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Facial dermatoses

Facial dermatoses. 25 interactive case reports. Daniel Wallach, MD Senior lecturer, Tarnier Hospital Paris. Facial dermatoses: general data. High frequency All dermatological diagnoses can be met Location is crucial in psychological-social consequences (quality of life)

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Facial dermatoses

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  1. Facial dermatoses 25 interactive case reports Daniel Wallach, MD Senior lecturer, Tarnier Hospital Paris

  2. Facial dermatoses: general data • High frequency • All dermatological diagnoses can be met • Location is crucial in psychological-social consequences (quality of life) • Parcimonious biopsies • Worsening role of sun exposure

  3. Case # 1 • 32-year-old woman, florist • Has suffered from erythematous dermatitis flare-ups on the face for several years • Treated more or less successfully with potent topical steroids • Generally consults when flare-ups occur

  4. What is your diagnosis? A – Lupus erythematosus B – Contact dermatitis C – Atopic dermatitis D – Contact photoallergy

  5. What is your diagnosis? A – Lupus erythematosus B – Contact dermatitis C – Atopic dermatitis D – Contact photoallergy

  6. Atopic dermatitis in adults • Persistent AD, with flare-ups during stressful situations • or rarely newly-onset : make sure of diagnosis • Includes severe forms, risks of complication, therapeutic difficulties • A particular form predominates on the head and neck. • Were incriminated : • photosensitization (phenothiazines) • airborne contact allergens • Malassezia • A good indication for topical tacrolimus

  7. Atopic dermatitis in adults

  8. Case # 2 • 46-year-old man • No relevant medical history • Plaques on the nose for the past six months • Unsuccessfully treated with tetracyclines

  9. What is your diagnosis? A – Rosacea B – Lupus erythematosus C – Lymphoma D – Sarcoidosis

  10. A biopsy was performed Well-defined nodules of epithelioid cells, surrounded by a lymphocytic ring

  11. What is your diagnosis? A – Rosacea B – Lupus erythematosus C – Lymphoma D – Sarcoidosis

  12. Another case of « plaque » cutaneous sarcoidosis

  13. Polymorphism of cutaneous sarcoidosis • Small smooth, pinkish-red nodules • Large nodules, with lupoid infiltrate • More diffuse infiltrates • Lupus perniosis (chilblain lupus, chilblain-like BBS) • Hypodermic Nodules, ulcerations, erythroderma, granulomas on scars, …

  14. Summary: sarcoidosis • Adenopathies • Mediastinal • Others • Pulmonary parenchyma • Micronodules • Macronodules • Diffuse infiltrates • Pulmonary fibrosis, emphysema • Other locations: • Eyes, salivary glands, bones, nerves, …. (all organs)

  15. Treatment for cutaneous sarcoidosis • Only systemic steroids (one to two years) are truly effective • Although they are difficult to prescribe in isolated cutaneous lesions • Facial involvement may represent an indication • Other treatments: • Topical or intralesional steroifs • Cryotherapy • Anti-malarials • Methotrexate.

  16. Case # 3 • 64-year-old man • Hypertensive • Treated for lung cancer • Consults for a recent pustular eruption of the face and trunk

  17. What is your diagnosis? • Late-onset acne • Pustular rosacea • Adverse drug reaction • Pustular psoriasis

  18. What is your diagnosis? • Late-onset acne • Pustular rosacea • Adverse drug reaction • Pustular psoriasis

  19. Acneiform eruption due to gefitinib • Inhibitor of EGF receptor tyrosine kinase (Receptor of the Epidermal Growth Factor, involved in tumoral growth) • Used in numerous types of advanced cancers (notably non-small cell lung cancers) • Well-tolerated, apart from cutaneous side-effects which may be correlated with the treatment’s effectiveness. • Often : acneiform or rosacea-like eruption • Rare : xerosis, eczematiform eruption, telangiectasias, hyperpigmentations, paronychias, pyogenic granulomas

  20. Case # 4 • 33-year-old woman, • Teacher, • No relevant medical history, • Treated for several months with tetracyclines, unsuccessfully, for an acneiform pruriginous eruption on the face

  21. Close-up:

  22. What is your diagnosis? • « Adult » acne • Rosacea • Demodecidosis • Sarcoidosis

  23. What is your diagnosis? • « Adult » acne • Rosacea • Demodecidosis • Sarcoidosis

  24. How to diagnose demodecidosis? • Rosacea-like erythema and papules • Without true rosacea features • Pruritus • « Rough » skin • Rapid and clear response with an antiparasitic treatment (crotamiton, lindane)

  25. If a biopsy were performed The presence of Demodex in the follicles is not pathognomonic of demodecidosis, and is less valuable than the successful tested treatment.

  26. Another case of demodecidosis

  27. Case # 5 • 72-year old woman, rushed to hospital for severe deterioration of her general state of health, • High fever, • facial eruption.

  28. What is your diagnosis? • Necrotizing fasciitis • Malignant staphylococcal infection • Sweet’s syndrome • Mucormycosis

  29. What is your diagnosis? • Necrotizing fasciitis • Malignant staphylococcal infection • Sweet’s syndrome • Mucormycosis

  30. Sweet’s syndrome • Belongs to the group of theneutrophilic dermatoses • is paraneoplastic in 30% of cases (leukemias, …) • Is very sensitive to systemic steroids

  31. Histopathology of Sweet’s syndrome Neutrophilic infiltrate of the superficial dermis, edema of the dermal papilla

  32. Sweet’s syndrome frequently involves the face

  33. Case # 6 • 62-year-old man, • No relevant medical history, • Consults for scaly lesions on the mediofacial area, present for about a year • Several topical antifungal treatments have been tested, with no improvement

  34. What is your diagnosis? • Seborrheic dermatitis • Psoriasis • Superficial pemphigus • Bazex syndrome

  35. What is your diagnosis? • Seborrheic dermatitis • Psoriasis • Superficial pemphigus • Bazex syndrome

  36. Seborrheic pemphigus, or Pemphigus erythematosus, or Senear – Usher syndrome • Belongs to the group of superficial pemphigus • Affects seborrheic facial areas • Spares mucous membranes • Nikolski’s sign is present • No to be mistaken for seborrheic dermatits or lupus erythematosus • May be sensitive to : • Topical steroids • Disulone • Low-dose systemic steroids One case of pemphigus vulgaris involving the face

  37. Biopsy is essential Superficial intra-epidermic blister, discrete acantholysis IFD : intercellular IgG and C3 deposits WB, ELISA : anti-desmoglein 1 auto-antibodies (160 kD)

  38. Case # 7 • 32-year-old woman, general practicioner • No relevant medical history, • Has had a lesion on the nose for two months

  39. What is your diagnosis? • Benign cutaneous lymphocytoma • Sarcoidosis • Lupus erythematosus • Facial granuloma

  40. We decided to perform a biopsy Dense and polymorphous dermal infiltrate. Numerous clearly visible eosinophils (formol) Integrity of follicles

  41. What is your diagnosis? • Benign cutaneous lymphocytoma • Sarcoidosis • Lupus Erythematosus D. Facial granuloma

  42. Facial granuloma • Sometimes called « eosinophilic grabuloma » • Described by Lever • Often solitary, reddish-brown plaque • Nose (+++), forehead, cheeks • The « orange skin » aspect is characteristic • Treatment is difficult treatment (beware of scars!). Try dapsone

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