Differential diagnoses: Facial rashes

Dr Nigel Stollery outlines the key clues to differentiate between these facial presentations.

Acne vulgaris

Presentation

  • Widespread distribution in sebum-rich areas
  • Onset usually with puberty but may start later in life
  • Comedones (open and closed), pustules and cysts may be seen
  • In females, it may be exacerbated by menses
  • Condition usually improves with sun exposure

Management

  • Treatment depends on severity
  • Topical antibiotics, benzoyl peroxide and topical zinc helpful
  • Oral antibiotics may be required
  • Topical isotretinoin is excellent for comedones and in more severe cases, an oral version may be required
  • Five per cent of cases will continue and may be life long

Rosacea

Presentation

  • Affects the face in adults and is more common in women
  • A chronic condition
  • Comedones are not a feature
  • Often associated with a past history of facial flushing
  • Most cases are made worse by exposure to sunlight
  • May be exacerbated by spicy food, heat and alcohol
  • In some cases, rhinophyma can also be a late feature

Management

  • In mild cases, a topical antibiotic, such as metronidazole, is helpful
  • In more persistent cases, oral antibiotic may be required
  • Oral isotretinoin can help where rhinophyma is present

Folliculitis

Presentation

  • Usually an acute condition affecting hair-bearing areas
  • In men, it may be associated with a shaving rash
  • May occur all over the body after swimming or hot tub use
  • In recurrent cases, nasal carriage of Staphylococcus aureus may be a factor

Management

  • A short course of oral antibiotics usually works well
  • If nasal Staph aureus detected, topical antibiotic can be helpful
  • If associated with shaving, avoid use of multi-blade razors
  • Emollients containing antiseptic can help to reduce the bacterial load on the skin

Perioral dermatitis

Presentation

  • Rash localised to the mouth
  • Usually only seen in females, especially those aged 20-45
  • Usually follows the use of topical steroids, especially fluorinated preparations
  • Rash has a tendency to recur
  • Usually exacerbated by soaps, facial washes and cream

Management

  • Stopping steroid cream advisable and usually helps
  • Topical antibiotics may be all that is required in mild cases
  • Oral tetracyclines usually help, but long courses of treatment may be required
  • Education about irritant effect of soaps and washes is important
  • Dr Stollery is a GP in Kibworth, Leicestershire

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