facial dermatoses

Facial dermatoses

25 interactive case reports

Daniel Wallach, MDSenior lecturer,

Tarnier Hospital Paris

Facial dermatoses: general data

• High frequency

• All dermatological diagnoses can be met

• Location is crucial in psychological-social

consequences (quality of life)

• Parcimonious biopsies

• Worsening role of sun exposure

Case # 1

• 32-year-old woman, florist

– Has suffered from erythematous dermatitis flare-ups on the face for several years

– Treated more or less successfully with potent topical steroids

– Generally consults when flare-ups occur

What is your diagnosis?

A – Lupus erythematosus

B – Contact dermatitis

C – Atopic dermatitis

D – Contact photoallergy

Atopic dermatitis in adults

• Persistent AD, with flare-ups during stressful situations– or rarely newly-onset : make sure of diagnosis

• Includes severe forms, risks of complication, therapeutic difficulties

• A particular form predominates on the head and neck. – Were incriminated :

• photosensitization (phenothiazines)• airborne contact allergens• Malassezia

– A good indication for topical tacrolimus

Atopic dermatitis in adults

Case # 2

• 46-year-old man

• No relevant medical history

• Plaques on the nose for the past six months

• Unsuccessfully treated with tetracyclines


A – Rosacea

B – Lupus erythematosus

C – Lymphoma

D – Sarcoidosis

A biopsy was performed

Well-defined nodules of epithelioid cells, surrounded by a

lymphocytic ring


A – Rosacea

B – Lupus erythematosus

C – Lymphoma

D – Sarcoidosis

Another case of « plaque »cutaneous sarcoidosis

Polymorphism of cutaneous sarcoidosis

• Small smooth, pinkish-red nodules

• Large nodules, with lupoid infiltrate

• More diffuse infiltrates

– Lupus perniosis (chilblain lupus, chilblain-like

BBS)

• Hypodermic Nodules, ulcerations,

erythroderma, granulomas on scars, …

Summary: sarcoidosis

• Adenopathies– Mediastinal– Others

• Pulmonary parenchyma – Micronodules– Macronodules– Diffuse infiltrates – Pulmonary fibrosis, emphysema

• Other locations:– Eyes, salivary glands, bones, nerves, …. (all organs)

Treatment for cutaneous sarcoidosis

• Only systemic steroids (one to two years) are truly effective

• Although they are difficult to prescribe in isolated cutaneous lesions

• Facial involvement may represent an indication• Other treatments:

– Topical or intralesional steroifs– Cryotherapy – Anti-malarials– Methotrexate.

Case # 3

• 64-year-old man • Hypertensive• Treated for lung cancer • Consults for a recent pustular eruption of the

face and trunk


A. Late-onset acne

B. Pustular rosacea

C. Adverse drug reaction

D. Pustular psoriasis

Acneiform eruption due to gefitinib

• Inhibitor of EGF receptor tyrosine kinase (Receptor of the Epidermal Growth Factor, involved in

tumoral growth)

• Used in numerous types of advanced cancers (notably non-small cell lung cancers)

• Well-tolerated, apart from cutaneous side-effects which may be correlated with the treatment’s effectiveness. – Often : acneiform or rosacea-like eruption– Rare : xerosis, eczematiform eruption, telangiectasias,

hyperpigmentations, paronychias, pyogenic granulomas

Case # 4

• 33-year-old woman,

• Teacher,

• No relevant medical history,

• Treated for several months with tetracyclines, unsuccessfully, for an acneiform pruriginous eruption on the face

Close-up:


A. « Adult » acne

B. Rosacea

C. Demodecidosis

D. Sarcoidosis

How to diagnose demodecidosis?

• Rosacea-like erythema and papules

• Without true rosacea features

• Pruritus

• « Rough » skin

• Rapid and clear response with an antiparasitic

treatment (crotamiton, lindane)

If a biopsy were performed

The presence of Demodex in the follicles is not pathognomonic of demodecidosis, and is less valuable than the successful tested treatment.

Another case of demodecidosis

Case # 5

• 72-year old woman, rushed to hospital for severe deterioration of her general state of health,

• High fever,

• facial eruption.


