History
A 59-year-old man attends the dermatology clinic for a skin review following renal
transplantation for hypertensive nephropathy. He is immunosuppressed with sirolimus and mycophenolate mofetil. He has a few viral warts on his hands but his main complaint is a 6-month history of facial redness and painful ‘spots’. The erythema is exacerbated by heat. He has applied a bland emollient cream and topical antibacterials to the affected areas with little benefit. At the initial consultation he is noted to have a florid facial ery-thema with multiple papules and pustules over his forehead and cheeks. He is commenced on oral minocycline 100 mg daily and is asked to come back in 3 months.
Examination
On review after 3 months of minocycline his facial eruption is starting to improve but he has persistent erythema, papules and pustules; he is also noted to have a slate grey colour starting to appear on his nose (Fig. 68.1).
Questions
• What is the initial cutaneous diagnosis?
• What is the cause of the grey pigmenta-tion on his nose?
• How would you now manage this patient?
Medicine
This renal transplantation patient was suffering from florid rosacea that was unrespon-sive to topical therapy. He was treated with oral minocycline with some improvement in his rosacea after a few months. Rosacea is an acneiform condition that causes facial flushing, fixed erythema, papules, pustules and cutaneous oedema. If the tissue swelling becomes chronic then rhinophyma can result. Patients usually report an exacerbation of their condition with heat, spicy food and alcohol. Their erythematous skin tends to be sensitive and numerous topical preparations can cause burning or stinging. Oral tetracyclines are usually highly effective in the treatment of rosacea. However, this patient developed slate-grey pigmentation on his nose secondary to the minocycline antibiotic. Of patients taking minocycline 3.7 per cent are reported to develop some altered skin pigmentation, usually within five months of commencing the treatment. The development of minocycline-induced pigmentation is not dose dependent. In many but not in all cases the slate-grey pigmentation fades eventually on discontinuation of the minocycline. This patient’s minocycline was stopped and he was switched to oral lyme-cycline 408 mg daily which was effective in treating his rosacea.
The patient was given some sun-protection advice as tetracyclines can be photosensitiz-ing. In addition patients who are post-transplantation and on immunosuppressive drugs are at an increased risk of skin cancer, therefore skin surveillance and sun-protection are paramount.
KEY POINTS
• Rosacea is an acne-like condition with pustules and papules but also erythema and flushing.
• A side effect of oral minocycline is a slate-grey pigmentation in the skin, which may be permanent.
• Post-transplant patients on immunosuppressive medication are at increased risk of skin cancer.
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