Approach to the patient with facial erythema

INTRODUCTION — Facial erythema (facial redness), a clinical finding most noticeable in individuals with lightly pigmented skin, occurs as a result of cutaneous blood vessel dilation and increased blood flow to the skin. Although transient facial erythema is often observed as a normal, neurologically mediated response to strong emotion, exercise, or heat exposure, inflammation and a variety of medical conditions can lead to longer-lasting and symptomatic or cosmetically distressing facial erythema.

Examples of disorders that may present with diffuse or localized facial erythema and the evaluation of patients with this clinical finding will be reviewed here. More detailed information on flushing and many of the other disorders associated with facial erythema is available separately. (See "Approach to flushing in adults" and 'Etiology' below.)

ETIOLOGY — A variety of factors, including primary skin diseases, external insults, and systemic illness may cause facial redness. Knowledge of the distinctive characteristics of these disorders is helpful for diagnosis.

Primary inflammatory skin diseases

●Rosacea – Centrofacial erythema and telangiectasias are common features of rosacea (picture 1A-C) [1-3]. Affected patients also often exhibit flushing and sensitivity of facial skin. The patient history and physical findings are usually sufficient for the diagnosis of this disorder. Other rosacea subtypes may also demonstrate these clinical features. (See "Rosacea: Pathogenesis, clinical features, and diagnosis".)

●Perioral dermatitis – Perioral dermatitis (also known as periorificial dermatitis) presents with multiple small, erythematous, inflammatory papules clustered around the mouth, nose, or eyes (picture 2). Fine scale is also often present, but the rash is characteristically more red and bumpy than red and scaly. In patients with perioral lesions, the skin immediately adjacent to the vermillion border of the lip is classically spared. Perioral dermatitis most frequently affects young females; occasionally, the disorder occurs in children. (See "Perioral (periorificial) dermatitis".)

●Seborrheic dermatitis – Erythema accompanied by greasy, yellow-white scale is a characteristic feature of seborrheic dermatitis in adults (picture 3). In patients with dark skin, the scale may have a gray or brown hue (picture 4). Involvement of the face typically manifests in the nasolabial folds, eyebrows, glabella, and lateral nasal areas (picture 5A-B). Other potential sites of involvement include the scalp, ears, chest, axillae, and groin. The diagnosis of seborrheic dermatitis is usually made based upon the clinical findings [4,5]. (See "Seborrheic dermatitis in adolescents and adults".)

●Atopic dermatitis – Facial involvement of atopic dermatitis is common in infants (picture 6A-C) but may also occur in older children and adults (picture 7A-B). Intensely pruritic, erythematous patches or plaques with accompanying scale, exudate, excoriations, or lichenification are often seen. The presence of a chronic, very pruritic, dermatitic skin disorder with lichenification in a typical distribution (eg, flexures in adults, cheeks in infants) suggests the possibility of atopic dermatitis [6]. Patients may also exhibit an extra skin fold beneath the bilateral lower eyelids that is known as a Dennie-Morgan fold (picture 8). An uncommon variant is photosensitive atopic dermatitis, which occurs predominantly in atopic skin exposed to ultraviolet light [7]. (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis".)

●Psoriasis – The clinical findings in facial psoriasis may be more subtle than the classic thick plaques with silver scale that are typical of lesions in other body areas (picture 9A-B). In some patients, lesions closely resemble the erythematous patches and finer scale of seborrheic dermatitis. The detection of lesions consistent with the classic presentation of psoriasis elsewhere on the body is helpful for diagnosis. (See "Psoriasis: Epidemiology, clinical manifestations, and diagnosis".)

Disorders due to external insults

●Irritant contact dermatitis – Contact with skin care products, cosmetics, or other substances that contain irritants may result in facial eruptions with features of eczematous dermatitis. The dermatitis may be diffuse or localized depending on the sites of contact. The facial folds and the delicate skin of the eyelids are particularly susceptible to more severe involvement. (See "Eyelid dermatitis (eczema)".)

Unlike allergic contact dermatitis, which is typically associated with intense pruritus, patients with irritant contact dermatitis tend to complain of burning or prickling sensations [8]. The patient history is critical for identifying this diagnosis. (See "Irritant contact dermatitis in adults".)

