[doctor] uh , mrn49282721 . patient's name is jacqueline miller . use last visit exam where appropriate .
[doctor] hi , how are you doing , jacqueline ?
[patient] i'm pretty . good . how are you ?
[doctor] good as well . so it sounds like we're , um , under good control right now .
[patient] yes . it's doing much better .
[doctor] good , good . do you have any rash leftover ?
[patient] yeah , i have a- a small bit leftover . i started using , uh , doxycycline only one a day because i think the pharmacist said if it's getting better , to just limit it to once a day .
[doctor] okay , that sounds good .
[patient] but i was taking it twice a day and i did notice a lotta improvement .
[doctor] okay .
[patient] and then when i started doing it only once a day , it seems the same and it's not continuing to get better . so it's kinda plateaued a little bit .
[doctor] i see . um , are you breastfeeding at this time ?
[patient] no , i'm not right now .
[doctor] okay , good . so you- you should not be breastfeeding while you're on that medication .
[patient] yeah , actually i stopped breastfeeding and then asked for the doxycycline at that time .
[doctor] okay . even with the doxycycline , you can keep using the elidel .
[patient] okay . and i did n't take the elidel because when i read about it i got worried . so i wanted to just try the doxycycline and see .
[doctor] okay . so we can talk about the elidel . a lot of the things you read about is not actually relevant to the cream or ointment form , but it's about the oral form that's used in really high doses , longterm , after people have a heart transplant or a kidney transplant or something like that .
[patient] okay . i did n't realize that .
[doctor] yeah , and when you suppress the immune system that hard for that long , it can predispose you for developing cancers like hematologic type cancers . it does n't apply to as-needed use of the medicine , a cream or an ointment , okay ?
[patient] okay . then i can resume taking - taking the doxycycline twice a day again ?
[doctor] so let me clarify . what exactly are you using ? and then we'll look at you and figure out , okay ? so you're using the sulfacetamide wash ? uh , how frequently are you using that one ?
[patient] twice a day .
[doctor] okay , and that's not drying you out too much ?
[patient] no , that's fine .
[doctor] okay . and you're using the metro cream ?
[patient] yes .
[doctor] how often are you using that one ?
[patient] after my face wash , i immediately apply the cream .
[doctor] okay . and then , are you using any other kind of lotions or anything ?
[patient] no .
[doctor] so you're not using the cetaphil cleanser ?
[patient] i'm not .
[doctor] okay . and no neutrogena wipes ?
[patient] no wipes .
[doctor] okay . um , and then what about , um , any lotions that you're using ?
[patient] i'm not using any lotion right now , just those two .
[doctor] no lotion , okay . so that may be something else we should add in , a lotion to just help moisturize . but we'll see .
[patient] okay .
[doctor] um , and then again , when did you go down to just taking the doxycycline once a day ?
[patient] that was last week . so the first two weeks , i did twice a day .
[doctor] okay .
[patient] and then i started seeing improvement , and then i changed to just once a day .
[doctor] okay . let me take a look at your face here . i'm gon na describe for the transcriptionist what i'm seeing . you're fitzpatrick skin type iv , meaning you're not going to burn , you're going to sun tan , um , essentially , iv to v. and then on bilateral medial cheeks , there are a few really faint erythematous papules and just maybe a little bit of redness around and underneath your nostrils . so you're right , it's not totally gone .
[patient] yeah .
[doctor] i think i would go ahead and go back to twice a day , every day , with the doxycycline .
[patient] okay .
[doctor] uh , but i would pickup the elidel too .
[patient] okay , i can do that .
[doctor] i mean , out of known risks associated with medications , topicals are usually safer and preferable to oral medications . with that being said , doxycycline is low risk .
[patient] it is ? okay .
[doctor] um , and doxycycline can give you bad upset stomach or heartburn . um , it will make you sunburn , even if you never sunburn , so you have to protect yourself .
[patient] yeah , i mean , i feel sun sensitive whenever i go out , so i am taking all the precautions , with wearing a hat and all of that .
[doctor] great . i just wanted to make sure you knew about that .
[patient] yes , i did . thank you .
[doctor] all right . but i think to help get rid of it sooner rather than later , if insurance will cover the elidel , pick it up and start using it .
[patient] yeah , i did check . the insurance is not covering it .
[doctor] it's not ? okay . well , let's look around really quick because if you use a goodrx coupon , it will be around 30 to $ 40 or something .
[patient] okay .
[doctor] let's see .
[patient] so with your coupon , it was around $ 850 or something .
[doctor] ugh , yeah . that's way too much .
[patient] i agree . and- and because i also looked at the eucrisa that you recommended in my notes , and if it's still ex- if it's still expensive , i could try that instead .
[doctor] yeah , so it ... actually ... it is actually more expensive . i think the prices fluctuate .
[patient] okay .
[doctor] because now it's showing the cheapest of $ 70 , and when i looked before , it was around 30 to $ 40 .
[patient] yeah . if it was around $ 200 , i would've picked it up . but it was coming to around $ 850 after insurance .
[doctor] okay . so i've found the cream form . we could try ointment form .
[patient] you mean the tacrolimus ?
[doctor] yeah , mm-hmm .
