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Why is this woman's face burnt and reddened?

Dr Mike Wyndham on how a patient left out the most crucial piece of diagnostic information

 

The patient

The 55-year-old patient coughed heavily as she sat down and said: ‘It's one thing after the other.'

Ten days previously, she had developed a sore throat and a fever. This was followed two days later, by the development of a cough. This persisted to the weekend and so she took herself off to the local walk-in centre. The result was that she had been diagnosed with a presumed chest infection.

Her condition improved to the extent that she felt well enough to resume her training for a sponsored walk towards the end of the treatment. She was also delighted to take the chance to top up her tan following a recent Far Eastern holiday.

The following day she woke with a burning sensation on her face. A look in the mirror confirmed redness affecting her forehead, eyelids, nose and cheeks.

First instinct

I felt I should go for the obvious and suggest that the problem was acute sunburn. She agreed with me but thought it was all a bit strange. She had enjoyed many sunny holidays abroad but had virtually never suffered with sunburn.

Differential diagnosis

• SLE

• Phototoxicity

• Polymorphic light eruption (PLE)

• Sunburn

• Acne rosacea

• Contact sensitivity to airborne allergens

The butterfly rash can be found in about one-third of people with SLE. But she had no other symptoms suggestive of the multisystem disease, making it unlikely.

Phototoxicity was definitely a possibility with areas such as the chin and under the nose being spared. I would have expected the eyelids to be spared but they seemed a little red.

PLE is more common in women with vesicles, papules and plaques developing within 24 hours of sun exposure. This diagnosis seemed unlikely as she hadn't suffered any sun exposure problems while on her recent holiday.

Acne rosacea certainly affects the cheeks but it usually has a papular or pustular appearance. This did not seem apparent here.

Allergens that are carried by air – hairsprays, animal hairs, pollens – may cause a dermatitis affecting the skin that is exposed to air. Usually, there is no skin-sparing with this condition.

Getting on the right track

Phototoxicity seemed the most likely diagnosis but the underlying cause was uncertain. That was until she pulled the medication she had been prescribed at the walk-in centre out of her handbag.

I've no idea why she hadn't told me right at the start that they had given her a prescription for doxycycline, especially as she added: ‘I had a look at the leaflet accompanying the antibiotics and it said my skin might be more sensitive to the sun.'

Dr Mike Wyndham is a GP in Edgware, north London

Why is this woman's face burnt and reddened? Why is this woman's face burnt and reddened?

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