Facial Rashes/eruptions Emily McGrath Dermatology Consultant Royal Devon and Exeter Hospital

Overview Cases Discuss differential – points in the history and examination to help Management tips

Case 1 21 year old female 4 year history of acne Tried Panoxyl over the counter

Treatment Topical Oral BPO Azaleic acid Retinoids Antibiotics Isotretinoin

Oral Antibiotics No benefit in concomitant oral and topical antibiotics. Intermittent benzoyl peroxide recommended during oral antibiotics to eliminate resistant strains. Dose: evidence to support erythromycin at 1g/day rather than 500mg/day. No evidence regarding dose of other oral antibiotics. Treatment should be at least 3 months, maximal effect by 6 months – then if relapse, change drug.

Case 2 17 year old 6th Former 2 year history of worsening acne. On 250mg bd oxytetracycline.

Case 3 6 year old girl Itchy face, neck, arms. Worsening over past 3 months. Not responding to hydrocortisone. Mum asks about allergy tests.

Atopic eczema - top tips Emollients - trial then large quanitities. Soap substitutes - simplify Topical steroids - appropriate to severity Short bursts of moderate / potent steroids to achieve control Topical tacrolimus 0.1% - equivalent strength to mod potent top steroid. Maintenance. Allergy: consider to be relevant if Instant urticaria/itching after eating/ contact Severe/ resistant eczema especially if bowel sx +/- FTT

Case 4 51 year old school teacher. Worsening facial rash. Uncomfotable, especially in hot weather.

Rosacea Subtypes: Treatment Depends on subtype Avoid triggers Erythematotelangectatic Papulopustular Phymatous Treatment Depends on subtype Avoid triggers Sun protection Topical azaleic acid/metronidazole Oral antibiotics

Rosacea Mild or moderate papulopustular rosacea Metronidazole Gel (Metrogel®) 0.75%......................................................................£9.95 (40g) Cream (Rozex®) 0.75%..................................................................£15.28 (40g) Apply twice daily for 3-4 months Moderate or severe papulopustular rosacea Oxytetracycline Tablets 500mg twice daily for 3-6 months.................................................£5.68 Lymecycline (unlicensed) Capsules 408mg once daily ………………………………..….£22.45 (3 months) Review at 2 months and continue for a total of 3 months if responding well. Repeat 3 monthly course when rosacea flares.

Case 5 55 year old art teacher. Worsening facial rash over 2 weeks. Sore, weeping.

Case 6 38 year old IT worker Persistent lesion R cheek

Case 7 35 year old nurse Irritating rash past 2 years central face

Joint Formulary For moderate and severe disease affecting the scalp Ketoconazole shampoo............................................................£3.02 (120mL) Use twice a week For more severe erythema and flaking on the scalp add Betamethasone scalp application............................................£3.81 (100mL) Apply to dry hair morning and evening and allow to dry Disease affecting face and body Ketoconazole cream.......................................................................£3.40 (30g) Apply once or twice a day until resolution then reduce frequency to daily or alternate daily use. For inflamed skin Daktacort® cream………………..…………………………………...……….£1.83 Apply once or twice a day until resolved.

Case 8 75 year old man Rough patches on forehead. Sore in strong sunlight.

Solar (actinic) keratosis: Treamtent Treatment: Diclofenac 5FU Photodynamic Therapy Cryotherapy Curettage