Follicular skin diseases
Facial rash case challenge 1
Select the term(s) which best describe this rash.
#! Erythematous papules || A small palpable lesion less than 0.5 cm diameter. They are raised above the skin surface, and may be solitary or multiple.
#! Scaly plaques || A palpable flat lesion greater than 0.5 cm diameter. Most plaques are elevated, but a plaque can also be a thickened area without being visibly raised above the skin surface. They may have well-defined or ill-defined borders.
Explanation: She has clustered erythematous papules and scaly plaques on the upper lip, chin, lower eyelid and lateral canthus. There are no comedones or telangiectases.
She tells you she has been applying several creams to her face off and on over the last year.
Which one is most likely to have caused this appearance?
*! Betamethasone valerate cream
* Oil-free moisturiser
* Sunscreen gel
* Benzoyl peroxide acne lotion
Choose the best diagnosis from the following options:
* Acne vulgaris
* Seborrhoeic dermatitis
*! Periorificial dermatitis
Explanation: The patient has severe periorificial dermatitis. Unlike acne, there are no comedones, and the papules are grouped, coalescing into plaques, some of which are scaly. The affected areas of the chin, nasolabial folds and eyelids are typical, with relative sparing of the skin on the vermilion border.
Which would be the most suitable twice-daily medication for the next six weeks?
* Metronidazole gel
*! Minocycline 50mg
* Ketoconazole cream
* Hydrocortisone cream
Explanation: Topical agents should generally be avoided in periorificial dermatitis, although short-term use of any of the suggested medications might be somewhat helpful. Minocycline should result in gradual disappearance of the papules and plaques over a few weeks but it may take longer for the erythema to disappear.
She is pregnant. What medication would you advise now?
Short answer: Tetraycline antibiotics such as minocycline should be avoided in pregnancy because they may cause yellowing of developing teeth in the fetus.
- The potent topical steroid cream should be discontinued
- She could apply 1% hydrocortisone cream for a couple of weeks then reduce frequency of applications, discontinuing altogether within one month
- Twice daily applications of topical azelaic acid are permitted
- If the rash fails to clear, she can be prescribed erythromycin 500mg twice daily for a month.