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Oral terbinafine
3%
1/33
Topical steroids
15%
5/33
Topical metronidazole
61%
20/33
Topical tetracycline
6%
2/33
UV light
9%
3/33
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The patient in this vignette suffers from acne rosacea. Topical metronidazole is a first-line treatment. Acne rosacea presents with inflammatory lesions (papules and pustules), telangiectasias over cheeks, nose, and chin that flush with emotion, heat, and hot beverages. It is the result of inflammation of the facial pilosebaceous unit, that has been related to Demodex folliculorum (mite) presence. Acne rosacea can be complicated by rhinophyma, or nasal enlargement. Goldgar et al. discuss treatment modalities for rosacea which can be effectively controlled with therapy directed to the specific subtype of rosacea. For mild rosacea, treatment options include topical metronidazole, sulfacetamide/sulfur, and azelaic acid. Combination therapy with oral tetracyclines and topical agents is used for moderate papulopustular rosacea. Importantly, remission may be maintained with a topical agent, such as metronidazole. Chauhan and Ellis review the pathophysiology and management of rosacea. According to Chauhan and Ellis (and many other sources) first line interventions are centered around lifestyle modification such as avoiding any triggers, temperature extremes, wind, hot beverages, caffeine, exercise, spicy food, emotional stresses or other irritating topical factors. After this first line approach the next step is very much dependent on the clinician and their clinical judgement based on the patient presentation. Other treatments include over the counter skin care products often with an active ingredient of metronidazole. In addition oral erythromycin as well as topical metroniadazole, topical erythromycin, and topical clindamycin are other approaches that are used in management of rosacea and have been shown to be effective. Other options in management include but are not limited to topical retinoids, laser therapy and surgical interventions. Figure A shows the hallmarks of acne rosacea: redness and "acne" over her cheeks, nose and chin. Illustration A shows an example of rhinophyma, a potential sequelae of acne rosacea. Incorrect Answers: Answer 1: Oral terbinafine is used in the treatment tinea fungal infections. Answer 2: Topical steroids should not be used on the face as they can irreversibly thin the skin. Answer 4: Oral, not topical, tetracycline is used in the treatment of acne rosacea. Answer 5: UV light is used in the treatment of psoriasis, not acne rosacea.
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