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Facial rash - sorting out the symptoms

In the second part of their new series on how to make sense of common presentations, GPs Dr Keith Hopcroft and Dr Vincent Forte look at facial rash

In the second part of their new series on how to make sense of common presentations, GPs Dr Keith Hopcroft and Dr Vincent Forte look at facial rash

The GP overview

Facial rash is a common presentation, with a wide differential and causes the patient significant concern, largely because of the cosmetic impact. Occasionally, it can represent significant pathology. Individual spots – such as basal cell carcinoma – are not considered here.

Differential diagnosis

Common

• acne

• rosacea

• seborrhoeic eczema

• impetigo

• perioral dermatitis

Occasional

• chloasma

• sycosis barbae

• drug side-effect – especially phototoxicity

• infection, such as herpes zoster and herpes simplex, cellulitis, chicken pox or slapped cheek disease

• allergic eczema

• acne excoriée

• post-inflammatory hypopigmentation or hyperpigmentation

• pityriasis alba

• petechiae from coughing, vomiting or straining

• other generalised skin diseases, such as psoriasis or vitiligo

Rare

• Stevens–Johnson syndrome

• SLE

• mitral flush

• tuberous sclerosis

• lupus vulgaris

• sarcoidosis

• dermatomyositis

Typical investigations

Likely None

Possible FBC, ESR, autoantibody screen, creatine phosphokinase

Small print Viral or bacterial swabs, skin biopsy, muscle biopsy

• FBC WCC raised in any infection; may be normochromic, normocytic anaemia in SLE

• ESR, autoantibody screen ESR likely to be raised in infection and SLE; autoantibodies may be positive in the latter

• Creatine phosphokinase Elevated in dermatomyositis

• Viral or bacterial swabs To help diagnosis in obscure cases or if secondary infection is suspected

• Skin biopsy; muscle biopsy The former for suspected lupus vulgaris or sarcoidosis; the latter to confirm dermatomyositis

Top tips

• Do not underestimate the possible impact of a facial rash on a patient's life. The cosmetic effect may be devastating.

• A therapeutic trial of antibiotics in acne may not take effect for three months – ensure the patient is aware of this.

• Remember that impetigo may simply represent superinfection of an underlying skin problem, such as eczema, which will require treatment in its own right.

• Check on over-the-counter medication use. Hydrocortisone 1% cream is available OTC – inappropriate use might aggravate rosacea and perioral dermatitis.

• Parents are sensitised to non-blanching rashes. They can be reassured that such a rash restricted to the face – indeed, restricted to the entire distribution of the superior vena cava – is not meningitis.

Dr Keith Hopcroft is a GP in Basildon, Essex

Dr Vincent Forte is a GP in Gorleston, Norfolk

This is an extract from the third edition of Symptom Sorter published by Radcliffe Publishing, priced £24.95 ISBN-10 1 84619 1955

SLE is a rare cause of facial rash SLE is a rare cause of facial rash

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