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AlexanderSalava

Facial Dermatoses

Essentials

  • It is important to differentiate between eczematous and acne-rosacea group diseases.
  • Keep in mind the possibility of allergic contact dermatitis (cosmetics, skin care products, etc.)
  • Other areas (the scalp, other skin areas, nails, ears) should also be examined because diagnostic signs can often be found in areas other than the face.

Causes

The most common causes

  • The most common causes of facial dermatoses are listed in table T1.

The most common causes of facial dermatoses

CauseLocationDiagnostic clues
Atopic eczema Atopic Eczema (Atopic Dermatitis) in AdultsEyelids, face, neck, upper limbs (pictures 1 2 3 4 5 6 7 8)
  1. Atopic tendency
  2. History, cases in immediate family
Seborrhoeic eczema Seborrhoeic Dermatitis in the AdultEyebrow area, beard area, nasolabial folds, forehead, hairline, ear area, chest (pictures 9 10 11 12)
  1. History
  2. Lesions in typical places
Acne AcneCheeks, forehead, chin (pictures 13 14 15 16 17 18 19)
  1. Comedones and papulopustules
  2. History
  3. Typical age
Rosacea RosaceaCentre of the face (pictures 20 21 22 23 24 25 26 27)
  1. Flushing
  2. Papulopustules, absence of comedones
  3. History
Perioral dermatitis Perioral DermatitisAround the mouth and/or eyes (pictures 28 29 30 31 32 )
  1. Typical age
  2. Papules, absence of comedones
Allergic contact dermatitis Allergic Contact Dermatitis
  1. Acute eczema
  2. Diagnosed contact allergies or earlier reactions?
  3. Cosmetics or skin care products?
Psoriasis PsoriasisMay occur on the face but symptoms usually also occur elsewhere on the skin (pictures 33 34)
  1. History, cases in immediate family
  2. Lesions in other typical places

Facial infections

  • Impetigo Impetigo and other Pyoderma (pictures 35 36 37)
    • Usually few symptoms
    • Clearly defined erythematous spots with yellow crust, blisters or sores
    • The disease is always contracted from infected persons in the patient's immediate environment (close contacts).
  • Shingles Shingles (Herpes Zoster) (picture 38)
    • Usually begins with pain or tingling.
    • Unilateral
    • Erythematous skin painful to the touch (allodynia)
    • Groups of vesicles in single dermatomes
  • Erysipelas Erysipelas (pictures 39 40)
    • Fever and general symptoms
    • Acute hot, patchy erythema, usually plaque-like oedema
  • Herpes Viral Infections of the Oral Mucosa (pictures 41 42 43 44)
    • Usually begins with pain or tingling.
    • Lesions repeatedly occur in the same place.
    • Patchy erythema with groups of blisters
  • Eczema herpeticum (Kaposi varicelliform eruption; pictures 45 46)
    • In patients with atopic eczema, there may be widespread herpes in the facial area.
    • Acute, spreading eruption of vesicles and erosions
  • Ringworm Dermatomycoses
    • Usually in the bearded area, on the neck
    • Clearly defined, scaly at margins, often papulopustules
    • Remember to ask about any animal contact.

Other causes for facial skin problems

  • Vitiligo Vitiligo (picture 47)
    • Particularly around the eyes and the mouth
    • Asymptomatic, clearly defined, symmetric, hypopigmented patches
    • Often small islands of repigmentation in the patches
  • After atopic eczema has healed, patchy hypopigmentation (pityriasis alba) may remain.
  • Angioedema Hereditary Angioedema (HAE) and ACE Inhibitor-Induced Angioedema (pictures 48 49)
    • Pain, tingling, swelling of lips or eyelids
    • Occurs acutely.
  • Paroxysmal erythema, flushing Episodic Attacks of Flushing
    • Acute-onset erythema, heat
    • Sweating may occur.
  • Melasma (picture 50)
    • Chronic, well-defined patches of hyperpigmentation usually on the cheeks or temples
    • Often occurs after starting to take oral contraceptives or during pregnancy
  • Photodermatitis and other skin disorders associated with photosensitivity Photodermatitis (picture 51)
    • Polymorphic light eruption or phototoxic reactions, for example
    • History of exposure to sunlight
    • Itching and tingling in the areas exposed to UV light
  • Lupus erythematosus Systemic Lupus Erythematosus (Sle) (picture 52)
    • Types restricted to the skin; e.g. discoid lupus erythematosus (DLE)
    • Cheeks, nose, forehead
    • Chronic scar-forming plaques
    • Exposure to sunlight will make it worse.