A. Necrotizing fasciitis

B. Malignant staphylococcal infection

C. Sweet’s syndrome

D. Mucormycosis

Sweet’s syndrome

• Belongs to the group of theneutrophilic dermatoses

• is paraneoplastic in 30% of cases (leukemias, …)

• Is very sensitive to systemic steroids

Histopathology of Sweet’s syndrome

Neutrophilic infiltrate of the superficial dermis, edema of the dermal papilla

Sweet’s syndrome frequently involves the face

Case # 6

• 62-year-old man,


• Consults for scaly lesions on the mediofacial area, present for about a year

• Several topical antifungal treatments have been tested, with no improvement


A. Seborrheic dermatitis

B. Psoriasis

C. Superficial pemphigus

D. Bazex syndrome

Seborrheic pemphigus, or Pemphigus erythematosus, or Senear – Usher syndrome

• Belongs to the group of superficial pemphigus

• Affects seborrheic facial areas

• Spares mucous membranes

• Nikolski’s sign is present

• No to be mistaken for seborrheic dermatits or lupus

erythematosus

• May be sensitive to : – Topical steroids

– Disulone

– Low-dose systemic steroids

One case of pemphigus vulgaris involving the face

Biopsy is essential

Superficial intra-epidermic blister, discrete acantholysisIFD : intercellular IgG and C3 depositsWB, ELISA : anti-desmoglein 1 auto-antibodies (160 kD)

Case # 7

• 32-year-old woman, general practicioner


• Has had a lesion on the nose for two months


A. Benign cutaneous lymphocytoma

B. Sarcoidosis

C. Lupus erythematosus

D. Facial granuloma

We decided to perform a biopsy

Dense and polymorphous dermal infiltrate.

Numerous clearly visible eosinophils (formol)Integrity of follicles


A. Benign cutaneous lymphocytoma

B. Sarcoidosis

C. Lupus Erythematosus

D. Facial granuloma

Facial granuloma

• Sometimes called « eosinophilic grabuloma »

• Described by Lever

• Often solitary, reddish-brown plaque

• Nose (+++), forehead, cheeks

• The « orange skin » aspect is characteristic

• Treatment is difficult treatment (beware of scars!).

Try dapsone

Case # 8

• 36-year-old man

• No medical history

• Has had for the past two months a firm and painless tumefaction on the forehead

• Which we recently biopsied.


A. Lymphoma

B. Dermatofibrosarcoma

C. Sub-aponeurotic lipoma

D. Granuloma Annulare

Areas of of dermal degeneration surrounded by a lympho-histiocytic granuloma, sometimes palissadic with epithelioid cells Elastic fibers are normal.


A. Lymphoma

B. Dermatofibrosarcoma

C. Sub-aponeurotic lipoma

D. Granuloma annulae

Granuloma annulare profundus

• Superficial (pink papules) or deep (raising the skin)• Limited or extensive • Limbs or face• Children or adults• …• The granuloma is never pruriginous nor painful, • Its cause in unknown, • And no treatment is effective.

Case # 9

• 42-year-old woman

• Seen at the Emergency Room for a facial eruption,

• Developing for ten days,

• Non-pruriginous


A. Drug rash

B. Secondary syphilis

C. Erythema multiforme

D. HIV primo-infection


A. Toxidermia

B. Secondary syphilis

C. Polymorphous erythema

D. HIV primo-infection

Secondary syphilis

• Still exists

• Even if it is now mainly frequent in HIV high risk groups (think of

other STDs)

• Is still as « simulator »

• Is confirmed by serology

• Can be efficiently treated with penicillin

A case of acneiform secondary syphilis

Case # 10

• 72-year-old man

• Former monk in Vietnam

• Medical history : malaria, amebiasis

• Consults for a diffuse nodular eruption which has gradually appeared in the past two months


A. Myeloid leukemia

B. B-Lymphoma

C. Hansen’s disease

D. Sarcoidosis

Histiocytic infiltrate, involves the nerves,

positive Ziehl’s staining

Hansen’s disease (leprosy)

• Think of it for patients having lived in endemic countries

• Perform the diagnostic tests– Biopsy with Ziehl’s stain

– Cutaneous and neurological examination

– Bacteriology

• Treat– According to WHO recommendations

• Manage the psychological and social component (don’t overdramatize)

Case # 11


• Consulting for an eruption on the eyelids

• Occurred following exposure to the sun

• Non-pruriginous


A. Lupus erythematosus

B. Contact dermatitis

C. Polymorphous light eruption

D. Dermatomyositis

Allergens of facial contact dermatitis

• Cosmetics (fragrances, preservatives, sunscreens,

others…)

• Topical drugs

• Airborne allergens

• Photoallergens

• + nail polish, jewellery, ….

