Transcript Flushing and Papule in Middle

Flushing and Papule
in Middle-Aged Woman
Obstetrics and gynecology
Vol. 105, No.2, Feb. 2005
R2 서 영 진
CASE
 42-year-old woman
no gynecologic complaints, no medical illness
does not smoke, takes no medications
menstruations : regular
considering beginning oral contraceptive method
 The review of systems
hot flushes: facial redness (burning, stinging)
pimples on her chin
acne and wrinkle
 Examination
slightly sunburned
under the eye & over the cheeks: dry, minimal flaking
on her chin & around her nose: 8~10 small red solid
papules
normal female hair pattern
no evidence of androgenization
 Management
avoiding direct sun exposure, wearing sunscreen
3rd generation oral contraceptive pill
▶ 1 year later
remains healthy but still her facial skin problem
now generally red and irritated
pimples on most days
eyes: irritated and watery most of the time
use skin care products, but no effect
diffuse erythema (nose,medial cheeks,forehead,chin)
acne-like lesion around the nose (not chest & back)
 refers her to a dermatologist
HISTORY AND EXAMINATION
 History
facial flushing, redness
pimples, burning sensation
negative for joint acnes, pruritus, other complaints
 Examination
dense network of prominent telangiectasias over
the nasal bridge, forehead, central cheeks
scattered inflammatory papules and pustules over
the nose and medial cheeks
no comedone
chest, back, upper extremities: non specific
 rosacea
QUESTIONS AND COMMENTARY
 What causes rosacea?
- abnormalities of the small vessels
sun damage to the surrounding connective tissue
abnormal inflammatory response
→ fluids leak out into the dermis
- hot drinks, spicy foods, alcoholic beverages
→exacerbate the vasoinflammatory response
- Demodex folliculorum (in sebaceous follicle)
 How common is rosacea?
- reliable data are lacking
- the 3rd or 4th decade
fair-skinned people of Celtic or northern European
- average of 1.1 million annual outpatients in U.S.A
from 1990 to 1997
 What is the differential diagnosis for rosacea and
what distinguishes it from other skin conditions?
<Acne vulgaris>
- younger age group
- comedonal lesion with or without associated
inflammatory papules and pustules
- chest and back (not rosacea)
- facial erythema, but secondary response of papules
- telangiectatic component ↓ (< rosacea)
<Seborrheic dermatitis>
- typically, erythema and scaling of the nasolabial
folds, eyebrows, scalp, postauricular folds, ear canal
and involve the central chest, axillae, groin
- flushing, inflammatory papules and pustules is
not characteristics of seborrheic dermatitis
<Systemic lupus erythematosus (SLE)>
- because rosacea affects the central face and can
be exacerbated by sun exposure, it may be mistaken
for the malar rash of SLE
→ but malar rash lacks papules or pustules
- other finding: follicular plugging, atrophy, scarring,
and adherent scale
- ANA is not specific, so blood studies are nor helpful
in differential diagnosis
<Perioral dermatitis>
- papules and vesicles appear in groups and
smaller than rosacea
- telangiectasia ↓ (<rosacea)
- no flushing and blushing
<Irritant or allergic contact dermatitis>
- resemble rosacea, but invariably pruritic
- geometric shape and pattern follows the size
and shape of the external causal agents
 How is rosacea diagnosed?
<Guidelines for diagnosis of rosacea>
- the presence of one or more primary features (with
or without secondary features) indicates rosacea
▪ Primary features
flushing (transient erythema)
nontransient erythema
papules and pustules
telangiectasia
▪ Secondary features
burning or stinging
plaque formation
dry or scaly appearance
edema
ocular manifestations
peripheral location
phymatous change
→laboratory marker, biopsy are not helpful !!!
<Subtypes and characteristics of rosacea>
▪ vascular rosacea
- flushing and persistent central facial erythema
with or without telangiectasia
▪ papulopustular rosacea
- persistent central facial erythema with occasional
central facial papules or pustules
▪ phymatous rosacea
- thickened skin, irregular surface nodularities of
nose, chin, forehead, cheeks, ears
▪ ocular rosacea
- burning, stinging, dryness, ocular photosensitivity,
blurry vision, telangiectasia of sclera, periobital
edema
 What are the risk factors?
- no specific risk factors
- commonly, northern European ethnicity
- alcoholic beverages
 What happens if rosacea remains untreated?
- rosacea : remissions and exacerbations
- various combination
various subtype (independently or evolution)
- mild~moderate~severe form
- psychological affects: disabling , quality of life ↓
- untreated rosacea: chronic inflammatory change
(erythema, edema, phymatous)
 How is rosacea initially treated?
- long-term treatment to suppress inflammation
- should be tailored to the specific variant of rosacea
- avoiding factors : sun, alcohol, hot beverages,
certain foods, irritating cosmetics
- regular use of sunscreen is important
 Topical therapy
- mild erythema, limited number of papules & pustules
: topical metronidazole
clindamycin
azelaic acid
sodium sulfacetamide
sufur lotion
- response is not immediate
 Oral therapy
<antiinflammatory antibiotics>
- more extensive papules or pustules
mild edematous change
: oral tetracycline (+ topical treatment)
- if improved : discontinue oral treatment
continue topical treatment
<isotretinoin>
- more severe, refractory, persistent cases
: 13-cis-retinoic acid (isotretinoin) therapy
- adverse effects : dry skin, mocosae and eye
pruritus, dermatitis, myalgia
liver enzyme↑, cholesterol ↑
→ indicated only for treatment-resistant rosacea
- risk of teratogenicity
<oral treatment of flushing symptoms>
- active -blocking hypotensive drug (clonidine)
low dose -blocker (nadolol)
- adverse effects : orthostatic hypotension
xerostomia
<procedural treatment>
- prominent telangiectasias associated with rosacea
: laser or intense pulsed light treatments
<contraindicated therapy>
- topical steroid : initially decrease
→ but prolonged use : telangiectasia
exacerbate flushing, etrythema
 When should the primary care provider refer to a
dermatology specialist?
- if the diagnosis is in doubt or if patients fail to
respond to first-line therapy
→ referral to a dermatologist