequently causes extrafacial lesions of the neck, torso, and/or axillae. Isolated axillary involvement without facial lesions has been reported, highlighting the importance of histopathologic evaluation in establishing the diagnosis and emphasizing the misleading nature of the current nomenclature. The name lupus miliaris disseminatus has been proposed. (7) (Editorial comment. While I understand the sentiment to change the name — and agree with it — it will likely remain LMDF, just as extrafacial granuloma faciale is still granuloma faciale.)

Histopathological analysis revealed epithelioid granulomas with inflammatory cell infiltration and, in some cases, central caseous necrosis. A relationship between the granuloma and the pilosebaceous unit was seen in 75.7% of cases. Epidermal changes, like acanthosis, were found in 47.1% of cases. We also report the existence of linear vessels in 25 (35.7%) cases. Fibrosis can present in late-stage lesions, correlating with clinical scar formation. (8) According to Dudani and Mehta,“Dermoscopic features include follicular plugs, some resembling a target surrounding the center, with short linear and linear-branching vessels on an orange-yellow/ erythematous background. Different stages of lesions have different dermoscopic features. With chronicity, there is an increase in follicular plugs and perifollicular scaling. The yellow perifollicular background is replaced by white structures in late lesions, corresponding to fibrosis replacing the granulomas.” (9) The main differential diagnoses for LMDF are granulomatous rosacea and sarcoidosis. Clinically, characteristic features of rosacea (flushing, pustules) are not observed in LMDF. There are no systemic complications in LMDF, so a standard workup for sarcoidosis (eye examination, chest X-ray, EKG, angiotensin-converting enzyme) is all normal. (3)

Conclusion: Most authors now consider LMDF a distinct entity, but because of its resemblance to other diseases like granulomatous rosacea, the diagnosis is challenging. Unlike many studies in this field, we provide a quite large sample and report telangiectasia in LMDF patients, which highlights the importance of precisely differentiating LMDF from rosacea. The main differential diagnoses for LMDF are granulomatous rosacea and sarcoidosis. Clinically, characteristic features of rosacea (flushing, pustules) are not observed in LMDF. There are no systemic complications in LMDF, so that a standard work up for sarcoidosis (eye examination, chest X-ray, EKG, angiotensin converting enzyme) are all normal. (3) Delay in diagnosis and treatment increases the risk of scarring. If I asked any dermatologist what the most effective treatment is for LMDF, the response would be the sound of silence. There are no consistently effective treatments for LMDF, but there must be at least 50 ways to leave LMDF behind. Treating the condition as rosacea with doxycycline is not very useful. Reducing inflammation with calcineurin inhibitors, steroids, topical ruxolitinib, dapsone, hydroxychloroquine, and cyclosporine may be helpful. (10,11) Isotretinoin has been reported useful, as have diode and non-ablative lasers. (2)

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Overall, we believe this study provides valuable insights into the demographics and histopathology of LMDF, contributing to the understanding of this challenging skin disorder. Dermatologists need to fight this battle as a wily boxer. Any treatment preventing scarring will serve as a bridge over troubled water, leaving your patient (and you) feeling groovy.

(PS – Kudos to Ken Grossman, MD, my co-chief resident, great friend, and drummer for the charity “Docs of Rock” who reminded me that late millennial/early Generation Z residents’ familiarity with Simon and Garfunkle is likely slip, slidin’ away.)

Point to Remember: Lupus miliaris disseminatus faciei is an idiopathic granulomatous disorder that needs to be treated early to prevent scarring.

Our expert’s viewpoint

Hanie Babaie, MD
School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

As someone who has done research on different dermatology disorders, lupus miliaris disseminatus faciei (LMDF) has always caught my interest because of how little we still know about it. Due to its clinical resemblance to more well-known conditions like rosacea or sarcoidosis, it is one of those conditions that often lies in diagnostic limbo and is easily overlooked or mistreated.

In many cases the absence of telangiectasia has been used to distinguish LMDF from granulomatous rosacea. However, in our study about LMDF, we noticed linear or fractured vessels, suggesting telangiectasia in histopathological examinations. (4) This highlights the need for a more thorough diagnostic approach.

Unfortunately, LMDF is rarely diagnosed at the initial clinical visit, and in many cases the scarring already exists by the time it is properly diagnosed. Furthermore, even after the diagnosis, managing it can be challenging because there is no recognized standard treatment option. This may add to patients’ frustration, since getting a diagnosis doesn’t always mean they’ll receive an effective treatment.

