Friday, August 31, 2007


This posting is from Liliana Rivis, a F.P. resident from Augusta, ME. It is intended for her colleagues as a learning experience, but others are welcome to read and comment if they wish.

The patient is a 43 yo CNA with a two year history of a facial eruption. She had tried metrolgel on a number of occasions and doxycycline for seven days at a time without significant improvement. She is a smoker( 1PPD x years).

O/E; She has an erythema on the cheeks, chin, bridge of the nose and up to the forehead. It spares the nasolabial folds and the hair line. On this erythematous rash are many red papules ( involving even the lower eye lid) covered with very dry skin. There are no obvious teleangiectasias.

She was started on doxycycline 50 mg PO QD for 1 month and I will see her in 2 weeks. I did not give her anything topical . I did not know if I can combine PO doxy and topical metrogel, and for how long. In Habif says to start doxy at 100-200 a day and taper off after rash is resolving.

Dave Elpern's Comments:
This is a woman with moderately severe rosacea. There's a good discussion on rosacea on Sometimes, one of the triggers is important (sunlight, hot liquids, alcohol, sunlight, etc.) but more often it's a combination of factors. If the patient is computer literate, I refer them to A lot of this is moot because these patients usually respond to doxycycline or minocycline. Mostly start with 100 mg b.i.d. and taper after a couple of months. (Small patients of less than 50 kg may get dizzy on this dose of minocycline so start lower and increase over 1 - 2 weeks). Even tetracycline can work well with a starting dose of 500 mg bid or tid. During the summer, one needs to warn the patients against TCN and doxycycline because these can cause a phototoxic eruption, Minocycline only very rarely does this. If no response to a tetracyclihne in 2 - 3 months consider isotretinoin.

The seven days of doxycycline she had was not a long enough trial.
Milder cases maay do well with topical metronidazole cream or gel (Metrogel, Metrocream, Noritate cream). Severe cases or those who do not respond to the tetracyclines should be considered for isotretinoin which usually works in doses lower than those employed for cystic acne. The biggest pitfall is not giving the drug enough time to work -- one must tell the patients to give it eight to twelve weeks. This patient needs to be encouraged to stick with the oral medication.



  1. I have just had a case of Rosacea like dermatitis due to demodex published in the Cutis who looked somewhat like your patient and he responded very well to IVERMECTIN orally and Permethrin cream topically.
    I would suggest you may want to try this out. Take a biopsy and see if you can show the demodex.


    Nico Mousdicas MD
    Dermatology Dept.
    Indiana University

  2. Such a severe case of Rosacea should be started on doxycycline 100mg b.i.d. 50mg is too small a dose. It can then be tapered as per response, and continued for 16-20 weeks. Adding topical therapy like metrogyl gel provides additive effect, along with photoprotection with a good broad spectrum sunscreen. And I think the patient should be stressed the need to quit smoking. Nico's experience with ivermectin and permithrin also appears interesting, although I haven't tried that personally.

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