Skin Diseases of the Face

INTRODUCTION TO CHAPTER

Listen

The face is the area of the body most exposed to sunlight and therefore at highest risk for ultraviolet (UV) light-induced dermatoses (photodermatoses), photoaging, and skin cancers. The face also has the highest density of sebaceous glands, predisposing this area to conditions such as acne, rosacea, and seborrheic dermatitis. Inflammation around the hair follicles may lead to skin diseases such as folliculitis and pseudofolliculitis barbae. In addition, skin diseases involving mucous membranes will typically affect the eyes, nose, and mouth. Since the face is so critical to nonverbal communication and social interactions, skin diseases involving this area can cause a significant degree of emotional distress.

APPROACH TO DIAGNOSIS

Listen

Skin diseases involving the face can be broadly categorized into pilosebaceous conditions, inflammatory dermatoses, infectious diseases, connective tissue diseases, UV-induced photodermatoses, and pigment disorders (see Table 31-1). Widespread actinic keratoses on the face are also included because they are sometimes misdiagnosed as a “rash.”

Table 31-1.Differential diagnosis for diseases of the face.

Disease	Epidemiology	History	Physical Examination
Pilosebaceous
Acne vulgaris	Common Teens: M > F Adults: F > M Age: adolescents and young adulthood	Asymptomatic, pruritic or tender Individual lesions last weeks to months Fluctuating course Menstrual flares	Open (black heads) and closed (white heads) comedones, erythematous papules, pustules, cysts, and nodules (Figures 15-1, 15-2, 15-3, 15-4)
Rosacea	Common F > M Age: 30-50 years	Facial flushing, stinging, or burning Eye dryness, itching, stinging, or burning Chronic course	Flushing (transient erythema), nontransient erythema, papules, pustules, and telangiectasias on central face. Blepharitis and conjunctivitis may be present (Figure 15-4, 15-5, 15-6)
Perioral dermatitis	Common F >> M Age: 20-45 years of age	Asymptomatic or symptomatic with pruritus or burning Duration: weeks to months	Grouped monomorphic follicular erythematous papules, vesicles, and pustules in the perioral region (Figure 15-7)
Pseudofolliculitis barbae	Common M >> F Age: teenagers and young adults, predominately African Americans	Asymptomatic or tender. Chronic course. Flares with shaving	Papules and pustules in the beard distribution, posterior neck, cheeks, mandibular area, and chin (Figure 15-10)
Inflammatory
Atopic dermatitis	Common M ≥ F Age: usually presents in childhood, but may persist	Pruritic Chronic course with exacerbations Usually worse in winter. Personal and family history of atopy	Infants: red papules, scaly plaques, and excoriations (Figure 7-7) Children and adults: red lichenified plaques on cheeks, and eyelids (Figure 8-8)
Allergic contact dermatitis	Common F > M Age: any age	Pruritic Onset: hours to days after contact with allergen	Acute: papules and vesicles on an erythematous base (Figures 8-4 and 8-5) Chronic: xerosis, fissuring, hyperpigmentation and lichenification on earlobes, lips, eyelids, and hairline (Figures 8-1, 8-2, 8-3)
Irritant contact dermatitis	Common F > M	Pruritic, painful, or burning. May have history of atopy	Well-demarcated plaques with a “glazed” appearance (Figures 8-1, 8-2, 8-3)
Seborrheic dermatitis	Common M > F Age: bimodal; peaks in infancy and adulthood	Asymptomatic or mildly pruritic Waxing and waning course with seasonal variations	Lesions are symmetric, with greasy scale and underlying erythema on the eyebrows, nasolabial folds, lateral aspects of the nose, retroauricular areas, and ears (Figure 9-7)
Infectious
