Time to Learn 6 th March 2018 Dr. Shirin Chakera GPwSI Integrated Dermatology Service
The Red Face Rosacea Acne Seborrhoeic eczema eczema Psoriasis Slapped cheek syndrome Fungal infection Erysipelas... Rare Systemic lupus erythematosus Lupus pernio
Rosacea Older age group Vasodilation and then sebacious hyperactivity Papules and pustules No comedones. Generally face only. Often flushing and telangectasia.
Rosacea Subtypes i)erythemovascular -erythema that is initially intermittent but becomes more permanent sparing peri-oral and periorbital skin. ii)papulopustular- central and facial erythema and telangiectasia. Transient pustules and/or papules present centrally or peri-orally. Frequently associated burning/ stinging
Rosacea subtypes continued (iii)phymatous rosacea (iv)ocular rosacea
Topical and oral treatment PCDS 2017 Subtype I Vascular Erythematotelangiectatic Subtype II Inflammatory Papulopustular Subtype IV Ocular +++ Intense Pulsed Light ++ Brimonidine Gel 0.33% ++ Pulsed Dye Laser ++ Clonidine 25-50 mcg TDS + Propranolol 10-40mg TDS +++ Ivermectin 10mg/g cream 1% +++ MR Doxycycline 40mgs OD ++ Doxycycline 100mg/ Lymecycline 408mg ++ Azelaic Acid 15% ++ Isotretinoin + Metronidazole gel/cream 0.75% + Oxytetracycline 500mgs b.d + Erythromycin/Clarythromycin 500mgs b.d +++ Eyelid hygiene measures, ocular lubricants ++ Doxycycline 100mg/ lymecycline 408mg + Oxytetracycline 250-500mg Refer to ophthalmologist +++ Strong recommendation ++ Moderate recommendation + Low recommendation
Acne Onset often at puberty 16-20yrs. Can also start 20-30s but can persist into 40s. Usually, symmetrical forehead, chin, lateral face, nose Mixed inflammatory and noninflammatory lesions Papules, pustules,nodules and comedones. Look at chest and back
Acne Open comedones (blackheads) Closed comedones (white heads)
Seborrhoeic eczema Scaling and erythema Often nasolabial folds, eyebrows, scalp. Sometimes also chest. Treat with topical antifungal e.g. ketoconazole +/- hydrocortisone or Pimecrolimus.
Erythema and fine scale of eyebrows,midline of face and behind ears-can affect any part of the ear but Seborrhoeic Eczema has a preference for the post auricular skin, and external auditory meatus. Associated with blepharitis
Atopic eczema Check past history of eczema symmetrical Evidence of eczema elsewhere such as flexure areas of elbows knee creases Intensely itchy Chronic dryness, lichenification, Dennis Morgan folds (2 creases in lower eyelids)
Contact dermatitis Acute, relapsing/intermittent or chronic presentation Irregular, variable, unilateral or symmetrical dermatitis Sharp border if contact irritant dermatitis Patch tests positive if contact allergy
The face is not a common site for psoriasis. It occasionally presents with well demarcated plaques. A more frequent finding is similar to tha seen in Treatment Emollients and gentle non soap cleansers Vitamin D analogues such as silkis ointment in combination with hydrocortisone Tacrolimus ( 0.1%Protopic ) ointment but unlicenced Psoriasis seborrhoeic dermatitis. In fact the two can be difficult to tell apart and sometimes referred to as sebopsoriasis
Facial psoriasis Eyelids, temples, retro- and preauricular skin and/or seborrhoeic dermatitis sites Also affects scalp, ears, elbows, knees, nails Well-demarcated erythematous plaques White scale symmetrical More persistent than seborrhoeic dermatitis
A rash presenting around the mouth and chin. Small papules. No comedones. Often associated with use of topical steroids Perioral Dermatitis Treatment 6-12 week course of oxytetracycline 250mg bd or lymecycline 408mg or doxycycline 40mg daily
Perioral dermatitis Small papules around the mouth and sometimes nose and eyes. No comedones. Often associated with use of topical steroids. Responds well to tetracycline.
Steroid Acne Caused by the excessive use of oral or potent topical corticosteroids. Monomorphic (similar) lesions
Photosensitivity rashes Exposed areas of face, arms, chest, legs Spares under hair, eyelids, creases Flares after exposure outdoors May be drug-induced-such as amiodarone, furosemide, nalidixic acid, and sulphonamides Drug induced phototoxic rash
Erysipelas A superficial form of cellulitis. It usually follows a breach in the skin. If promptly treated the infection is Iconfined to the affected area. Strep infection iespecially group A Is the most common cause of erysipelas
Acute cutaneous LE affects atleast 50% of patients with systemic lupus erythematosus (SLE) SLE Butterfly erythematous rash Systemic symptoms:tiredness, lethargy,arthralgia
Cutaneous Lupus Erythematosus Inflammatory plaques
Sarcoidosis Approximately 20-35 % of patients with systemic sarcoidosis have skin lesions but cutaneous sarcoidosis can occur without systemic involvement Lupus Pernio : large bluish-red and dusky purple infiltrated nodules and plaque-like lesions on nose, cheeks, ears, fingers and toes (not chilblains)
Facial involvement in sarcoid Maculopapular Most common cutaneous finding especially black women Red brown macules and papules commonly involving periorbital areas and nasolabial folds
Erythema infectiosum A so called slapped cheek appearanceconfluent erythematous patches or plaques on the cheeks with sparing of the nasal bridge and periorbital regions
Acknowledgements Slides and content from PCDS and Dermnet new Zealand Slides from other presenters for About Health Useful websites www.pcds.org.uk www.dermnetnz.org www.bad.org.uk