A 45-year-old woman comes to the physician with a facial rash she has had for the last several months. She also has occasional facial flushing. The patient has no systemic or musculoskeletal problems, takes no medications, and has regular menstrual periods. She has no significant past medical history. Her mother has disabling rheumatoid arthritis. The general physical examination is unremarkable. The skin findings are shown in the photograph below.

Which of the following is the best next step in the management of this patient?

Question

A 45-year-old woman comes to the physician with a facial rash she has had for the last several months. She also has occasional facial flushing. The patient has no systemic or musculoskeletal problems, takes no medications, and has regular menstrual periods. She has no significant past medical history. Her mother has disabling rheumatoid arthritis. The general physical examination is unremarkable. The skin findings are shown in the photograph below.

Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

Papulopustular rosacea is a form of rosacea characterized by sterile papules and pustules in the central face; this is usually seen in patients with pre-existing erythematotelangiectatic rosacea (flushing, erythema, telangiectasias). Untreated papulopustular rosacea may progress to cause persistent erythema, sebaceous hyperplasia, and fibrosis. Rosacea occurs most commonly in patients age 30-60 with fair skin, light hair, and light eye color. The pathogenesis is unknown but proposed contributing factors include inflammatory reactions to cutaneous microorganisms, ultraviolet light damage, and vasomotor dysfunction. A topical antibiotic such as metronidazole is the most frequently prescribed initial therapy for mild-to-moderate rosacea. Topical azelaic acid is also useful. However, patients with more severe papulopustular rosacea, or those who fail topical therapy, may require oral antibiotics. In particular, oral tetracyclines (tetracycline, doxycycline, minocycline) and erythromycin are effective. Patients should also be educated on gentle skin care, sun protection, and avoidance of flushing triggers (eg, hot drinks, hot/cold weather, alcohol, spicy foods). mild-to-moderate rosacea (Choice A) Patients with carcinoid syndrome may also experience flushing (20-30 seconds is characteristic) and develop telangiectasias. However, the flushing associated with rosacea tends to last much longer. Diarrhea and cyanosis are also seen in patients with carcinoid. Therefore, assessment of 5-hydroxyindoleacetic acid (5-HIAA) levels is not indicated. (Choice B) The classic butterfly rash of systemic lupus erythematosus (SLE) appears as erythema and scaling over the cheeks and bridge of the nose with sparing of the nasolabial folds. There are no papules or pustules. This patient has nasolabial sparing but no systemic symptoms (eg, fever, arthralgias, malaise) to suggest SLE; the pustular lesions are more consistent with rosacea. systemic lupus erythematosus (SLE) (Choice C) Dermatitis herpetiformis is commonly associated with gluten sensitive enteropathy (celiac disease). It classically presents as an intensely pruritic skin eruption with inflammatory papules, vesicles, or bullae on the extensor surfaces, elbows, knees, upper back, and buttocks. Dermatitis herpetiformis (Choice E) The use of topical corticosteroids on the face can result in harmful skin effects such as atrophy, telangiectasia, and periorificial dermatitis. Topical corticosteroids can also cause a condition similar to rosacea known as steroid-induced rosacea. Educational objective: Rosacea should be suspected in patients age 30-60 with erythema and telangiectasias over the cheeks, nose, and chin. Papules and pustules may also be present. A topical antibiotic such as metronidazole is the most frequently prescribed initial therapy for mild-to-moderate rosacea. Oral antibiotics may be needed for more severe disease (especially if it is papulopustular). __________ References: Rosacea (http://www.ncbi.nlm.nih.gov/pubmed/19932325)

A 45-Year-Old Woman Comes to the Physician with a Facial