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.
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
b,a
B, A
B, D
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
SECOND-LINE THERAPIES
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.
treat with oral doxicycline
bd
b d
B
D
100%
B and D
BD
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