It can be difficult to diagnose the cause of a red face. A good knowledge of differential diagnoses is required. Specific history and full skin examination are needed to differentiate conditions such as rosacea, perioral dermatitis, atopic eczema, seborrhoeic dermatitis, psoriasis, contact dermatitis and discoid lupus erythematosus (Tables 23.1–23.3).

Rosacea

Rosacea is a common inflammatory skin disease seen in adults over 30 years old. It is usually confined to the face, mainly affecting the cheeks, forehead, nose and chin. Flushing may occur. Papules, pustules, telangiectasia and erythema are common but no comedones or scaling occur (Figure 23.1). Hypertrophy and lymphoedema of subcutaneous tissue may present with rhinophyma of the nose (Figure 23.2). The cause of rosacea is unknown but it may be triggered by spicy foods and alcohol, leading to flushing and then telangiectasia.

Complications of rosacea include conjunctivitis, keratitis and iritis. Papules and pustules can be treated with antibiotics (topical metronidazole, oral tetracyclines and oral erythromycin) and topical retinoids. Flushing and telangiectasia may not fully respond even to pulse dye laser.

Perioral Dermatitis

This is a variant of rosacea that occurs in young females around the mouth or sometimes around the eyes. It usually presents with papules and occasional pustules sparing the skin adjacent to the vermillion border. Other features of rosacea such as flushing and telangiectasia are usually absent. Most cases have a recent history of topical steroid usage. This can improve the eruption but it relapses once the treatment is stopped. Topical steroids need to be stopped and other standard treatments for rosacea such as topical metronidazole and oral antibiotics can be helpful.