Clinical images: Adult faces

The face may be the main presentation or a clue to the diagnosis, explains Dr Philip Marazzi.


This 22-year-old man developed chickenpox. As is often the case in adults, the infection was quite severe, causing significant systemic disturbance as well as the rash. He was treated with valaciclovir and needed two weeks off work to recover. Complications are more common in adults, with a significant number developing pneumonia. Once infected, the virus remains long term, often reappearing as shingles in the future.


This man initially presented with recurrent lacrimal duct infections. There was no obvious cause, but he was investigated and found to have extensive disease in his maxillary sinus, orbit and nasal cavity. Histology confirmed squamous cell carcinoma. He was treated with radical radiotherapy, but later found to have developed lymph node and cerebral metastases. Here, he has developed a reaction following his radiotherapy, with a very sore face. Sadly, his condition deteriorated and he died soon after.

Necrotising fasciitis

This 43-year-old man played rugby. He was kicked in the face during a game and presented in the surgery the following day. It was difficult to tell how much damage had been done, so he was referred to the eye clinic. His skin worsened and he was diagnosed as having necrotising fasciitis. The condition required subsequent skin grafting to the eyelid as the skin died. He has done well since then, with no further problems.

Bell's palsy

This 49-year-old man developed the characteristic facial weakness as a result of a facial nerve problem. This nerve controls many of the facial muscles. The cause is often a herpes virus infection, so a combination of antivirals and steroids is often prescribed (antivirals are yet to be proven beneficial for this condition), with most patients making a full recovery within a few weeks.


This young woman has an atopic history, but this reaction is angioedema and may or may not be allergy related. The only possible cause that could be isolated was the fact that she had recently started taking citalopram. This was stopped and she was treated with high-dose antihistamines and steroids. She had no breathing problems and was not treated with adrenaline, although she was given some for any future reactions.


Exfoliative dermatitis

This elderly man had initially presented years earlier with bowel symptoms. He was found to have a caecal carcinoma and had successful surgery. Unfortunately, he was then found to have metastatic spread and was maintained for several years on 5-fluorouracil. He again relapsed and was given bevacizumab, which produced this rash. Moderate potency steroids and emollients calmed it down, although his disease no longer responded to treatment and he died soon after.


This woman had a difficult combination of aggressive rheumatoid disease and Crohn’s disease. Her management was further complicated by the fact that she spent much of her time abroad, where her specialists’ view of how to manage her differed from that of our DGH. She presented feeling tired and looking very pale. Her haemoglobin was 6.1, so she was admitted for transfusion and aggressive management of her two main diseases.

Alcoholic liver disease

This woman presented with mild jaundice. On questioning, it became clear that she had been drinking heavily for some time. She had deranged blood test results. She was quite unwell and finally recognised the reason for her illness and reduced her drinking. Her blood tests improved.

  • Dr Marazzi is a GP in East Horsley, Surrey

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