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Flushing and Papules in a Middle-Aged Woman

Vanbeek, Marta J. MD, MPH; Strauss, John S. MD; Nygaard, Ingrid MD, MS

doi: 10.1097/01.AOG.0000151956.00804.78
In the Trenches

CASE: A 42-year-old woman presents for her annual gynecologic examination. She has no gynecologic complaints, and no medical illnesses. Her menses are regular. She does not smoke and takes no medications but is considering beginning oral contraceptive pills to replace her current contraceptive method of condoms. During the review of systems, the patient notes that she believes that she is having hot flushes because she has intermittent facial redness accompanied by a burning or stinging sensation. She also complains of pimples that have developed on her chin over the last few months. She has used an over-the-counter acne product, which did not resolve the pimples. She expresses irritation over having acne and wrinkles develop at the same time.

On examination, her face appears slightly sunburned. The skin under her eyes and over her cheeks is dry and has minimal flaking. On her chin and around her nose are 8–10 small red solid papules without blackheads. Her examination shows a normal female hair pattern and no evidence of androgenization. Her gynecologist counsels her on the importance of avoiding direct sun exposure and wearing sunscreen and prescribes a third-generation oral contraceptive pill to aid in both contraception and acne.

One year later, the patient returns for her annual examination. She remains healthy but is still concerned about her facial skin. She notes that her face is now generally red and irritated, despite daily use of sunscreen. The pimples are present on most days. She has bought various expensive skin care products and used them faithfully, with no effect. In addition, her eyes feel irritated and watery most of the time. On examination there is diffuse erythema of the nose, medial cheeks, forehead, and chin. There are small acne-like lesions around the nose. The chest and back are uninvolved. Her gynecologist refers her to a dermatologist.

An overview of challenging clinical situations.

Received October 19, 2004. Received in revised form October 20, 2004. Accepted October 21, 2004.

The editors thank the following individuals who, in addition to members of our Editorial Board, will serve as referees for this series: Sanford M. Markham, MD, Hope K. Haefner, MD, Ronald S. Gibbs, MD, Neil J. Murphy, MD, Linda T. Taylor, MD, and Jerry Rozeboom, MD.

Corresponding author: Ingrid Nygaard, MD, MS, University of Iowa Health Care, Department of Obstetrics and Gynecology, 200 Hawkins Drive, 2 BT, Iowa City, IA 52242; e-mail:

© 2005 The American College of Obstetricians and Gynecologists