Dr Rebecca Mawson Discusses Possible Causes of a Facial Rash in Adults and How to Diagnose on the Basis of Clinical Observations
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Facial rashes are a common presentation in primary care and are often very distressing for the affected individual, causing embarrassment and frustration. Approximately 14% of GP consultations are for the management of skin conditions1 and around 8% of all antibiotics prescribed in the UK2 are thought to be for the management of skin conditions. Antibiotics have been an important treatment of choice for acne for around 50 years, but with the continuing global increase in the use of antibiotics, and resistance reported in all major regions of the world, the responsible use of antibiotics is of major concern.3
Making a clear diagnosis before starting treatment can help improve outcomes and management. The Primary Care Dermatology Society (PCDS) has developed a range of guidelines on skin conditions, which aim to help GPs create targeted, rational treatment plans for people with skin conditions.
The following differential diagnosis case studies will explore possible causes of facial rashes, with the aim of making it easier to understand the presentations and complexity.
Samantha is 45 years old and works in a media job, which involves entertaining guests and public speaking. Samantha tells you that 18 months ago she noticed she had started blushing more, especially when consuming alcohol and when she is stressed due to public speaking. Her skin often feels flushed and hot. She has recently started to get some raised pimples on the skin. She mentions that on a recent trip to Spain, her skin seemed to flare in the sunlight.
The likely diagnosis is rosacea. The following clinical features are often observed in people with rosacea (see Figure 1, above):
- telangiectasia (small vessel growth)
- skin inflammation across surface
- absence of open comedones (blackheads).
Making a clear diagnosis is important with rosacea so that the patient can develop a better understanding of the condition, which in turn leads to better management.
Rosacea is a chronic skin condition requiring long-term therapy to maintain control of symptoms. A stepwise approach targeting the predominant symptoms of the patient’s rosacea is essential; the PCDS rosacea guideline can advise on appropriate treatment options.4 There are also general measures that patients can take to help themselves, such as avoiding direct sunlight and using face lotions with sun protection factor (30+).5 Topical brimonidine can be used to treat erythema symptoms in adults.4
Ocular rosacea occurs in over 50% of people with rosacea. Symptoms include:4,6
- gritty eyes with blepharitis
- inflammation of the lids and meibomian glands
- conjunctival telangiectasia.
There may also be stinging or burning of the eyes, dryness, irritation with light, or foreign body sensation.6 Refer to the PCDS rosacea guideline for information on managing ocular symptoms.4
For Samantha, the facial flushing was a predominant feature. Her symptoms improved after using brimonidine gel for 4 weeks. Following her GP’s advice, she now takes care to limit her exposure to sunlight, and uses high-factor sunblock. Samantha has been using tips from the National Rosacea Society on self-management and feels empowered to control her symptoms, even though no ‘cure’ has been achieved.
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John is 21 years old and has come to you with symptoms of depression. A closer discussion reveals that much of his unhappiness stems from his ‘spots’, which developed a few years ago. He has tried various over-the-counter products without much luck and is now reluctant to leave home and is socially isolated.
The likely diagnosis for John is acne. The following clinical features are often present (see Figure 2, above):
- open and closed comedones (black and white heads)
- inflammation surrounding the comedones
- seborrhoea (increased sebum production)—the patient may describe this as a ‘shine’ to their skin.
Occasionally, the inflammation and infection can lead to scarring. In most cases, this can be prevented with the timely administration of a suitable treatment.7
The most important aspect of acne treatment is support and monitoring for improvement, with close attention to development of scarring. It is not appropriate to send a patient away with no plans for further review. Inform the patient that it may take 4–8 weeks of treatment before there are any signs of improvement8 and support them with compliance. Selecting an appropriate treatment for acne depends on the clinical findings and patient choice; follow the stepwise approach described in the PCDS acne vulgaris guideline to inform this.9 Oral antibiotics should not be prescribed as monotherapy for the treatment of acne.8
Acne can cause a significant degree of psychological distress to the affected individual. In the author’s clinical experience, people with acne often feel that they are not taken seriously by healthcare professionals. There are links between acne and depression as well as a risk of self-harm.9 It is worth asking the patient about their mental health state, which may indicate referral to secondary care if the acne is causing significant distress.8 Acne scarring is also an important aspect to identify as this is a marker for severity but also requires urgent action to prevent further scars forming.
