A 63-year-old woman comes to the office due to a rash on her face. She has had pustules and pink bumps in this area for years; the rash appears to wax and wane but never fully resolves. The patient has also had a tingling sensation in the involved areas following sun exposure, but there are no other associated symptoms. Skin examination findings are shown in the exhibit. Which of the following is the best next step in management of this patient's skin condition?

Question

A 63-year-old woman comes to the office due to a rash on her face.  She has had pustules and pink bumps in this area for years; the rash appears to wax and wane but never fully resolves.  The patient has also had a tingling sensation in the involved areas following sun exposure, but there are no other associated symptoms.  Skin examination findings are shown in the exhibit.  Which of the following is the best next step in management of this patient's skin condition?

Quizplus · Accepted Answer

11ec25c8_d389_72be_bc81_45f668bac258_MD0003_00 Rosacea is a chronic erythematous rash that is most prominent on the convex areas of the face. The etiology is unknown, but the rash may be due to a chronic inflammatory reaction to cutaneous microorganisms, ultraviolet light damage, or vasomotor dysfunction. Symptoms (eg, flushing, skin sensitivity) are often precipitated by hot or spicy foods, alcohol, sun exposure, or high ambient temperatures. The initial management of rosacea depends on the general phenotype. Mild facial flushing and sensitivity can often be managed with simple behavioral measures (eg, avoiding sun exposure). However, this patient has papulopustular rosacea, which is characterized by overgrowth of the sebaceous glands manifesting as small papules and pustules on the central face. Patients with these features typically require pharmacologic treatment. First-line options include topical metronidazole, azelaic acid, or ivermectin. Oral tetracyclines (eg, doxycycline, minocycline) are used for severe or refractory disease. (Choice A) Topical clotrimazole is appropriate for the treatment of uncomplicated dermatophyte infections. Dermatophyte infection of the face (ie, tinea facialis) is uncommon and typically presents as an annular lesion with pruritus and a scaly border. (Choice B) Topical corticosteroids (eg, triamcinolone) are not recommended as routine therapy for rosacea because they can cause a rebound worsening of symptoms. (Choice D) Permethrin is most commonly used to treat head lice and scabies. Although rosacea has been linked to colonization by Demodex mites, the effectiveness of permethrin in rosacea is uncertain. (Choice E) Topical salicylic acid is used for the management of acne vulgaris but is not the first-line treatment for rosacea. Educational objective: Mild facial flushing and sensitivity due to rosacea can often be managed with simple behavioral measures (eg, avoidance of sun exposure, hot/spicy foods, or alcohol). However, patients with papulopustular rosacea (ie, papules and pustules on the central face) typically require pharmacologic treatment. First-line options include topical metronidazole, azelaic acid, and ivermectin. References: Rosacea: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/26280139) Swiss S1 guideline for the treatment of rosacea. (http://www.ncbi.nlm.nih.gov/pubmed/28833645)

A 63-Year-Old Woman Comes to the Office Due to a Rash