Facial eczemas Anti-herpes gel

Eye drops

HexamidineDay cream

The importance of patch tests

Case # 12

• 18-year old girl

• Treated for acne for two years, with oral tetracyclines and topicals

• Wishes to have a second opinion before taking oral isotretinoin


A. Acne resistant to tetracyclines, a good indication for isotretinoin

B. Gram negative folliculitis

C. Excoriated acne

D. This is not acne

Excoriated acne « des jeunes filles »

• Often seen in women, but not always in « young » patients

• Belongs to the so-called “psychodermatoses”, generally managed by dermatologists

Case # 13

• 41-year-old man

• With an eruption on the eyelids

• Has been progressing in flare-ups for several years

• Sensitive to topical steroids


1. Atopic dermatitis

2. Contact dermatitis

3. Peri-ocular dermatitis

4. Psoriasis



2. Contact eczema

3. Peri-ocular dermatitis

4. Psoriasis

Facial psoriasis

• Relatively rare• Often « seborrheic »

– Involves the scalp, the ears

• Often « classic »• Rarely hyperkeratotic

• A good indication (off-label) for topical tacrolimus

Facial psoriasis

Case #14

• 38-year-old man

• Undergoing treatment for acute myeloblastic leukemia

• Sudden eruption on the face


1. Adverse reaction to chemotherapy

2. Cellulitis

3. Sweet’s syndrome

4. Neutrophilic eccrine hidradenitis

Neutrophilic infiltrate in contact with the eccerine glands and ducts.

Here, no necrosis or malpighian metaplasia


1. Adverse reaction to chemotherapy

2. Cellulitis

1. Sweet’s syndrome

2. Neutrophilic eccrine hidradenitis

Neutrophilic eccrine hidradenitis

• Belongs to the spectrum of the neutrophilic dermatoses

• Clinically resembles Sweet’s syndrome

• Histologically includes a neutrophilic infiltrate exclusively localized in and around

the eccrine glands and ducts

• Generally occurs in leukemic patients treated with cytarabine

• A benign palmoplantar variant exists in children.

Case #15

• 6-year-old child,

• In good health

• With plaques on the face following sun exposure


1. Lupus erythematosus

2. Benign solar eruption

3. Polymorphous light eruption

4. Erythema multiforme

Polymorphous light eruption

• Differential Diagnosis: – Drug-induced photosensitivity– Lupus erythematosus (PLE may precede)– Contact photoallergy

• Generally intense• Several clinical (pseudo-urticaria, lichen, lupus, erythema

multiforme, prurigo, eczema). • Pruritus is constant • Histology : eczematous• Phototests : Repeated polychromatic test positive

Papular polymorphous light eruption

Case #16

• 76-year-old woman,

• Diabetes, hypertension

• Consulting for an eruption on the face and forearms which appeared in June 2005.


1. Erythroderma

2. Psoriasis

3. Photosensitization

4. Eczema

Photosensitizing drugs

AntibioticsTetracyclines, fluoroquinolones, nalidixic acid, ceftazidime, sulfonamides, isoniazid, pyrazinamide

Other anti-infectiousGriseofulvin, ketoconazole

NSAIDIbuprofene, naproxene, and other by-products of arylpropionic acid, Phenylbutazone, oxyphenbutazone, mefenamic acid, meclofenamic acid, Piroxicam, diclofenac

DiureticsHydrochlorothiazide, bendroflumethiazide, furosemide

RetinoidsIsotretinoin, acitretin

Antimitotics5-fluoro uracile, dacarbazine, methotrexate, vinblastine

PsychotropicsAntidepressant tricyclics, Phenothiazines, Carbamazepine

MiscellaneousAmiodarone, diltiazem, quinidine, capatopril, ….

Case #17

• 15-year-old girl

• Consulting for skin eruption – Initially thought to be a sunburn– But which persisted after several weeks



2. Persistent photodermatitis


4. Dermatomyositis

Cutaneous forms of lupus erythematosus

• Lupus may be – Chronic cutaneous– Disseminated cutaneous– Subacute– Acute, systemic

• Therefore, adequate, simple workup is mandatory

Workup of a patient d’un patient in whom lupus is suspected

• Confirm diagnosis– Cutaneous biopsy, IF if possible

• Assess the lupus disease – Clinical examination– Warning signs towards another lupus localization – Blood biology, urinary biology– anti-nuclear antibodies, typing– Complement

• General examination– Medical history– Risk of drug interactions

Cutaneous LE

Case # 18

• 21-year-old man, baker,

• Consulting for circinate lesions on the face, present for about fifteen days


1. Pityriasis rosea

2. Erythema multiforme

3. Dermatophyosis

4. Psoriasis

No comment.

we had to think about it, and carry a mycologic sample

And treat his cat!

