Atopic dermatitis (eczema) |
- Erythema, scale, excoriations, xerosis
- Lichenification
- Ill-defined plaques
- Honey-coloured crusts if secondarily infected
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- Anywhere on face, neck, scalp
- Variants:
- Neck
- Lips (eg licker’s eczema)
- Eyelids (eg Dennie–Morgan folds)
- Might have eczema elsewhere (eg flexures, nipples, palmoplantar [dyshidrotic eczema])
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- History of atopy (eg asthma, allergic rhinitis, eczema [including in family members])
- Keratosis pilaris on upper arms/thighs
- Lichenification suggestive of chronicity
- Itch can be significant
- Predominance of face/neck eczema might suggest aeroallergens (eg dust mites, pollen, grasses, animal dander)
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- Clinical diagnosis
- Bacterial MCS if secondarily infected
- Allergen-specific IgE testing for common aeroallergens if indicated
- Skin biopsy: histopathology if diagnosis unclear
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Irritant contact dermatitis |
- Xerosis
- Erythema and scale might be present
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- Worse in skin creases (eg corners of mouth, ala creases)
- Sparing of eyelids, ears, frontal hairline or neck if irritant not in contact with those areas
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- Timeline with use of one or more new products
- Over-cleansing of face
- Might or might not be itchy
- Patients with atopic dermatitis more prone to developing irritant contact dermatitis
- Might have single exposure to strong irritant or chronic exposure to weak irritants
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- Clinical diagnosis
- Cessation of new or unnecessary products and gentle skin care (eg bland unscented moisturiser, sunscreen)
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Psoriasis |
- Well-defined, scaly, salmon-pink plaques
- Scale can be significant especially in scalp
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- Favours ears and scalp (especially frontal hairline and occipital scalp)
- Might have psoriasis elsewhere (eg extensors, umbilicus, natal cleft, palmoplantar)
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- Mostly asymptomatic but can be itchy
- Concurrent seborrhoeic dermatitis (sebopsoriasis)
- Personal or family history of psoriasis
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- Clinical diagnosis
- Skin biopsy: histopathology if diagnosis unclear
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Seborrhoeic dermatitis |
- Ill-defined erythema, greasy scale
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- Favours seborrhoeic areas: scalp, forehead, eyebrows, nasolabial fold, conchal bowl, post-auricular
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- History of dandruff or flaking scalp
- Other sites might be involved including chest, axillae
- Can be itchy if inflamed, otherwise relatively asymptomatic
- Winter flares with improvement in summer
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- Clinical diagnosis
- Skin biopsy: histopathology if diagnosis unclear
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Actinic keratoses |
- Ill-defined erythema and scale
- Might be discrete or confluent to involve large areas
- Hyperkeratotic papules or nodules in some areas
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- Photo-exposed sites (eg nose, cheeks, temples, ear helices); scalp involvement if bald or thin hair
- Might have actinic keratoses elsewhere (eg dorsal hands, forearms, lower legs
- Sparing of photoprotected sites
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- Asymptomatic
- Gradual onset over time
- History of chronic sun exposure/limited photoprotection
- No history or other features of primary dermatosis
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- Skin biopsy: histopathology (particularly for hyperkeratotic, tender or indurated lesions to exclude invasive SCC)
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Acne |
- Polymorphic erythematous papules, pustules and nodules
- Cysts might be present in severe cases
- Closed or open comedones
- Postinflammatory pigmentation
- Excoriations (if picking)
- Acne scars (eg box car, rolling, atrophic, ice pick scars)
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- Favours face, back and chest
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- Family history of acne
- Papules, pustules and nodules are in different stages of evolution
- Teens: onset around puberty
- Adults: persistence since teens or onset early 20s. In women, might flare with menses
- Might be associated with testosterone or anabolic steroid usage
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Rosacea |
- Monomorphic erythematous papules and pustules (papulopustular subtype)
- Absence of comedones (unless there is co-existing acne)
- Telangiectasia and erythema (in erythematotelangiectatic subtype)
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- Favours dorsum of nose, cheeks, chin, forehead
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- Favours fair-skinned patients
- Might be associated with flushing
- History of sensitive skin to various products
- Flares with sun exposure
- Family history of rosacea
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Malassezia folliculitis |
- Monomorphic erythematous papules and pustules based around hair follicles
- Absence of comedones
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- Favours forehead, chin, lateral cheeks
- Central face usually spared
- Chest and back might be involved
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- Might have other forms of cutaneous Malassezia spp. overgrowth (eg seborrhoeic dermatitis, pityriasis versicolour)
- Oily skin
- Flares with heat, sweat, occlusion or in hot, humid conditions
- Might be itchy
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- Clinical diagnosis
- Yellow–orange fluorescence on Woods lamp
- Skin scrapings of a pustule, KOH test (culture not routinely performed because isolation and culture of Malassezia spp. is difficult)
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Pseudofolliculitis barbae |
- Erythematous papules and sterile pustules based around hair follicles
- Associated ingrown hairs
- Postinflammatory pigmentation
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- ‘Beard’ area of the face (ie cheeks, upper lip, chin, neck)
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- Flares with hair removal (eg shaving, waxing, plucking)
- Favours patients with curly hair
- Most common in men with African ancestry
- Might be itchy
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- Clinical diagnosis
- Bacterial MCS to exclude bacterial folliculitis
- Fungal skin scrapings to exclude tinea barbae
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Sunburn |
- Acute phase: erythema and oedema; blistering in severe cases
