Time to Learn

6th March 2018 Dr. Shirin Chakera GPwSI Integrated Dermatology Service

The Red Face Rosacea Acne Seborrhoeic eczema eczema Psoriasis Slapped cheek syndrome Fungal infection Erysipelas ...... Rare Systemic lupus erythematosus Lupus pernio

Rosacea • Older age group • Vasodilation and then sebacious hyperactivity • Papules and pustules • No comedones. • Generally face only. • Often flushing and telangectasia.

ii)papulopustular- central and Rosacea facial erythema and telangiectasia. • Transient pustules and/or Subtypes papules present centrally or i)Erythemovascular peri-orally. • Frequently associated burning/ -erythema that is initially intermittent but becomes more permanent sparing stinging peri-oral and periorbital skin.

Rosacea –subtypes continued

(iii)Phymatous rosacea (iv)Ocular rosacea Topical and oral treatment PCDS 2017 Subtype I Subtype II Subtype IV Vascular Erythematotelangiectatic Inflammatory Papulopustular Ocular

+++ Intense Pulsed Light +++ Ivermectin 10mg/g cream 1% +++ Eyelid hygiene measures, ++ Brimonidine Gel +++ MR Doxycycline 40mgs OD ocular lubricants 0.33% ++ Doxycycline 100mg/ Lymecycline 408mg ++ Doxycycline 100mg/ ++ Pulsed Dye Laser lymecycline 408mg ++ Azelaic Acid 15% ++ Clonidine 25-50 mcg + Oxytetracycline 250-500mg ++ Isotretinoin TDS Refer to ophthalmologist + Metronidazole gel/cream 0.75% + Propranolol 10-40mg TDS + Oxytetracycline 500mgs b.d + Erythromycin/Clarythromycin 500mgs b.d

+++ Strong recommendation ++ Moderate recommendation + Low recommendation Acne Onset often at puberty 16-20yrs. Can also start 20-30s but can persist into 40s. Usually, symmetrical forehead, chin, lateral face, nose Mixed inflammatory and non- inflammatory lesions Papules, pustules ,nodules and comedones. Look at chest and back

Acne Open comedones Closed comedones (white (blackheads) heads) Seborrhoeic eczema

• Scaling and erythema • Often nasolabial folds, eyebrows, scalp. Sometimes also chest. • Treat with topical antifungal e.g. ketoconazole +/- hydrocortisone or Pimecrolimus.

Seborrhoeic Eczema Erythema and fine scale of has a preference for the post auricular eyebrows,midline of face and behind skin, and external auditory meatus. ears-can affect any part of the ear but Associated with blepharitis Atopic eczema

Check past history of eczema symmetrical Evidence of eczema elsewhere such as flexure areas of elbows knee creases Intensely itchy Chronic dryness , lichenification, Dennis Morgan folds (2 creases in lower eyelids)

Contact dermatitis Acute, relapsing/intermittent or chronic presentation Irregular, variable, unilateral or symmetrical dermatitis Sharp border if contact irritant dermatitis Patch tests positive if contact allergy

The face is not a common site forPsoriasis psoriasis. It occasionally presents with seborrhoeic dermatitis. In fact the two well demarcated plaques. A more can be difficult to tell apart and frequent finding is similar to tha seen sometimes referred to as sebo- in psoriasis • Treatment • Emollients and gentle non soap cleansers • Vitamin D analogues such as silkis ointment in combination with hydrocortisone • Tacrolimus ( 0.1%Protopic ) ointment but unlicenced Facial psoriasis Eyelids, temples, retro- and pre- auricular skin and/or seborrhoeic dermatitis sites Also affects scalp, ears, elbows, knees, nails Well-demarcated erythematous plaques White scale symmetrical More persistent than seborrhoeic dermatitis

Perioral Dermatitis A rash presenting around the mouth and chin. Small papules. No Treatment 6-12 week course of comedones. oxytetracycline 250mg bd or Often associated with use of topical lymecycline 408mg or doxycycline steroids 40mg daily Perioral dermatitis

• Small papules around the mouth and sometimes nose and eyes. • No comedones. • Often associated with use of topical steroids. • Responds well to tetracycline. Steroid Acne

• Caused by the excessive use of oral or potent topical corticosteroids. • Monomorphic (similar) lesions Photosensitivity rashes

Drug induced phototoxic rash Exposed areas of face, arms, chest, legs Spares under hair, eyelids, creases Flares after exposure outdoors May be drug-induced-such as amiodarone, furosemide, nalidixic acid, and sulphonamides Erysipelas

A superficial form of cellulitis. It usually follows a breach in the skin. If promptly treated the infection is Iconfined to the affected area. Strep infection iespecially group A Is the most common cause of erysIpelas

SLE Acute cutaneous LE affects atleast 50% Butterfly erythematous rash of patients with systemic lupus Systemic symptoms:tiredness, erythematosus (SLE) lethargy,arthralgia Cutaneous Lupus Erythematosus

Inflammatory plaques Approximately 20-35 % of patientsSarcoidosis with systemic sarcoidosis have skin lesions but cutaneous sarcoidosis can occur without systemic involvement Lupus Pernio : large bluish-red and dusky purple infiltrated nodules and plaque-like lesions on nose, cheeks, ears, fingers and toes (not chilblains) Facial involvement in sarcoid

Maculopapular Red brown macules and papules Most common cutaneous finding commonly involving periorbital areas especially black women and nasolabial folds Erythema infectiosum

A so called slapped cheek appearance- confluent erythematous patches or plaques on the cheeks with sparing of the nasal bridge and periorbital regions

Acknowledgements

Slides and content from PCDS and Dermnet new Zealand Slides from other presenters for ‘About Health’ • Useful websites • www.pcds.org.uk • www.dermnetnz.org • www.bad.org.uk