HPI: The patient is a 44 yo health care professional with an 18 month history of erythema of the chin and perioral area. She has been seen by four dermatologists who have treated her for rosacea and perioral dermatitis with doxycycline and various topicals. Nothing has helped. The process began after her mother died. She lives at home with her boyfriend of 16 years and their two preteen children.
She admits to being anxious and depressed as there
are significant social problems at home.
She used a topical steroid for a few days when her lips were
prurituc, not for weeks to months.
She takes no medications p.o. other than Xanax 0.25 mg h.s. There is no history of using a mask or any local contactant to this area that might explain this pattern.
O/E: Shows a
light-complected Caucasian with sharply demarcated erythema and mild scaling of
the chin, and submental region.
Clinical Images:
Patch Testing: True Test negative at 96 hours
Discussion: This is a perioral rash that does not look like perioral dermatitis. The pattern suggests a contact dermatitis, but the history and patch testing do not corroborate that. Perhaps, one of our readers will have had a similar patient. At present, this is medically unexplained, but I suspect that I am missing something.
Addendum: See comments of Dr. Howard Maibach.
In Malaysia, my first concern is whether this patient has tinea incognito? It may be helpful to check her skin scrapping for hyphae. If positive a course of oral terbinafine 250mg daily for 2 weeks with topical anti fungal cream.
ReplyDeleteNext i will consider irritant dermatitis. Avoidance of irritants and try topical tacrolimus/ pimecrolimus cream if skin scrapping for hyphae is negative. i would not use topical steroids as this may mask out other conditions and may cause iatrogenic rosacea.
Unless there is photosensitivity or other associated symptoms, you may consider cutaneous lupus.
from Dr. Ong (Malaysia):
ReplyDeleteI’m not sure contact dermatitis have been ruled out. She very likely have some perioral dermatitis and rosacea anyway, from steroid applications. The reason why treatments given for these have not helped much raise another possibile cause.
I’ve managed quite a number of patients, men more than women, with red face originated from seborrheic dermatitis, which has no reason to behave and limit itself to nasolabial folds, ie, it easily spills out of the textbook distribution. Her ears look red, the pitfalls of teledermatology, since many people especially Caucasians have red ears, possibly as a weather temperature detector. I advised original ketoconazole shampoo and free use of sebclair cream. Steroids to be tailed off.
also: I thought it’s usual practice to rule out contact dermatitis especially with skin care products their use in their rituals of cleansers, foundations, toners and moisturisers. I personally rule that out first when any woman comes to me with rashes in the face. Locally the rash may be one or even all of three colours, erythematous, hypopigmented or hyperpigmented patches. The last one may not be so common in Caucasians.
from Dr. Sharquie (Iraq): In Iraq facial tinea is so common that is why any persistent facial erythema ,tinea should be excluded.The present patient has well demarcated perioral scaly erythema with active border where chronic tinea on top of the list of differential diagnosis.Scrape for fungus is suggested but even negative give topical lamasin cream and oral nizirol tab.This is not perioral dermatitis.
ReplyDeleteRick Sontheimer: Our two patch test specialist faculty at University of Utah agreed that this really looks like an occult contact dermatitis.
ReplyDelete