Case # 19

• 28-year-old man, no medical history

• Consults for persistent « sunburn » on the face



2. Persistent light eruption


4. Dermatomyositis

Cutaneous signs of dermatomyositis

• Heliotrope erythema

• Similar to Light Eruption, but: • More pinkish, violaceous• Predominates on the eyelids and back of the hands

– sometimes edematous

• Poikiloderma, at a later stage

In case of cutaneous dermatomyositis

• Assess the muscular involvement

• Search for concomitant cancer (20% of DM in adults)

• Treat (difficult)

Hydrea-induced pseudo-dermatomyositis

Case # 20


• Treated for several years for seborrheic dermatitis

• Worsening and progressive extension


1. Seborrheic dermatitis

2. Perioral dermatitis

3. Adult acne

4. Sarcoidosis

Perioral dermatitis is an inflammatory reaction that is

poorly understood, often caused by topical steroids, even at low

doses.

Case # 21

• 45-year-old man

• With plaques on the face

• Triggered by emotional stress



2. Seborrheic dermatitis

3. Psoriasis


Seborrheic dermatitis

• The most frequent skin condition

• Often clearly related to stress

• Located in areas rich in sebaceous glands

– Mid-facial area, scalp, mid-trunk

• A psoriasiform inflammation (erythema, desquamation) promoted by the

presence of Malassezias

• Improvement with antifungals (ketoconazole, ciclopiroxolamine)

• Severe forms justify short, controlled, low-dose topical steroid therapy.

Case # 22


• Has had small blemishes on her face for several years

• Treated for acne, unsuccessfully


1. Acne

2. Sarcoidosis

3. Tuberculide

4. Lupus miliaris faciei

Epithelioid granuloma with giant cells

Caseous central necrosis


1. Acne

2. Sarcoidosis

3. Tuberculide

4. Lupus miliaris faciei

Lupus miliaris disseminated on the face

• Brown-red papules, 1-3mm

• Over the entire face (mid-facial area, eyelids)

• Evolves into scars

• No other symptom

• No clear link with : – Tuberculosis

– Sarcoidosis

– Acne

– …

• Treatment : dapsone / topical steroids

Two recently published cases(Bohran R, Vignon-Pennamen MD, Morel P, Ann Dermatol 2005)

Case # 23

• 20-year-old girl

• Sudden ocular eruption

• Fever 38°2 C, lymph node enlargement


1. Sweet’s Syndrome

2. Erysipelas

3. Malignant staphylococcal infection

4. Insect bite

Erysipelas

• Streptococcal dermatitis

• Often without warning sign nor identifiable portal of entry

• Often with systemic symptoms

• Rarely bacteriologically proven

• But needs to be treated rapidly (penicillin G, or amoxicillin or oral macrolide)

Case #24

• 32-year-old man

• Moderate atopic dermatitis since childhood

• Sudden facial eruption


1. Secondary superinfection of atopic dermatitis

2. Chicken pox

3. Eczema herpeticum

4. Molluscum contagiosum

Eczem herpeticum (Kaposi-Juliusberg’s varicelliform eruption)

• Corresponds to an herpetic primo-infection on a

preexisting dermatosis, usually atopic dermatitis

• Varicella- or smallpox-like vesicles-pustules

• Possible complications

• Currently of favorable outcomes (anti-virals)

Case # 25

• 5-year-old child

• Always had « rosy cheeks »

• Treated for atopic dermatitis, unsuccessfully




3. Keratosis pilaris

4. Congenital erythroderma

Keratosis pilaris

• Simple– Arms and thighs – Visible in children, will improve with age

• Red, atrophic– Permanent erythema on the cheeks, « rough » to palpation– May involve the eyebrows, the ears

• Spinulosic, decalvant (causes baldness)

• No efficient treatment

Facial dermatoses

25 interactive case reports

Daniel Wallach, MD

Senior lecturerTarnier Hospital

Paris

Special thanks: MD Vignon-Pennamen, MDhttp://atlases.muni.cz/_atlas-top-cont-5up.html

facial dermatoses

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