Question of the Week # 38

A 45-year-old woman is very concerned about an eruption on her face. She has developed lesions on the cheeks and forehead over the last few months. They are not associated with itching.  The eruptions are worsened with by prologed exposure to sun, excessive stress and hot drinks. She denies any history of alcoholism. Physical examination reveals a papular eruptions with assocaited erythema, telangiectasia and  pustules. There are no lesions in any other areas except on her face.

What are my options?

The Most Likely Diagnosis :

A.Nodulo cystic acne

B. Rosacea

C.Porphyria Cutanea Tarda

D. Seborrheic Dermatitis

E. Cutaneous Lupus

The most apprpriate next step in management :

A) Topical Corticosteroid

B) Topical Benzoyl Peroxide

C) Oral Isotretinoin

D) Topical Metronidazole

E) Oral Doxycycline

23 Responses

  1. b,a

  2. B, A

  3. B, D

  4. Oral antibiotics, such as tetracycline, doxycycline (Vibramycin), and metronidazole (Flagyl) effectively treat papulopustular rosacea. Topical metronidazole (cream [MetroCream] or gel [MetroGel]) administered twice daily is as effective as oral tetracycline22 and is considered the agent of choice for pustular and papular rosacea [Evidence level A, randomized controlled trials]; however, some patients experience burning and stinging with the use of topical metronidazole. Some studies23 suggest that topical metronidazole also reduces erythema and telangiectasis in some patients. Topical clindamycin (Cleocin) is an effective alternative in patients who are pregnant; the use of oral tetracycline or metronidazole is undesirable during pregnancy24 [Evidence level A, randomized controlled trial]. The antibiotic gel or cream should be applied across the entire face, rather than “spot treating” the lesions.25

    Rosacea is a chronic, relapsing disorder, and long-term treatment is generally required. Control of symptoms can be successfully maintained by long-term use of metronidazole gel.25


    In recalcitrant cases where antibiotics have failed or were partially successful, oral isotretinoin (Accutane) or topical tretinoin (RetinA) therapy may be effective26,27 [Evidence level B, nonrandomized studies]. Retinoid treatment (especially in the topical form) may help recalcitrant papular and pustular forms of rosacea but may worsen erythema and telangiectasis.3 Some authorities question the role of retinoids in rosacea treatment.

    Other second-line therapies include: trimethoprim-sulfamethoxazole (Bactrim, Septra), methotrexate, dapsone, primaquine, chloroquine (Aralen), and oral prednisone; however, no studies have evaluated the comparative efficacy or optimal dosing regimens of these agents.3,7

    Topical corticosteroids must be avoided on the face.16 The use of fluorinated topical steroids on the face frequently produces a rosacea-like syndrome, and even low-potency, nonfluorinated steroids may worsen pre-existing rosacea and delay the resolution of steroid-induced flare-ups by months.

  5. treat with oral doxicycline

  6. bd

  7. b d

  8. B

  9. E,A

  10. Bd

  11. E, D

  12. sorry BD rosasea

  13. C

  14. B d

  15. B D

  16. b, d

  17. the answer is B,E
    there are 4 stages of rosacea, 1-prerosacea(blushing)
    2-vascular stage ,transitory edema
    3-deeper facial edema , papules and pustules formation
    4-tissue hyperplasia -rhinophyma
    in all type first tell the pa . to avoid the sun(using sunblock..etc.) and stressors
    second for stage 1,2 (mild to mod) start with topical AB( metro gel) or sulfacetamide lotion (less irritant than metro gel)
    for stage 3 start oral AB ( doxycyclin the best)
    for stage 4 or advanced dis . which causes irreversible fibrotic changes such as rhinophyma that does not respond to other medical therapy start oral isotretinoin( ofcourse with precautions for woman of childbearing ages )

  18. B,D
    “The goals of pharmacotherapy are to reduce morbidity and prevent complications.
    Topical metronidazole is commonly used as a first-line agent. Topical azelaic acid, sulfacetamide products, and topical acne medications are also commonly used. Topical and oral antibiotics are also very effective, and for oral rosacea, they are usually considered as a first-line therapy. Retinoids are advocated by some authorities.[17, 18, 19]
    A topical form of the alpha-2 agonist brimonidine was approved by the FDA in August 2013 for treatment of erythema associated with rosacea. Approval was based on data collected from more than 550 patients enrolled in two phase 3 clinical studies of one-month duration. The results from both studies showed that adults who used brimonidine topical gel demonstrated significantly greater improvement in the facial redness of rosacea than those who used vehicle gel alone.[2] In addition, a long-term study in 276 subjects who used brimonidine topical gel for up to 12-months was also conducted.
    In addition to the agents listed below, anecdotal evidence indicates effective treatment of rosacea with medications that reduce flushing, including beta-blockers, clonidine, naloxone, ondansetron, and selective serotonin reuptake inhibitors.
    Oral contraceptive therapy has been helpful in patients who provide historical information of worsening rosacea with their hormonal cycle.
    Dapsone has been used in severe, refractory rosacea, and dapsone has been particularly beneficial for patients who cannot take isotretinoin.[20]” – Medscape

  19. official answer?

  20. BC

  21. B,D

    papular and pustular rosacea : topical metronidazole
    severe / occular rosacea : P.O Doxy or erythromycin
    refractory : topical retinoic acid

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