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 the same site
Swabs: Herpes simplex

Herpes zoster

Acute dermatomal eruption
Painful: pain may precede the 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)

Face: scaly rash

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
Can be drug-induced

Face: localised areas of dermatitis

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 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
Can occur in children

Rosacea

Most prevalent in middle-aged adults
Mid-facial: cheeks + nose, chin and forehead
Erythema, flushing, papules, pustules, telangiectasia
Rhinophyma causes enlargement of the nose in some patients
Sensitive skin
Lesions can approach the lips

Pseudofolliculitis barbae

Shaving rash
Follicular papules, pustules, curled-in hair

Face: follicular rash

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 when hot, embarrassed or with certain foods
Often lifelong tendency
Systemically well
Associated with rosacea

Sunburn

Sun-exposed site
Spares eyelids, furrows, under the chin

Face: erythema

Systemic lupus erythematosus

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

Solar lentigines

Sun-exposed sites
Small to large freckles
Well-demarcated flat or slightly scaly brown marks or thin plaques

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: brown patches

Face: pale or white macules/patches

Guttate hypomelanosis

More commonly observed on limbs

Pityriasis alba

Young child
Cheeks
Hypopigmentation, light scale

Face: pale patches

Post-inflammatory hypopigmentation

Preceding eczema, psoriasis, acne etc
Distribution depends on cause

Vitiligo

Most often periocular, perioral
White, smooth surface

Face: white patches

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

Face: papules and plaques

Solar comedones

Smoker, sun damaged older patient
Periocular, cheekbones, 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

Face: lesions

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

Face: multiple papules

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