A 49-year-old woman comes to the physician requesting treatment for "this unattractive redness of my skin." In the past 3 months, she developed blemishes on her nose, cheeks, and chin. She now flushes intensely in response to hot or cold temperatures, emotion, and the consumption of spicy foods or alcohol. She has no history of dermatological problems. Physical examination shows a reddening of the central face, erythematous papules on the nose, and sporadic telangiectasias on the nose and cheeks as shown below.
Which of the following is the most appropriate treatment for this condition?

Question

A 49-year-old woman comes to the physician requesting treatment for "this unattractive redness of my skin."  In the past 3 months, she developed blemishes on her nose, cheeks, and chin.  She now flushes intensely in response to hot or cold temperatures, emotion, and the consumption of spicy foods or alcohol.  She has no history of dermatological problems.  Physical examination shows a reddening of the central face, erythematous papules on the nose, and sporadic telangiectasias on the nose and cheeks as shown below.  
Which of the following is the most appropriate treatment for this condition?

Quizplus · Accepted Answer

Explanation: This patient has mild-to-moderate papulopustular rosacea, which is characterized by erythema in the central face and is often associated with flushing, telangiectasias, and pustules (occasionally). The inflammatory lesions may appear similar to those found in acne, although comedones are not present. It is most common in adults age 30-60 and occurs most often in individuals with light skin, hair, and eye color. Periods of exacerbation and remission are expected. Patients with only erythema and telangiectasias can often be managed with the use of mild cleansers and sunscreens. However, avoidance of factors that trigger flushing (eg, hot or spicy foods, alcohol, temperature extremes, emotional distress) should also be recommended. Laser or pulsed light therapy and topical brimonidine can also be considered. For patients with papulopustular rosacea, topical metronidazole is the most commonly prescribed treatment, though azelaic acid, topical clindamycin, and benzoyl peroxide are also useful. Topical treatment may be required on a long-term basis to maintain remission. Oral antibiotics (eg, metronidazole, tetracyclines) are sometimes required for more severe cases. Therapy is usually successful in reducing the number and severity of the inflammatory lesions, but facial erythema may persist despite treatment. (Choice A) Oral griseofulvin is indicated for a variety of superficial fungal infections of the skin and scalp. It is not prescribed for the treatment of rosacea. The oral antibiotics commonly used in rosacea include metronidazole, tetracycline, doxycycline, minocycline, and erythromycin. (Choice B) Topical clindamycin is available in the form of a solution, gel, or lotion. It can be used for rosacea but is generally considered less effective than topical metronidazole. (Choice C) Topical clotrimazole is used for superficial fungal infections such as tinea corporis. tinea corporis (Choice E) Topical tretinoin may be considered for those patients with papular or pustular lesions unresponsive to initial therapies, though response appears variable. It may also be used in conjunction with topical antibiotics, especially for those patients with refractory symptoms. Educational objective: Rosacea is characterized by erythema in the central face and is often associated with flushing, telangiectasias, and pustules (occasionally). Patients with only erythema and telangiectasias may be managed with topical brimonidine and avoidance of factors which trigger flushing (eg, hot or spicy foods, alcohol, extreme temperatures, emotional distress). Patients with papular or pustular lesions are treated with topical metronidazole or azelaic acid. Oral antibiotics are considered for more severe or refractory cases. References: Interventions for rosacea. (http://www.ncbi.nlm.nih.gov/pubmed/21412882)

A 49-Year-Old Woman Comes to the Physician Requesting Treatment for "This