A 65-year-old man comes to the clinic with 1 week of pruritic facial rash. He was recently diagnosed with community-acquired pneumonia and is on day 8 of his 10-day antibiotic course. He otherwise feels healthy and has no other complaints.
His past medical history includes Parkinson disease, mild dementia, and hypertension. His medications include carbidopa-levodopa, donepezil, amlodipine, and levofloxacin.
The rash is shown in the image below.

Which of the following is the best next step in management of this patient's facial rash?

Question

A 65-year-old man comes to the clinic with 1 week of pruritic facial rash.  He was recently diagnosed with community-acquired pneumonia and is on day 8 of his 10-day antibiotic course.  He otherwise feels healthy and has no other complaints.
His past medical history includes Parkinson disease, mild dementia, and hypertension.  His medications include carbidopa-levodopa, donepezil, amlodipine, and levofloxacin.
The rash is shown in the image below.

Which of the following is the best next step in management of this patient's facial rash?

Quizplus · Accepted Answer

This patient's presentation is most consistent with seborrheic dermatitis (SD). SD commonly affects areas with a high content of sebaceous glands such as the scalp (dandruff), face (nasolabial folds, eyebrows, and external ear), chest, and intertriginous areas. The etiology is unclear but is thought to be due to the growth of lipid-dependent Malassezia fungus. It occurs in all age groups but is seen with increased frequency in patients with Parkinson disease and HIV. Patients typically present with pruritic, erythematous plaques with fine, loose, yellow, and greasy scales. Symptoms may worsen during stressful periods or winter months. Treatment consists of topical corticosteroids to control inflammation and itching, antifungal creams or shampoos, or a combination of these. High-potency steroid creams are typically not used on the face due to the potential for discoloration, skin atrophy, and telangiectasias. The least potent steroid necessary should thus be used to minimize adverse effects (Choice B). SD is a chronic condition that usually recurs despite adequate treatment and requires repeated or long-term maintenance treatment. (Choice A) Drug rashes are maculopapular and typically occur in dependent areas with subsequent generalization. They are not usually localized to areas of the body rich in sebaceous glands. Drug rashes (Choice D) The diagnosis of seborrheic dermatitis is usually made by physical examination alone and does not require skin biopsy. However, biopsy is performed on rare occasions to exclude other conditions. (Choice E) Triple antibiotic cream is normally used to treat a bacterial infection. This patient's scaly-appearing rash and its distribution are less consistent with bacterial infection. Educational objective: Seborrheic dermatitis typically presents as erythematous plaques with fine, loose, yellow, greasy scales on areas of body rich in sebaceous glands. All age groups are affected, but it is seen with increased frequency in patients with Parkinson disease and HIV. Treatment consists of low-potency corticosteroids, antifungal creams, or a combination of these. __________ References: Optimizing treatment approaches in seborrheic dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/23441240)

A 65-Year-Old Man Comes to the Clinic with 1 Week