●Allergic contact dermatitis – Delayed hypersensitivity reactions to external substances that contact the skin can cause acute, intense inflammatory reactions characterized by bright erythema, scale, and exudate (picture 10A-B) [8]. Other times, the dermatitis is only mildly inflamed and chronic. Patch testing can be useful for identifying the causative antigenic substance. (See "Clinical features and diagnosis of allergic contact dermatitis" and "Patch testing".)

Photosensitive disorders

●Sunburn – The appearance of confluent, erythematous patches following sun exposure is a classic feature of sunburn (picture 11). Pruritus or pain may also be present. In severe cases, edema and blistering can occur. Desquamation commonly occurs during healing. (See "Sunburn".)

●Polymorphous light eruption (PMLE) – Often colloquially referred to as sun poisoning or sun allergy, PMLE may present with a wide variety of clinical manifestations [9,10]. Erythematous patches, papules, vesicles, or plaques may occur within hours to days after sun exposure (picture 12). PMLE is particularly likely to occur in early spring, as patient tolerance to sunlight tends to rise with increasing exposure. (See "Polymorphous light eruption".)

●Phototoxic and photoallergic eruptions – Phototoxic eruptions are sunburn-like reactions induced by the ingestion or application of photosensitizing substances (picture 13) [11-14]. The photosensitizing agent decreases the amount of ultraviolet light exposure required to elicit this reaction. Severe eruptions with blistering and edema may occur. (See "Photosensitivity disorders (photodermatoses): Clinical manifestations, diagnosis, and treatment", section on 'Phototoxicity'.)

Photoallergic reactions are characterized by pruritic, eczematous eruptions in sun-exposed areas [11-13]. Topical, rather than ingested, agents are the most frequent causes of photoallergic reactions [15]. (See "Photosensitivity disorders (photodermatoses): Clinical manifestations, diagnosis, and treatment", section on 'Photoallergy'.)

●Photodamage – The formation of numerous telangiectasias and a ruddy complexion secondary to chronic sun exposure is a common cause of facial redness [16]. Sun-protected areas of the face are relatively spared. Patients may have accompanying poikiloderma of Civatte, a disorder characterized by mottled pigmentation and telangiectasias on the lateral neck (picture 14). (See "Photoaging", section on 'Clinical features'.)

●Acute cutaneous lupus erythematosus, dermatomyositis, and lupus tumidus erythematosus [17]. (See 'Systemic disorders' below and 'Localized inflammatory infiltrates' below.)

Systemic disorders

●Lupus erythematosus – Patients with systemic lupus erythematosus may develop acute cutaneous lupus erythematosus, which often manifests as persistent, violaceous erythema on the malar area of the face (picture 15A-B) [18,19]. This clinical finding is often referred to as a "butterfly rash." The prominent telangiectasias of rosacea are not a feature of acute cutaneous lupus erythematosus. The presence of signs or symptoms of systemic lupus erythematosus suggests this diagnosis. (See "Overview of cutaneous lupus erythematosus", section on 'Acute cutaneous lupus erythematosus' and "Childhood-onset systemic lupus erythematosus (SLE): Clinical manifestations and diagnosis" and "Clinical manifestations and diagnosis of systemic lupus erythematosus in adults", section on 'Clinical manifestations'.)

Patients with subacute cutaneous lupus erythematosus have a photosensitive form of lupus erythematosus. Erythematous, annular, scaly, psoriasiform plaques usually appear on the trunk, but the face may be involved. The inner edge of annular plaques often shows fine, white, trailing scales. Patients may be otherwise usually "healthy," but some may have arthritis or other systemic features of lupus erythematosus. (See "Overview of cutaneous lupus erythematosus", section on 'Subacute cutaneous lupus erythematosus'.)

●Dermatomyositis – A classic sign of dermatomyositis is the "heliotrope eruption," a violaceous and often edematous eruption that occurs on the eyelids and periorbital skin (picture 16A-B). Patients may or may not have accompanying proximal muscle weakness. The detection of other cutaneous signs of dermatomyositis, such as Gottron papules and periungual telangiectasias, raises suspicion for this diagnosis. In addition, the possibility of an underlying malignancy must be considered in adults with dermatomyositis. (See "Clinical manifestations of dermatomyositis and polymyositis in adults" and "Juvenile dermatomyositis and other idiopathic inflammatory myopathies: Epidemiology, pathogenesis, and clinical manifestations".)

