General Pattern Recognition by Location
Initial diagnosis of the “red face” often depends on identifying exactly where the redness and lesions appear:
- Psoriasis: Typically found at the hair line, scalp, and ears (both in and behind).
- Acne: Primarily affects the forehead, cheeks, chest, and back.
- Rosacea: Concentrated on the cheeks, forehead, and chin, but notably excludes the nasolabial folds and the vermillion border of the lips.
- Seborrheic Dermatitis: Found in the nasolabial folds, at the vermillion border, and behind the ears.
- Periorifacial Dermatitis: Affects the nasolabial folds but excludes the vermillion border.
- Eczema: Can appear anywhere, but frequently involves the eyelids.
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Seborrheic Dermatitis vs. Periorifacial Dermatitis (POD)
Key Differences
- Aetiology & Demographics: Seborrheic dermatitis is a common chronic eczema affecting sebaceous-rich areas, appearing more often in males. POD is a chronic inflammatory eruption around orifices, more common in females aged 20–45.
- Risk Factors: POD is specifically linked to steroid use (nasal, inhalers, or creams), cosmetics, and occlusive emollients. Seborrheic dermatitis flares in winter and is associated with HIV and Parkinson’s Disease.
- Sensation: POD often presents with a burning sensation or skin tightness, whereas seborrheic dermatitis typically has minimal itch.
- Clinical Presentation: Seborrheic dermatitis presents as salmon pink, thin, scaly macules or patches. POD appears as an acneiform eruption of clusters of tiny (<2mm) papules, vesicles, or pustules on an erythematous base.
Treatments
- Seborrheic Dermatitis: Includes avoiding soaps and thin moisturisers. It is treated with daily topical antifungals (e.g., Ketoconazole or Miconazole) for 4 weeks, mild topical steroids for 1–2 weeks, or topical calcineurin inhibitors.
- Periorifacial Dermatitis: The primary treatment is to stop all topical products, especially steroids, and wash only with water. Medical interventions include topical antibiotics (Metronidazole or Clindamycin) or a 4–8 week course of systemic tetracycline antibiotics.
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Acne Vulgaris vs. Acne Rosacea
Key Differences
- Age & Appearance: Acne generally affects younger patients and is characterized by comedones (blackheads/whiteheads), whereas Rosacea affects older patients and is defined by erythema (redness) and flushing.
- Aetiology: Acne is caused by seborrhoea, comedones, and colonization with P. acnes. Rosacea is linked to changes in blood supply, UV damage, and potentially the Demodex mite.
- Triggers & Features: Rosacea involves flushing triggered by stress, alcohol, UV, or spicy food, and may show telangiectasia (visible blood vessels) or phymatous changes (skin thickening). Acne may result in scarring and frequently affects the back and chest.
Treatments
- Acne: Requires patience, as it takes 3 months to show results.
- Mild: Topical retinoids, Benzoyl Peroxide (BPO), or combination gels like Epiduo or Duac.
- Moderate: Oral tetracycline antibiotics for 3–6 months, which must be co-prescribed with a topical BPO or retinoid.
- Severe: Referral to dermatology for Isotretinoin (Roaccutane) if there is a risk of scarring.
- Rosacea: Works faster than acne treatments, typically taking 1–2 months.
- Topical: Ivermectin, Azelaic Acid, or Metronidazole gel.
- Systemic: Oral tetracyclines for 1–2 months to gain control before stepping down to topical treatments.
- Note: Treatments for the underlying redness (erythema) are often less effective than those for inflammatory lesions.
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