Psoriasis including facial psoriasis

Facial psoriasis is a subtype of psoriasis that can cause significant discomfort for patients. Most patients with facial psoriasis also have psoriatic plaques elsewhere on the body (Van de Kerhof et al. 2007). Facial psoriasis produces plaques that arise on the neck, forehead, ears, and face that appear indurated and less prominent in comparison to the characteristic psoriatic plaques. The clinical presentation involves erythematous, scaly, well-defined plaques that are often pruritic. The presentation of psoriatic lesions on other parts of the body aids in the diagnosis (Park et al. 2004).

The visibility of the plaques can interfere with a patient’s well-being (Jacobi et al. 2008). The noticeable location of the lesions can lead to a decrease in self-confidence and problems in acquiring employment (Ortonne et al. 2003). Additionally, the plaques are often treatment resistant and tend to reoccur. Facial psoriasis may indicate a more severe form of psoriasis that is diagnosed at an early age with a long duration of disease (Woo et al. 2008). Patients with facial psoriasis also often have a strong family history of psoriasis and experience the Koebner response (Kim et al. 2016). The Koebner response is the development of psoriatic lesions at a site of cutaneous trauma. Patients may also have nail and joint involvement. The disease severity in facial psoriasis may vary based on seasons in which exacerbations may occur during certain seasons (Park et al. 2004). Facial psoriasis can also present after a patient discontinues systemic treatment as a relapse. In this situation, patients often present with a more severe disease than that prior to treatment (Park et al. 2004).

Facial plaques could be due to multiple different etiologies. Seborrheic dermatitis also presents as scaly, well-defined, erythematous lesions. In contrast to facial psoriasis, seborrheic dermatitis produces plaques that are more yellow with greasy scales (Naldi and Rebora 2009). Atopic dermatitis tends to appear on the face in infancy, but can present in older children and adults. Atopic dermatitis can also present with erythematous plaques yet are often severely pruritic. Lupus tumidus erythematosus also produces plaques that are erythematous and may appear on the face. In contrast to facial psoriasis, the plaques in lupus tumidus erythematosus often do not scale (Choonhakarn et al. 2004).

If there is isolated facial psoriasis or facial psoriasis does not clear with systemic therapy for associated severe psoriasis, topical vitamin D analogs (calcipotriene, calcitriol), tacrolimus ointment, and pimecrolimus cream are considered first-line treatments. Avoid high-potency topical corticosteroids on the face. In contrast to psoriatic lesions on other parts of the body, facial psoriasis creates thinner plaques. The decreased thickness of plaques allows for increased absorption of topical medication, which can lead to a higher risk of side effects. Skin atrophy, telangiectasia, glaucoma, acne, cataracts, and perioral dermatitis have been reported with the use of high-potency topical corticosteroids on the face (Park et al. 2004; Jacobi et al. 2008). Lower-potency corticosteroids may still be used, as these are less likely to cause severe side effects. Consider the use of class 5–6 corticosteroids for maintenance therapy (2 weeks on, 2 weeks off, repeat).