Herpes simplex labialis (HSV)	Common M:F unknown Primary infection is in childhood, recurrence at any age HSV1 > HSV2	Fever and pharyngitis may be present with primary infection. Pain or tingling may precede recurrent infections. Lasts 2 weeks	Symptomatic primary infection usually presents with gingivostomatitis with vesicles on lips, tongue, gingiva, buccal mucosa, and oropharynx. Recurrent infections present with grouped vesicles on central face, usually on lips or perioral area (Figure 11-1)
Herpes zoster (Shingles)	Common M:F unknown Age: any age, but usually >50 years	Severe pain, pruritus, or paresthesias may precede eruption. Lasts 3 weeks	Grouped vesicles on an erythematous base that crust over in a unilateral dermatome (Figure 11-3)
Impetigo	Common M = F Age: young children	May be pruritic Lasts days to weeks Frequently spreads through schools and day care centers	Nonbullous impetigo: honey-colored crusts with erosions on central face (Figure 12-1) Bullous impetigo: starts as superficial vesicles rapidly enlarging into flaccid bullae
Tinea faciei	Uncommon F ≥ M Age: any age, with peaks in childhood and between 20 and 40 years of age	Asymptomatic or pruritic More common in children in contact with domestic pets and livestock	Starts as a scaly annular plaque that develops a raised border that advances peripherally and may develop papules and pustules (Figure 10-5)
Connective tissue diseases
Discoid lupus erythematosus	Common F > M Age: 20-45 years of age More common in African Americans	Asymptomatic or mildly pruritic Sunlight may precipitate flares 5%-10% develop SLE May resolve spontaneously	Red or purple patch with superficial scale that enlarges into a plaque with central scarring and depigmentation on scalp, face, ears, upper chest, neck, and extensor surfaces of the arms and hands (Figures 24-1 and 24-2)
Localized acute cutaneous lupus (also known as malar or butterfly rash)	Uncommon F > M Age: any age, but most commonly age 30-40 years	Pruritic or burning Maybe related to sun exposure. Associated with fevers, fatigue, oral ulcers, and other findings consistent with SLE	Red clustered papules, urticarial plaques, and patchy erythema with variable scale on malar eminence and nasal bridge with sparing of the nasolabial folds (Figure 24-4)
Neoplastic
Actinic keratoses	Common M > F Age: >50 years Fair skin	May be tender. Persists for months to years History of excessive sun exposure	Skin-colored, yellow-brown, pink gritty papules and plaques with adherent hyperkeratotic scale on face and ears (Figure 17-1)
Pigmentation
Melasma	Common F >> M Age: young adulthood	Asymptomatic Last months to years May have history of UV exposure, pregnancy, or exogenous hormone exposure	Symmetric patches of hyperpigmentation on the forehead, cheeks, nose, upper lip, chin, and jawline (Figure 21-3)
Vitiligo	Common M = F Age: any age	Asymptomatic Chronic and progressive Family history of autoimmune disease	Well-demarcated white depigmented macules and patches typically favoring the perioral and periocular areas (Figure 21-1)
Pityriasis alba	Common F ≥ M Age: usually in children. More common in skin of color	Asymptomatic or mildly pruritic. Last several months. More common in atopic individuals	Lightly hypopigmented or white patches with fine scale, typically on the cheeks
Photodermatoses
Photoaging	Common M:F unknown Age >40 years Risk is inversely related to skin pigmentation	Asymptomatic Cigarette smoking hastens skin aging	Dyspigmentation, wrinkling, telangiectasias, atrophy, and leathery thickening, on the face, lateral neck, central upper chest, extensor forearms, and dorsal hands
Phototoxicity	Common M:F unknown Age: any age Risk is inversely related to skin pigmentation	Pain, burning, and pruritus. Worse in summer. Several medications, chronic porphyrias, and photosensitive dermatoses can cause exaggerated response to UV exposure	Bright red patches with edema and blistering that heal with desquamation and hyperpigmentation on sun-exposed areas including the forehead, nose, malar cheeks, neck, upper chest, upper back, extensor forearms, and dorsal hands (Figure 2-30)