Facial problems in adults

Contributed by Dr Philip Marazzi, a GP in East Horsley, Surrey.

Trauma
Older patients frequently suffer falls. This man was doing his best to maintain his general fitness by cycling on a regular basis. Unfortunately, he fell off his bicycle sustaining these facial injuries. Although they look dramatic, there were no bone injuries and his injuries settled down over a couple of weeks.

Psoriasis


This patient has quite severe psoriasis. It affects her face, which is not very common. Although many triggers may bring on an episode of psoriasis, she has a strong family history of the condition with both her mother and son being affected. She has been treated with a variety of different options, including psoralen combined with UVA, but methotrexate has been the most successful treatment.

Anaemia


This young woman presented after collapsing. She was very pale and had a history of menorrhagia. Her blood was checked and the haemoglobin found to be 69g/l with an MCV of 60fl. This was in spite of her taking oral iron supplements. She was treated with a combination of tranexamic acid and mefenamic acid. The treatment appears to have been effective and her haemoglobin levels have remained normal ever since.

Eczema


This 50-year-old woman had lifelong atopic eczema. Her face shows some of the characteristic appearances of chronic eczema with dry, red skin. The management of the condition consists of moisturising, anti-inflammatory medication and avoiding skin irritants. Skin irritants can be difficult to pinpoint and may include chemicals found in certain emollients. Choice of emollient is therefore important. Care must also be taken to avoid potent steroids as they carry significant risks when used on the face.

Rosacea


This elderly man presented with a rash on his face due to rosacea. The condition often develops in middle age and is twice as common in women, affecting up to one in 10. The cause is unknown and there is no cure. Patients present with redness and spots on the face. A more severe form is rhinophyma, mostly seen in elderly men. Management is aimed at control with avoidance of triggers. Most patients can be treated with topical or oral antibiotics. Severe cases may require isotretinoin and plastic surgery.

COPD


This elderly smoker has the classic appearance of Pickwickian syndrome with a large neck and obesity. Although he snores, the possibility of sleep apnoea was uncertain. He also has a range of major health issues, including COPD, IHD, cerebrovascular disease, diabetes and hypertension, so he was investigated at a sleep laboratory. He was diagnosed with obstructive sleep apnoea.

Ramsay Hunt syndrome


This 48-year-old woman presented with right-sided facial weakness. This condition is caused by herpes zoster infection of the geniculate ganglion of the facial nerve. The facial weakness is more commonly seen in Bell's palsy, but this woman also had some blisters in her mouth. She was treated with oral aciclovir and made a complete recovery. However, it is not uncommon to develop potentially long-lasting complications from this condition, including tinnitus, hearing loss and neuralgia.

Jaundice

This 68-year-old woman presented with non-specific symptoms, including back pain. No obvious cause was apparent but she subsequently became jaundiced, with an ALT of more than 1000IU/L. A malignancy was the likely cause but investigations revealed that she was suffering from hepatitis B. She was not a high-risk individual and had not indulged in any high-risk behaviour - in fact, she had been a blood donor for several years without any sign of the infection. Her husband was tested and found to be negative. She had no specific treatment and the virus cleared with no sequelae.

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