Facial rashes

Author: Hon A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand, May 2016.

 


Facial rashes

Patients often present with quite mild signs when they have a facial lesion or rash — due to embarrassment — and the diagnosis may be tricky.

 Significant itch suggests atopic dermatitis or contact dermatitis.

Face: erosions/crusting

Herpes simplex  

  • Monomorphic clustered vesicles or crusted papules
  • Often locally recurrent in same site
  • Swabs: Herpes simplex

Herpes zoster 

  • Acute dermatomal eruption
  • Painful: pain may precede rash
  • Erythema may precede vesicles
  • Swabs: Herpes zoster

Impetigo  

  • Irregular enlarging plaque
  • Honey-coloured crusts
  • Swabs: Staphylococcus aureus +/- Streptococcus pyogenes
Face: erosions/crusting

Dry or scaly rash

Seborrhoeic dermatitis 

  • Often also affects scalp, retroauricular sites, ears
  • Hairline, eyebrows, medial cheeks, nasolabial folds, chin creases
  • Scaly blepharitis
  • Poorly defined, variable white or yellowish flaking
  • May have erythematous patches or thin plaques
  • Follicular prominence or follicular digitate keratoses

Psoriasis 

  • Eyelids, temples, retro- and pre-auricular skin and/or seborrhoeic dermatitis sites
  • Also affects scalp, ears, elbows, knees, nails
  • Well-demarcated erythematous plaques
  • White scale
  • More persistent than seborrhoeic dermatitis

Atopic eczema 

  • Often affects flexures: retroauricular, elbow and knee creases
  • Symmetrical dermatitis of eyelids, perioral skin (up to lips)
  • Intensely itchy
  • Acute flare: oedema, erythema, crusting, fissuring
  • Subacute: dryness, pinkness
  • Chronic: dryness, lichenification, Dennie Morgan folds (2 creases in lower eyelids)

Contact eczema 

  • Acute, relapsing/intermittent or chronic presentation
  • Irregular, variable, unilateral or asymmetrical dermatitis
  • Sharp border if contact irritant dermatitis
  • Patch tests positive if contact allergy

Photosensitive dermatitis  

  • Exposed areas of face, arms, chest, legs
  • Spares under hair, eyelids, creases
  • Flares after exposure outdoors
  • May be drug-induced

Tinea faciei 

  • Asymmetrical eruption
  • Annular configuration is common
  • Scaly edge
  • Mycology positive

Actinic keratoses 

  • Located on sun exposed sites of temples, forehead, nose, cheekbones, angle of jaw, upper lip, lower vermilion lip
  • Persistent small tender scaly papules, macules, plaques

Cutaneous lupus erythematosus

Discoid lupus erythematosus 

  • Nose, cheeks, ears, lips, scalp
  • Circumscribed plaques with follicular prominence, scale
  • Post-inflammatory pigmentation, atrophic scarring
  • CBC, ANA, ENA often normal

 Lupus tumidus / Jessner lymphocytic infiltrate 

  • Cheeks, upper trunk
  • Smooth surface to erythematous dermal plaques
Cutaneous lupus erythematosus

Papulopustular rash

Acne 

  • Onset often at puberty
  • Usually, symmetrical forehead, chin, lateral face, nose
  • Mixed inflammatory and non-inflammatory lesions
  • Papules, pustules, nodules, comedones

Perioral/periorificial dermatitis 

  • Usually adult females using face cream, often topical corticosteroid
  • Often, asymmetrical first in perioral sites, later in perinasal and periocular sites
  • Spares a centimetre of skin around vermilion of lips
  • Grouped erythematous papules and pustules on erythematous patches, flaky surface

Rosacea 

  • Usually middle-aged or elderly adults
  • Mid-facial erythema, flushing, papules, pustules, telangiectasia
  • Sensitive skin
  • Lesions can approach the lips

Pseudofolliculitis barbae 

  • Shaving rash
  • Follicular papules, pustules, curled-in hair

Face: erythema

Erythema is less pronounced in dark skin

Dermatomyositis 

  • Violaceous eyelids – may be swollen
  • Poikiloderma on the trunk and limbs
  • Gottron papules on fingers
  • May have muscle weakness

Flushing 

  • Intermittent redness eg when hot, embarrassed or with certain foods
  • Often lifelong tendency
  • Systemically well
  • Consider rosacea

Sunburn 

  • Sun exposed site
  • Spares eyelids, furrows, under chin

Systemic LE 

  • Butterfly erythematous rash
  • Systemic symptoms: tiredness, lethargy, arthralgia
  • Check CBC, ANA, ENA  

Telangiectasia 

  • May accompany flushing
  • Vascular dilatation
  • Various types

Face: brown macules/patches

Pigmentation is more pronounced in dark skin

Erythema dyschromicum perstans 

  • Grey-brown discolouration
  • Any distribution
  • Distinct border, sometimes red at first

Melasma 

  • Usually adult female
  • Centrofacial, malar and mandibular patterns
  • Spares eyelids, rare below jawline
  • Symmetrical pigmentation with ragged border

Post-inflammatory pigmentation 

  • Preceding eczema, psoriasis, acne etc
  • Distribution depends on cause

Face: pale or white macules/patches

Guttate hypomelanosis 

  • More commonly observed on limbs

Pityriasis alba 

  • Young child
  • Cheeks
  • Hypopigmentation, light scale

Post-inflammatory hypopigmentation 

  • Preceding eczema, psoriasis, acne etc
  • Distribution depends on cause

Vitiligo 

  • Most often periocular, perioral
  • White, smooth surface

Skin lesions

Granuloma faciale 

  • Middle-aged adult
  • Solitary thickened smooth, purplish-brown plaque or plaques

Sarcoidosis 

  • Yellowish-brown to mauve infiltrated plaque
  • May arise within existing scar
  • Lupus pernio affects nose and ears

Sebaceous hyperplasia 

  • Mostly > 40 years
  • Forehead, temples
  • Yellowish papules with central follicular dimple

Solar comedones 

  • Smoker, sun damaged older patient
  • Periocular, cheek bones, nose, neck
  • Usually symmetrical

Basal cell carcinoma 

  • Slowly enlarging, destructive papule, nodule or plaque
  • Early erosion, ulceration and bleeding

Squamous cell carcinoma 

  • Enlarging tender scaly or crusted nodule

Adnexal tumours 

  • Various types and syndromes
  • Follicular or eccrine origin

Milia  

  • Periorbital or cheeks
  • Superficial firm small papules
  • Scattered on forehead, cheeks
  • Yellowish with central dell

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