[patient] okay .
[doctor] so if we send it to pick'n save or metro market ... let's see where else .
[patient] can you do the metro market ?
[doctor] yeah . let me put in the prescription and we'll see what we can find .
[patient] sure .
[doctor] pharmacy is what i'm trying to say .
[patient] okay . but it's not a steroid , right ?
[doctor] correct , it's not a steroid .
[patient] okay , good .
[doctor] it's called a calcineurin inhibitor . it's kinda like a steroid in that it calms inflammation .
[patient] okay .
[doctor] but it's not a steroid , so do n't use steroids on your face , for sure , as they'll make this kind of rash worse . but also , steroids carry the risk of causing thinning of the skin .
[patient] all right .
[doctor] these medications do n't cause thinning of the skin and they're not going to cause some other kind of rash . um , the thing to know is that sometimes five to 10 minutes after you put it on , it can cause this weird kind of tingly or needle-like sensation or make it redder or flush . but it should only last a few seconds and then go away . it's not an allergy or anything bad .
[patient] okay . got it .
[doctor] so it only lasts a couple seconds . it does n't mean it's going to happen again . it's nothing bad . it will still work , so keep using it as long as you know you can stand it , okay ?
[patient] okay , thank you for explaining .
[doctor] so i will say , " apply to rash on face twice daily , until resolved . "
[patient] okay . so only apply to the rash area ?
[doctor] yes , and keep using the face wash.
[patient] okay .
[doctor] i think you could just do it once a day . i do n't think you need to do it twice a day , just because i do n't wan na dry your sky out too much , okay ?
[patient] i never noticed that my face is dry or got thin . i feel so good after using it .
[doctor] i understand , but it could get dry and i do n't wan na create other problems for you .
[patient] all right . i'll just wash once a day with it . but it was feeling very good , like there's this little bit of moisture getting back in . with the other wash , when i would use it twice a day , i was drying out . but not with this one .
[doctor] i see . okay . well then do what feels good . if you do notice that you're starting to get dry , then reduce to once per day .
[patient] that sounds good .
[doctor] so to review , um , continue using the same face wash , continue with metro cream , and increase the use of doxycycline to twice a day .
[patient] okay .
[doctor] and then just do it until it's gone , and then do it for once a day for another week before stopping .
[patient] okay , sounds good .
[doctor] all right . and i'll rewrite your instructions here .
[patient] thank you so much .
[doctor] if there are any other questions or you're getting different instructions , feel free to reach out to me and we'll clarify , okay ?
[patient] okay .
[doctor] but in general , doxycycline is such a low risk . we're not gon na have you on this forever . but especially since we're adding the tacrolimus , i expect it will clear quickly .
[patient] sounds good .
[doctor] all right . and i just wan na really help knock it out as fast as possible , since you've been dealing with it for so long now . i would take it twice a day until it's gone , and then once a day for a week before you stop . i'll write it out like that . so twice a day until rash is gone , and then once a day for another week before stopping .
[patient] okay .
[doctor] once the rash stops , you can stop the tacrolimus ointment . um , continue doxycycline another week and then stop . but you can keep using the wash and the metro cream .
[patient] okay , that sounds good . i can do that .
[doctor] and then hold off until i see you again before you start back any of your old products . um , if it's starting to flair again , um , if it's just a little bit , you can try just doing the tacrolimus for a couple days , to see if that's enough . if it's not , then restart the dy- doxycycline as well .
[patient] all right .
[doctor] i do n't expect that to happen , but , you know , if it does , you have the tools . um , then you'll be seeing me for a followup . we can figure out what to do next . i would say if it's getting worse rather than better , just give me a call or send me a mychart message , okay ?
[patient] yeah , sounds good .
[doctor] do you have enough refills ?
[patient] yeah , i think so .
[doctor] okay . so it looks like you have another refill of the doxycycline , so you're good there . metro cream , you probably still have enough of that one .
[patient] yes , i do .
[doctor] all right . and i'll cancel the elidel cream , just so we do n't complicate your list . uh , you have plenty of the face wash still .
[patient] yes .
[doctor] okay . uh , and we'll get rid of the clindamycin from your list as well .
[patient] and what would you suggest for a moisturizer ?
[doctor] yeah , so for that i would do something really basic like vanicream . or even , if it's just really dry , you could use a little bit of petroleum jelly . um , i'll give you a couple samples , okay ? let's make sure we have a followup in about four weeks .
[patient] okay , thank you .
[doctor] okay . and i would stay away from any kind of anti-aging thing , any kind of plant thing . um , really let's just be sure we talk about any new products , or reach out to me if you're gon na try something else . um , let's go get those samples .
[patient] okay , that sounds good .
[doctor] for assessment and plan , perioral dermatitis , rosacea , including ocular rosacea , and copy and paste her patient instructions . i recommend that she gently wash her eyelids once a day with gentle cleanser such as vanicream , also use bruder mask as needed .
CHIEF COMPLAINT

