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Simple cases
Case 12
A 71-year-old man with a chronic facial dermatitis
History
How long have you had this skin problem?
It has been increasing over a number of years.
Reasonable question, as this disease is chronic and slowly progressive, but sometimes flares.
Is it painful or itchy?
Sometimes it itches a little bit, but usually I don't feel anything.
Good question. Sometimes this disease does cause pruritus.
What you think might be trigger factors?
Sometimes when I drink a bit too much alcohol, it seems worse. I think the sun also makes it worse.
Good question. Many different trigger factors are known: temperature variations, cold, UV light, wind, warm drinks, alcohol and exercise.
Do you often overindulgence with alcohol?
No, not really, but I do drink a glass of red wine every evening with dinner, Sometimes when we get together to play jazz, I overdo it.
This question really doesn't help with the diagnosis and may annoy the patient. It can be important to help identify contraindications for different therapeutic approaches.
Have you tried any creams or ointments?
Yes, I have received a few things from my family doctor and from the drugstore, but none of them helped much.
Good question in two ways. Topical corticosteroids can make this disease worse. In addition, severe forms of the disease are usually hard to treat topically.
Do you have any other health problems?
I have to take pills every day for high blood pressure.
Useful question, since the incidence of this disease is increased in patients with hypertension.
Have you had extramarital sexual relations recently.
Hmm..no. Actually at my age, that isn't much of a question.
This question is inappropriate. It is not needed and may suggest to the patient that the disease is sexually transmitted, which is not the case at all.
Lesion
Choose the right efflorescences:
Correct. Erythematous macules are part of this disease. They often occurring as flushing and are admixed with telangiectases.
There are multiple papules with the erythematous areas.
Goodthere are also a few pustules.
Good. On the nose there are nodules representing sebaceous gland hyperplasia. This process creates an uneven skin surface with dilated follicular openings.
Diagnosis
Choose the right diagnosis:
Incorrect. Acne occurs in younger patients who have open and closed comedones.
LE is an important consideration. It is more common in young women and rarely starts at this advanced age. The most typical cutaneous finding is a butterfly erythema of the midface in systemic LE.
Correct. This chronic dermatosis with erythema, telangiectases, papules and pustules is rosacea. Comedones are not present. The nasal enlargement is known as rhinophyma.
Incorrect. Perioral dermatitis is an important differential diagnostic consideration, as it also contains erythematous macules, papules and pustules. It is caused by the excessive use of moisturizing creams by young women.
Incorrect. Seborrheic dermatitis features erythema and yellow greasy scales, accompanied by oily skin.
Therapy
Choose the right therapy(ies):
These medications are contraindicated in rosacea, as they usually make the condition worse.
Correct. Mild forms can be treated topically usually with metronidazole. More severe forms may require systemic tetracycline or metronidazole. The rhinophyma does not respond to antibiotics.
Correct. This is another possibility. The rhinophyma may also improve.
No. This may even worsen the condition.
Correct. The excessive tissue on the nose may be removed in a number of ways, producing a most grateful patient.
Test
The following questions are related to the current case. Try to solve them.