Infectious disorders

●Viral infections – Erythema infectiosum (fifth disease) is a viral disease caused by parvovirus B19, which most commonly occurs in children [20]. A common feature of this disorder is the appearance of red patches on the cheeks that resemble facial skin after a slap on the face (picture 17). Nonspecific constitutional symptoms, such as fever, coryza, headache, or gastrointestinal distress, usually precede the cutaneous findings. A reticulated eruption on the trunk and extremities frequently appears one to two days after the facial lesions. (See "Clinical manifestations and diagnosis of parvovirus B19 infection", section on 'Erythema infectiosum'.)

Morbilliform or confluent facial redness may also occur as early features of other viral infections, such as measles or rubella; other body sites are typically also involved (picture 18A-B). (See "Measles: Clinical manifestations, diagnosis, treatment, and prevention" and "Rubella".)

●Erysipelas – Erysipelas is a superficial form of cellulitis that usually results from infection with beta-hemolytic streptococci [21]. Patients typically present with the acute development of an erythematous, warm, edematous, and well-defined plaque (picture 19A-B). Fever and lymphadenopathy often accompany the cutaneous symptoms. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis".)

Localized inflammatory infiltrates

●Lupus tumidus erythematosus – Also known as tumid lupus erythematosus, lupus tumidus erythematosus is an uncommon disorder that presents with erythematous plaques in sun-exposed areas, such as the face, neck, upper trunk, and upper extremities, and scale is typically absent (picture 20) [22,23]. The vast majority of patients do not have associated systemic lupus. The performance of a biopsy assists with diagnosis. (See "Overview of cutaneous lupus erythematosus", section on 'Lupus erythematosus tumidus'.)

●Jessner's lymphocytic infiltrate – This idiopathic disorder most commonly manifests as erythematous, asymptomatic, often annular plaques on the face, neck, or upper trunk (picture 21A-B) [24,25]. A skin biopsy is useful for diagnosis. Jessner's lymphocytic infiltrate shares clinical and histopathologic features with lupus tumidus erythematous. The relationship between these disorders remains unclear [25].

●Granuloma faciale – Granuloma faciale usually presents as a solitary, red-brown, asymptomatic, round plaque with follicular prominence on the face (picture 22) [26]. The histopathologic finding of a normal-appearing thin zone in the papillary dermis (Grenz zone) above a dense inflammatory dermal infiltrate containing eosinophils, lymphocytes, neutrophils, and plasma cells is characteristic of this diagnosis. The disorder is most common in White males [26]. (See "Granuloma faciale".)

●Cutaneous B cell pseudolymphomas – Cutaneous B cell pseudolymphomas occur as a result of antigenic stimulation in the skin leading to lymphocyte proliferation. The specific cause is often unknown, but insect bites and infections, including Lyme disease, have been linked to some cases [27,28]. Patients typically present with a red-brown to violaceous nodule or plaque (picture 23). A skin biopsy is necessary for diagnosis. (See "Cutaneous B cell pseudolymphoma".)

●Tinea faciei – Infections with dermatophytic fungi can mimic other acute and chronic facial skin diseases depending upon the nature of the infecting organism and the intensity of the host's defense reaction. In general, facial fungal infections tend to be unilateral; sharply marginated; occasionally annular, scaling, or weeping; and slowly enlarging plaques (picture 24) [29]. Potassium hydroxide examination of scale or culture confirms the clinical diagnosis. If lesions have been treated with a topical corticosteroid, they typically seem to improve as inflammation is reduced (tinea incognito) but recur when treatments are stopped. (See "Dermatophyte (tinea) infections", section on 'Tinea faciei'.)

Other

●Flushing – Flushing is characterized by the sudden and transient appearance of facial erythema. The etiology and clinical manifestations of flushing are discussed separately [30]. (See "Approach to flushing in adults".)

●Ruddy complexion – Generalized redness of the skin may occur as a normal feature in some individuals with fair skin (eg, Fitzpatrick skin phototype I or II (table 1)). Unlike erythematotelangiectatic rosacea, redness is not limited to the central face.

