QuestionSBA
QuestionChoice
The image shows inflamed phymatous disease, which may require treatment in secondary care with oral isotretinoin, despite good compliance with first line topical and oral therapy.
10028271
a
Refer to dermatology
QuestionChoice
Ivermectin is the first choice topical treatment, with metronidazole and azelaic acid reserved for patients for whom this is inappropriate (e.g. breastfeeding or where ivermectin is unavailable). Current guidelines do not suggest switching through the different topical preparation choices.
10028272
b
Switch ivermectin to metronidazole
QuestionChoice
Ivermectin is the first choice topical treatment, with metronidazole and azelaic acid reserved for patients for whom this is inappropriate (e.g. breastfeeding or where ivermectin is unavailable). Current guidelines do not suggest switching through the different topical preparation choices.
10028273
c
Add azelaic acid
QuestionChoice
Doxycycline is the first choice oral antibiotic in moderate to severe disease. It is also the preferred agent when inflamed phymatous disease is present. Tetracyclines are alternative preparations for when doxycycline cannot be used. Current guidelines do not suggest switching between oral agents.
10028274
d
Switch doxycycline to oxytetracycline
QuestionChoice
This would be appropriate if there was prominent NON-inflamed phymatous disease. As the nose appears to be inflamed, a dermatology referral should be undertaken first, so the disease can be controlled.
10028275
e
Refer to plastic surgery
QuestionComment
its mr jp morgan
51297
User
subscriber
Raphael de la Ghetto
Concept
Chapter
2693
3919
acne rosacea
Topic
144
Dermatology
18052
Phymatous rosacea may necessitate referral to dermatology for advanced treatment options, such as oral isotretinoin, when first-line therapies are insufficient.
Picture
https://dermnetnz.org/assets/Uploads/acne/rhinophyma-07__WatermarkedWyJXYXRlcm1hcmtlZCJd.jpg
2324
acne rosacea.jpeg
images/bwv0xpai1701431540223.jpg
images/bwv0xpai1701431540223_256.jpg
images/bwv0xpai1701431540223_512.jpg
WlgODYhQdXd4hoh0p5l5hwCENkA3
Topic
144
Dermatology
A 52-year-old woman with a long history of rosacea visits her GP as she is becoming increasingly distressed with her appearance.

She reports good compliance with UV-blocking sunscreen, topical brimonidine (used as needed for flushing) and topical ivermectin with oral doxycycline.

On examination, the following appearance is noted:

[lightgallery]

What is the most appropriate next step in management?
a