John needs to be monitored carefully and regularly. He will likely need a combination of topical treatment and oral antibiotics—especially in view of the psychological impact the acne is having on him. If there is an improvement and his mood stabilises then it would be reasonable to persist with treatment for up to 3 months. If his mood deteriorates or his skin worsens then referral to secondary care would be warranted. This psychological distress needs to be clearly stated in the referral letter, as some commissioners will not accept referral unless multiple courses of antibiotic therapies have been tried.
- for practitioners:
Anthony is a 34-year-old man. He presents with a salmon-pink rash on his face, which he says appeared a few months ago in the middle of winter. On examination, the rash is found mainly to affect the creases of his face but also appears slightly on the scalp. Anthony says that he is not particularly bothered about it, but he has found the scales and dryness uncomfortable. He explains that the rash first appeared last winter, but it got better over the following summer when he was in the sun.
The likely diagnosis is seborrhoeic dermatitis. The following clinical features are often present (see Figure 3, above):
- ill-defined plaques in skin folds on both sides of the face
- itchy and flaky skin
- salmon-pink rash.
The NICE Clinical Knowledge Summary on Seborrhoeic dermatitis recommends treatment for at least 4 weeks with ketoconazole 2% cream, applied either once or twice a day.10 Other imidazole creams, such as clotrimazole, econazole, or miconazole, can be used as alternatives.10 A mild corticosteroid might also help with inflammation.10 Once the symptoms settle, advise the patient to reduce the frequency of application to once or twice a week to prevent recurrence.10
Seborrhoeic dermatitis is the most common skin manifestation of HIV infection. There is a current drive to destigmatise HIV testing in primary care and increase uptake. This does not mean everyone with seborrhoeic dermatitis needs an HIV test, but it should raise a red flag if a patient with severe or widespread seborrhoeic dermatitis repeatedly presents to general practice and has risk factors for HIV.
Anthony was prescribed ketoconazole cream for 4 weeks—his skin showed a good response to the treatment. Following his GP’s instructions, Anthony then went on to use the cream once a week in the winter months to reduce the likelihood of reoccurrence.
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Kelly is a 21-year-old shop assistant and has two children. Kelly is usually fit and healthy, and does not come to see the GP very often, but when you call her from the waiting room she looks unwell and has a red butterfly rash over her cheeks. She says she feels like she has flu. On examination, you notice a malar rash across her cheeks.
The diagnosis is cutaneous lupus erythematosus. Look out for a malar rash across both cheeks (see Figure 4, left). Photosensitivity is common, and the lesions are often induced by exposure to sunlight.11
Cutaneous lupus erythematosus is very rare and practitioners may never see a case in primary care. The author has included it in this differential diagnoses article as often there is fear of missing a critical diagnosis. Generally, rheumatology or dermatology specialists would investigate and manage this disease. If you suspect that a patient has either cutaneous or systemic lupus, contacting the local on-call dermatology service for advice would be the best option as different areas manage the disease in different ways. Treatment depends on the severity of the disease and how it affects the individual. Cutaneous lupus erythematosus is an autoimmune disorder, and may respond to treatment with low-potency immunosuppression medications such as hydroxychloroquine.12
Cutaneous lupus erythematosus has some features similar to rosacea and should be considered if the patient has not responded to rosacea treatment, or if systemic symptoms are present.
- for patients:
- for practitioners:
- Okon L, Werth V. Cutaneous lupus erythematosus: diagnosis and treatment. Best Pract Res Clin Rheumatol 2013; 27 (3): 391–404.11
Managing facial rashes can be frustrating for both patients and clinicians. The key to success is to make a clear diagnosis and to aid the patient with treatment compliance. Offering a review appointment and discussing how to manage flares are essential elements for developing a patient-led management plan.