●Keratosis pilaris rubra – Keratosis pilaris rubra faciei is most common in children, adolescents, and young adults with fair complexions. Triangular, erythematous patches are present on the bilateral cheeks (picture 25). Follicular keratotic papules are located within the areas of redness, giving the skin a rough texture [31]. Clinical examination is usually sufficient for diagnosis.

●Topical corticosteroid withdrawal syndrome – Some patients develop a red face from prolonged use of moderate- to high-potency topical corticosteroids on the face. Symptoms of burning or stinging develop within several days after applications are stopped or reduced. Diagnostic difficulties arise from the inability to clearly distinguish the redness from topical corticosteroid withdrawal from the redness due to exacerbation of the underlying dermatosis. Features suggesting topical corticosteroid withdrawal include the appearance of generalized redness of the face within four days of withdrawal and symptoms of pain, especially burning sensations [32]. (See "Topical corticosteroids: Use and adverse effects", section on 'Adverse effects'.)

●Burning face syndrome (facial erythrodysesthesia) – Painful or burning sensations are associated with facial erythema due to mild dilation of blood vessels. Some patients have rosacea, while others seem to have a neuropathic pain syndrome [33].

PATIENT ASSESSMENT — The first step for narrowing the differential diagnosis of facial erythema is the performance of a thorough patient history and skin examination. The recognition of associated symptoms, exacerbating factors, lesion time course, and subtle clinical features of the affected area are often valuable for diagnosis. In addition, the performance of a full skin examination may yield additional skin findings that suggest an underlying cutaneous or systemic disorder.

The clinician should consider the following points during the patient evaluation:

●What are the physical characteristics of the eruption?

•Diffuse and symmetrical without scale – Ruddy complexion, flushing

•Diffuse and symmetrical with scale – Irritant contact dermatitis, airborne allergic contact dermatitis, atopic dermatitis in infants

•Symmetrical, central face or cheeks without scale – Rosacea, erythema infectiosum, keratosis pilaris rubra faciei

•Symmetrical, central face with scale – Seborrheic dermatitis, atopic dermatitis, psoriasis

•Photodistributed – Sunburn; polymorphous light eruption; phototoxic reaction; photoallergic reaction; photodamage; acute, subacute, and discoid cutaneous lupus erythematosus; dermatomyositis; lupus erythematosus tumidus

•Localized plaques or patches – Erysipelas, lupus tumidus erythematosus, cutaneous lymphoid hyperplasia, Jessner's lymphocytic infiltrate, granuloma faciale

•Presence of telangiectasias – Photodamage, rosacea

●Are there associated symptoms?

•Prominent pruritus – Allergic contact dermatitis, atopic dermatitis, photoallergic reaction

•Painful or burning sensations – Sunburn, irritant contact dermatitis, phototoxicity, erysipelas, rosacea

•Sick patient – Lupus erythematosus, dermatomyositis, systemic infection, drug eruption

●How long has the eruption been present; how long do symptoms last?

•Acute – Allergic contact dermatitis, atopic dermatitis flare, erythema infectiosum and other viral infections, sunburn, phototoxic reaction, photoallergic reaction

•Transient – Flushing

●Has the patient applied any products to the skin that could cause an irritant or allergic reaction?

•Allergic contact dermatitis, irritant contact dermatitis, photoallergic reaction

●Is the eruption exacerbated by sun exposure?

•Sunburn, phototoxic reaction, photoallergic reaction, cutaneous lupus erythematosus, dermatomyositis, lupus tumidus erythematosus

●Is the patient ingesting any photosensitizing medications or supplements (table 2)?

•Phototoxic reaction, occasionally photoallergic reactions

●Are other body sites involved, and in what distribution?

•Psoriasis, atopic dermatitis, seborrheic dermatitis, viral exanthems, drug eruptions, photodermatoses, erythroderma, other disorders

DIAGNOSTIC TESTS — The workup of patients with facial redness is dependent upon the disorders suspected as a result of the clinical assessment. Diagnostic tests that can be useful for the evaluation of select patients include:

●Patch testing

●Skin biopsy

●Directed serologic studies (eg, investigative tests for autoimmune disease)

Patch testing — Patch testing can be useful for identifying the causative allergen in patients with contact dermatitis. The procedure is most appropriate for patients in whom an allergic contact dermatitis is strongly suspected (eg, history of contact with a potential allergen, paroxysmal nature of eruptions, or severe pruritus) or in patients with persistent, pruritic, eczematous facial eruptions without another identifiable cause. (See "Patch testing".)