Follow-up for perioral dermatitis.

HISTORY OF PRESENT ILLNESS

Jacqueline Miller is a 40-year-old female who is being seen today for a follow-up skin exam for perioral dermatitis. She also has a history of rosacea, including ocular rosacea. Today, she states that her perioral dermatitis is well-controlled, although it has not fully resolved. The patient was applying doxycycline twice a day with improvement, but her pharmacist advised her to reduce to once daily since it had started to improve; therefore, for approximately the past week, she has been using the doxycycline only once per day. She has not seen continued improvement but it has not worsened. She is using the sulfacetamide wash twice daily, denies drying of the skin, and reports that her skin is much improved moisturization. She also applies MetroCream immediately after using the sulfacetamide wash. She denies using other lotions and products, Cetaphil lotion or soap, or Neutrogena wipes. The patient did not begin Elidel because it is not covered by her insurance, and she was concerned about possible side effects from the medication.

PAST HISTORY

Medical
Perioral dermatitis.

CURRENT MEDICATIONS

Doxycycline cream. Apply twice daily.
MetroCream. 
Sulfacetamide wash. Apply topically twice daily.

PHYSICAL EXAM

Integumentary
Skin inspection of the face was performed today. On bilateral medial cheeks, there are a few, very faint, erythematous papules with mild redness around and underneath the nostrils. Fitzpatrick skin type is 4 to 5.

ASSESSMENT

• Perioral dermatitis
• Rosacea, including ocular rosacea

Jacqueline Miller is a 40-year-old female who presented today for follow-up for her perioral dermatitis, which has improved but not resolved. She decreased her doxycycline per her pharmacist’s recommendation, which possibly stagnated the resolution of symptoms.

PLAN

Perioral dermatitis.
I counseled the patient about the risks and benefits of doxycycline and recommended she resume twice daily application until she reaches full resolution, and at that point she should reduce application to once a day for an additional week. The patient will not be using Elidel as I reviewed the cost of the medication and without insurance, it was too expensive. I provided a prescription for Tacrolimus and counseled her on possible side effects of using the medication. She will continue with Sulfacetamide face wash once a day. Also, use Bruder mask as needed.

Rosacea, including ocular rosacea.
Continue using MetroCream twice daily. I recommended to gently wash her eyelids once daily with a gentle cleanser and try a gentle cream such as Vanicream.

INSTRUCTIONS

Call the clinic if symptoms worsen. The patient will have a follow-up appointment in 4 weeks.