Examination

History

  • Is this an acute or chronic problem? Aggravation of a pre-existing skin disorder?
  • Is there any history of skin disorders? Is there a family history of atopic eczema, for example?
  • Does the patient have any diagnosed contact allergy? Has the patient earlier developed reactions to cosmetics or skin care products, for example?
  • Are the lesions itchy (atopic eczema, allergic contact dermatitis)?
  • Does the patient have pain or general symptoms (infections)?

Clinical examination

  • Skin lesions should be examined both by taking a general look and at closer distance. Attention should be paid to:
    • Location (symmetric, unilateral, perioral, etc.)
    • Whether the lesions are scaly (suggesting an eczema) or whether there are papules or pustules (suggesting an acne-rosacea group disease)?
    • Whether the lesions are clearly defined?
    • Whether there is patchy erythema, blisters or sores (impetigo?), comedones or papulopustules (acne-rosacea group disease)?
  • Check other areas too (scalp, other skin areas, nails, ears, etc.).

Laboratory tests

  • In atopic eczema total serum IgE levels may be elevated but normal levels do not exclude the disease. Atopic eczemas in adults are usually not directly associated with IgE-mediated allergy and do not, as such, warrant allergy testing. In some patients, there may be IgE-mediated aggravation of the eczema (e.g. foodstuffs, animals, pollen) and, if so, specific IgE antibodies (dust analysis etc.) or skin prick testing may be indicated.
  • Samples for microscopy and fungal culture are required if facial ringworm is suspected.
  • In seborrhoeic eczema, Malassezia yeast may be seen on microscopy but fungal culture may still be negative. The diagnosis should be based on clinical features.
  • Epicutaneous tests may be indicated if allergic contact dermatitis is suspected.
  • Skin biopsy (to exclude malignancy or actinic keratosis, for example) is useful only if there is a skin tumour or if there are circumscribed, erythematous, scaly lesions.
    • In eczematous diseases, acne-rosacea group diseases and skin infections, skin biopsy is of use only in differential diagnosis (no specific histology).
  • In lupus erythematosus, serum antinuclear antibodies may be elevated. Negative findings do not exclude disease restricted to the skin Discoid Lupus Erythematosus.
    • If cutaneous lupus erythematosus is suspected, skin biopsy and immunofluorescence tests should be performed.

Treatment

  • Causative treatment, if possible
    • In allergic contact dermatitis, for example, the triggering factor should be avoided
    • Atopic facial eczema may be aggravated by airborne allergens (aggravation during the pollen season, by animal contact, etc.). In such cases, avoidance or reduction of exposure may be indicated.
    • Acne-rosacea group diseases may be aggravated or triggered by local glucocorticoids, systemic glucocorticoids or other hormones or some other systemic medications.
  • In eczematous diseases, the treatment of first choice is intermittent mild (Class I) topical glucocorticoids for 1 to 2 weeks, for example. In severe cases, mid-potency (Class II) products may be used for a short time (courses 1-2 weeks, for example).
    • The facial area is particularly sensitive to adverse effects of topical glucocorticoid ointments (telangiectasis, atrophy, changes in pigmentation). Potent or very potent topical glucocorticoids are to be applied to the facial area only in special cases.
  • Topical calcineurin inhibitors Topical Tacrolimus for Atopic Dermatitis (tacrolimus and pimecrolimus ointments) are also quite effective in the treatment of atopic eczema, often also other types of eczema and facial psoriasis.
  • In addition, there is evidence for the efficacy of topical antifungal medication, azelaic acid ointment or gel and metronidazole ointment or gel in the treatment of seborrhoeic eczema Topical Anti-Inflammatory Agents for Seborrhoeic Dermatitis of the Face or Scalp Seborrhoeic Dermatitis in the Adult.
  • The treatment of acne-rosacea group diseases differs essentially from that of eczematous diseases Rosacea Acne Perioral Dermatitis. Facial ringworm should be treated with topical antifungal medication. In difficult-to-treat Fungal Infections extending deep into the hair follicle (pustules, abscesses), systemic antifungal medication of 1 to 4 weeks should be combined with the treatment Interventions for Rosacea, see also Dermatomycoses Dermatomycoses.

Specialist consultation

  • Epicutaneous tests should be performed if allergic contact dermatitis is suspected.
  • A dermatologist should be consulted in case of severe facial rashes resistant to treatment.
  • Severe acne should be treated by isotretinoin under the supervision of a dermatologist.

    References

    • Gamble R, Dunn J, Dawson A et al. Topical antimicrobial treatment of acne vulgaris: an evidence-based review. Am J Clin Dermatol 2012;13(3):141-52. [PubMed]

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Primary/Secondary Keywords