The results of patch testing must be interpreted carefully since a positive patch test result does not definitively indicate that a specific allergen is the cause of dermatitis. A thorough patient interview prior to patch testing and reevaluation following the elimination of the identified allergen are essential for confirming the relevance of patch test results.

Biopsy — Skin biopsies are not necessary in most patients with facial erythema, as a thorough clinical history and skin examination often yields the diagnosis. However, in cases in which the diagnosis remains uncertain and the disorders being considered have distinctive histopathologic findings, skin biopsies can be of value.

Punch biopsies are typically performed for the evaluation of facial dermatoses as they allow for the evaluation of the full thickness of the epidermis and dermis through the removal of a relatively small skin sample. We most commonly perform 3 mm punch biopsies when evaluating inflammatory facial dermatoses. Larger punch biopsies are typically avoided to minimize scarring, and smaller biopsies may increase the risk for inconclusive histopathologic results. (See "Skin biopsy techniques", section on 'Punch biopsy'.)

If multiple sites are acceptable for biopsy, a site that minimizes cosmetic disfigurement should be selected.

Serology and other tests — Serologic studies and other investigative tests may be useful in the diagnostic workup of patients with facial redness related to systemic disorders such as acute cutaneous lupus erythematosus, dermatomyositis, or certain infections. The selection of studies is based upon the clinical suspicion for specific underlying disorders. (See "Clinical manifestations and diagnosis of systemic lupus erythematosus in adults" and "Childhood-onset systemic lupus erythematosus (SLE): Clinical manifestations and diagnosis", section on 'Diagnosis' and "Juvenile dermatomyositis and other idiopathic inflammatory myopathies: Diagnosis" and "Diagnosis and differential diagnosis of dermatomyositis and polymyositis in adults", section on 'Laboratory testing and imaging'.)

TOPICAL CORTICOSTEROID USE — The treatment of facial erythema should be selected based upon the measures appropriate for the specific underlying disorder. For corticosteroid-responsive inflammatory dermatoses, low-potency agents (eg, hydrocortisone 1% or 2.5%) are most frequently employed to minimize risk for the induction of acneiform eruptions and cutaneous atrophy that may lead to telangiectasias and a red hue to the skin (table 3).

With the exception of specific disorders in which higher-potency topical corticosteroids are required (eg, discoid lupus erythematosus), the use of medium- or high-potency topical corticosteroids for inflammatory facial dermatoses generally is not recommended. Facial dermatoses requiring treatment with medium- or high-potency topical corticosteroids are best managed by a dermatologist. (See "Topical corticosteroids: Use and adverse effects", section on 'Adverse effects'.)

INDICATIONS FOR REFERRAL — Evaluation by a dermatologist is appropriate for patients with facial redness of unknown cause or that fails to respond as expected to therapy. Facial biopsies and patch testing are best performed by clinicians trained in these procedures. (See 'Patch testing' above and 'Biopsy' above.)

SUMMARY AND RECOMMENDATIONS

●Facial redness is a common cutaneous finding that may occur as a normal feature or as a consequence of cutaneous or systemic disorders. Examples of conditions that may lead to facial redness include inflammatory skin disease, photosensitive disorders, autoimmune disorders, vascular reactions, and infections. (See 'Etiology' above.)

●The evaluation of the patient with facial redness begins with a thorough patient history and whole body skin examination. Details such as the features of cutaneous lesions, symptoms, duration of the eruption, and exacerbating factors should be assessed. (See 'Patient assessment' above.)

●Although the diagnosis of disorders of facial erythema can commonly be made based upon the patient history and clinical examination, patch testing, skin biopsy, or laboratory studies may be beneficial in select patients. Antinuclear antibody testing is not indicated in all patients with facial redness. (See 'Diagnostic tests' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Mark V Dahl, MD, who contributed to an earlier version of this topic review.