Granulomatous Rosacea:
A Rosacea Variant

This variant of rosacea is characterized by firm, yellow, brownish or redish, cutaneous papules or nodules. These lesions are less inflammatory and frequently sit upon relatively normal-appearing skin but sometimes it is diffusely red and thickened. Typically, they are monomorphic in each individual patient affecting the cheeks and the periorifical areas. For diagnosing this form of rosacea, other signs and symptoms of rosacea are not necessary. Diascopy with a glass spatula reveals the lupoid character of the infiltrations. Lupoid or granulomatous rosacea may lead to scarring of the skin. This rosacea variant is the only one recognized by the expert committee commissioned by the NRS.

Granulomatous rosacea
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Online Journal

One source describes granulomatous rosacea:

"A rare caseating granulomatous variant of rosacea (acne agminata/lupus miliaris disseminatus faciei) can manifest with inflammatory erythematous or flesh-colored papules distributed symmetrically across the upper part of the face, particularly around the eyes and the nose. The lesions tend to be discrete, and surrounding erythema is not a marked feature but may be present. This pattern of rosacea is sometimes associated with scarring and may be resistant to conventional treatment."

Lupus Miliaris
Image - emedicine.medscape.com

Differential diagnoses are lupoid perioral dermatitis, lupoid steroid rosacea, sarcoidosis (small nodular form), lupus miliaris disseminatus faciei, foreign body reactions. source

Granulomatous rosacea associated with Demodex folliculorum

"...Although usually considered a non-pathogenic parasite in parasitological textbooks, Demodex folliculorum has been implicated as a causative agent for some dermatological conditions, such as rosacea-like eruptions and some types of blepharitis. Several anecdotal reports have demonstrated unequivocal tissue damage directly related to the presence of the parasite. However, this seems to be exceedingly rare, in contrast with the marked prevalence of this infestation. We have had the opportunity to observe one of such cases. A 38-year-old woman presented with rosacea-like papular lesions in her right cheek. Histopathological examination revealed granulomatous dermal inflammation with a well-preserved mite phagocytized by a multinucleated giant cell. This finding may be taken as an evidence for the pathogenicity of the parasite, inasmuch as it does not explain how such a common parasite is able to produce such a rare disease." source

"Histological investigation revealed follicular cysts and a chronic granulomatous perifolliculitis with many of Demodex folliculorum. " source

A research report in Germany in 1974 was entitled: "Demodex folliculorum and the histogenesis of granulomatous rosacea." source

Granulomatous rosacea
Sánchez JL, Berlingeri-Ramos AC, Dueño DV.
Department of Dermatology, University of Puerto Rico, School of Medicine, San Juan, Puerto Rico.
Am J Dermatopathol. 2008 Feb;30(1):6-9.

A case of granulomatous rosacea: Sorting granulomatous rosacea from other granulomatous diseases that affect the face.
Omar Khokhar MD, and Amor Khachemoune MD CWS
Dermatology Online Journal 10 (1): 6
Division of Dermatology, Georgetown University Medical Center, Washington, DC.