Facial rashes
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