Over just the last 2 years, successful treatments have spanned from topical ivermectin in a 44-year-old woman (12) and adapalene plus benzoyl peroxide in a man in his 50s (13) to pulsed dye laser therapy in a 28-year-old male. (14) That degree of variation is a reminder of how unpredictable the responses to treatment can be.

Since LMDF mostly affects the face and frequently results in permanent scarring, early diagnosis and treatment are essential. Beyond scattered case reports, more comprehensive research is required to understand its causes and treatments. Until then, it’s important to keep sharing observations like these to build awareness and help to guide clinicians.

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References

1. Levell NJ. William Tibury Fox. In Löser C, Plewig G, and Burgdorf WHC (eds). Pantheon of Dermatology, 2013, Berlin, Springer, pp 337-340.

2. Rogel-Vence M, Carmona-Rodríguez M, Herrera-Montoro V, González-Ruiz L, Cortina-de la Calle MP, Sánchez-Caminero MP. Lupus miliaris disseminatus faciei with complete response to isotretinoin. Dermatol Online J. 2021 Jan 15;27(1):13030/qt2c42p7q0. PMID: 33560791.

3. Slater N, Sathe NC, Rapini RP. Lupus Miliaris Disseminatus Faciei. 2024 Jan 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 32644491.

4. Nasimi M, Bandani S, Kamyab K, Etesami I, Montazeri S, Saberi F, Babaie H. Clinical and Histopathological Insights Into Lupus Miliaris Disseminatus Faciei: A Review of 70 Cases. J Cutan Pathol. 2025 May;52(5):386-391. doi: 10.1111/cup.14796. Epub 2025 Feb 13. PMID: 39945109.]

5. Kwon HJ, Park KD, Yoo DW, Seo JW, Kim KH, Yoon JH. Recalcitrant lupus miliaris disseminatus faciei improved by cyclosporine monotherapy. JAAD Case Rep. 2022 Jul 6;27:16-19. doi: 10.1016/j.jdcr.2022.06.038. PMID: 35990227; PMCID: PMC9389132.

6. Tang K, Jin H. Lupus miliaris disseminatus faciei in a 10-year-old child: A case report and literature review. J Cosmet Dermatol. 2022 Nov;21(11):6484-6486. doi: 10.1111/jocd.15176. Epub 2022 Jul 19. PMID: 35748528.

7. Fields AB, Margheim AM, Callen JP, Strickley JD, JC Malone. Lupus miliaris disseminatus faciei: A unique presentation with extrafacial involvement. Dermatology Online Journal 2025; 31(1): 8.

8. Gosch M, Larrondo J. Lupus Miliaris Disseminatus Faciei. JAMA Dermatol. 2022 Mar 1;158(3):314. doi: 10.1001/jamadermatol.2021.5010. PMID: 35044421.

9. Dudani P, Mehta N. Dermoscopy of Lupus Miliaris Disseminatus Faciei Lesions in Different Stages of Evolution. Dermatol Pract Concept. 2022 Jan 1;12(1):e2022017. doi: 10.5826/dpc.1201a17. PMID: 35223162; PMCID: PMC8824751.

10. Gorham NC, Jacobs J, Wu SZ. Response of Severe Lupus Miliaris Disseminatus Faciei to Treatment With Ruxolitinib Cream. JAMA Dermatol. 2023 Jul 1;159(7):790-791. doi: 10.1001/jamadermatol.2023.0528. PMID: 37099285.

11. Kwon HJ, Park KD, Yoo DW, Seo JW, Kim KH, Yoon JH. Recalcitrant lupus miliaris disseminatus faciei improved by cyclosporine monotherapy. JAAD Case Rep. 2022 Jul 6;27:16-19. doi: 10.1016/j.jdcr.2022.06.038. PMID: 35990227; PMCID: PMC9389132.

12. Dash A, Verma P, Srivastava P, Choudhary A, Goyal A, Khunger N, Sharma S. Successful use of topical ivermectin in the treatment and maintenance of lupus miliaris disseminatus faciei. Indian J Dermatol Venereol Leprol. 2024:1-3.

13. Asai J, Maruyama A, Katoh N. Lupus miliaris disseminatus faciei successfully treated with topical adapalene and benzoyl peroxide. J Dermatol. 2024;51(6):e214-e5.

14. Bazargan AS, Roohaninasab M, Kahjoogh HA, Aghdam SB, Taheri A, Jafarzadeh A. From drug therapy failures to laser therapy victory: A case report and literature review of lupus miliaris disseminatus faciei resolution. Clinical Case Reports. 2024;12(9):e9370.

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