- Resolution phase: peeling and flaking of affected skin
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- Photo-exposed sites (eg face, trunk, limbs)
- Sharp cut-off and sparing of areas covered by clothing
- Associated ephelides or lentigines (if chronic) in sun-exposed sites
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- Associated with total duration of sun exposure and UV index
- Favours patients with lighter skin phototype
- Might be more likely to occur if taking photosensitising medications
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Periorificial dermatitis/steroid-induced rosacea |
- Classically numerous papules and pustules; might be more confluent than rosacea
- Absence of comedones
- Might be erythematous, oedematous and scaly in some cases
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- Clustered around orifices (eg skin inferior to nostrils, chin, lateral cheeks/temples around eyelids)
- Sparing vermillion border of lip
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- Might be associated with steroid exposure (eg topical mid- to high-potency steroids). Other triggers include intranasal/inhaled or oral steroids
- Paradoxical flare with cessation of steroid
- Associated stinging or burning sensation
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Tinea faciei |
- Annular eruption with a leading edge, central clearing and peripheral scale
- Might become non-scaly/non-specific if treatment modified with topical steroids (tinea incognito)
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- Anywhere on face, neck, scalp
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- Paradoxical worsening with use of topical steroids
- Asymmetrical
- History of recent visit to barber
- Pets with scaly patches of hair loss (eg cats, dogs, guinea pigs)
- Might have associated onychomycosis
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- Skin scrapings for fungal microscopy and culture
- Skin biopsy (if required): histopathology
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Allergic contact dermatitis |
- Acute phase: oedema, erythema, vesicles or bullae
- Chronic phase: mimics atopic dermatitis (erythema, scale, excoriations, lichenification)
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- Common sites: eyelids, lips/perioral skin, neck
- Other sites also exposed to allergen might be affected
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- Can occur to products/chemicals that have previously been tolerated for many months or years, not just newly introduced products
- Associated itch
- In acute phase might be triggered 24–48 h following exposure to allergen
- Ongoing exposure can lead to chronic phase
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- Clinical diagnosis
- Referral for allergy skin patch testing
- Skin biopsy: histopathology if diagnosis unclear
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Shingles |
- Prevesicular phase: crops of erythematous papules and macules
- Vesicular phase: pustules, vesicles followed by crusting
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- Favours dermatomal distribution or is unilateral
- Might be multidermatomal or disseminated, especially in immunosuppressed patients
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- Associated burning, pain or tingling sensation precedes skin manifestations
- Might be associated with systemic symptoms (eg malaise)
- Red flags: ocular involvement, facial weakness, ear canal involvement
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Cutaneous lupus |
- ACLE: smooth, erythematous, oedematous plaques
- DLE: coin-shaped, scaly hyperpigmented plaques, follicular plugging. Might have scarring
- Note: subacute cutaneous lupus erythematosus might less commonly present on the face as annular scaly plaques
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- ACLE: ‘Butterfly’ distribution, namely bilateral cheeks and across the dorsum of the nose, sparing nasolabial folds. Can affect other photo-exposed sites
- DLE: face, scalp, conchal bowl and ears. In diffuse form, might occur on trunk
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- Might have associated systemic symptoms of lupus (eg synovitis, chest pain, shortness of breath)
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- Skin biopsy: histopathology, direct immunofluorescence
- Blood tests: ANA, ENA, dsDNA, complement
- Urine microscopy: proteinuria, dysmorphic red blood cells, red cell casts
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Dermatomyositis |
- Pink to violaceous erythema of eyelids; might have associated oedema (heliotrope rash)
- Erythema, scale and diffuse alopecia affecting the scalp
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- Eyelids, forehead, scalp
- Might have other clinical signs of dermatomyositis (eg shawl sign, V-neck sign, Holster sign, Gottron’s papules, Gottron’s sign, nail fold changes)
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- Might have associated muscle weakness (except in amyopathic forms)
- Associated photosensitivity
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- Skin biopsy: histopathology
- Special blood tests: CK, myositis-specific antibodies
- Consider malignancy screen
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Facial erythema secondary to a non-dermatological systemic process (eg pulmonary hypertension, liver failure, SVC obstruction, carcinoid syndrome) |
- Plethora, fixed erythema, oedema, facial flushing
- Absence of more specific skin changes such as pustules, papules, scale, vesicles or erosions
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- Variable distribution
- Might present as facial flushing, fixed erythema and telangiectasia involving the cheeks, forehead, periorbital region and/or neck
- Might also involve other body sites (eg palmar erythema, spider naevi on chest)
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- Known respiratory, gastrointestinal or cardiovascular comorbidities
- Systemic symptoms such as dyspnoea, hoarse voice, chest pain, weight loss, fatigue, peripheral oedema, diarrhoea and/or jaundice
- Abnormal cardiorespiratory
and/or gastrointestinal examination
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- Depending on suspected cause:
- Electrocardiogram
- Bloods: liver function test, full blood count, renal function test
- Chest X-ray
- Echocardiogram
- 24-h urinary 5-HIAA for suspected carcinoid syndrome
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5-HIAA, 5-hydroxyindoleacetic acid; ACLE, acute cutaneous lupus erythematosus; ANA, antinuclear antibodies; CK, creatine kinase; DLE, discoid lupus erythematosus; dsDNA, double-stranded DNA; ENA, extractable nuclear antigen antibodies; IgE, immunoglobulin E; KOH, potassium hydroxide; MCS, microscopy, culture, sensitivity; PCR, polymerase chain reaction; SCC, squamous cell carcinoma; SVC, superior vena cava; UV, ultraviolet; VZV, varicella zoster virus. |