Listen to Your Face: It Is Not Always Just a Cosmetic Problem

Photo by Laura Marques on Unsplash

There is still some debate about whether skin can be considered an organ, but if it is, then it is the largest organ in human body. While most of the skin conditions are local, there are a number of serious diseases and medical conditions that can manifest as skin ailments. Recognizing when a skin condition is potentially more than just an “irritation’ or a “rash” and getting professional help can be life-saving. In this series of articles we will discuss some of the medical ailments that can affect your face. Please note that this is not a scientific article and that any illness can manifest in more than one way; thus, if ever in doubt, please consult your health care provider immediately.

Facial Redness

Facial redness, also called facial erythema is caused by increased blood flow and is most noticeable in people with fair skin. It is a normal skin reaction when it happens transiently, due to strong emotion, exercise, or heat exposure. However, when it becomes longer lasting, it can be a sign of something more serious. A number of causes, including primary skin diseases, external insults, and medical diseases may cause facial redness. Knowing what to look for and when to start paying closer attention can be extremely important.

Below we will review some of the medical conditions that cause facial redness that may require a visit to your healthcare provider.

1. Diseases of the skin

Rosacea — presents as redness in the center of the face. Upon close inspection you can see something called telangiectasias, which are widened blood vessels that have spider web-like appearance. (picture 1A-B). People with rosacea also often exhibit flushing and skin sensitivity. There are a number of exacerbating factors that make worsen the appearance of the skin in patients with rosacea. These include: exposure to extremes of temperature, sun exposure, hot beverages and spicy foods, alcohol, exercise, irritation from topical products, emotional stress, and certain drugs such as nicotinic acid. The appearance is usually so typical that it is sufficient to make a diagnosis and start the treatment.

Pictures 1A-B. Redness and telangectasias in patients with rosacea

Rhinophyma is one subtype of rosacea that should be mentioned separately as it stands out in its presentation. It affects the nose and causes it to become enlarged and bulbous (picture 1С). The nose may look red, swollen, and distorted. It is more prevalent in men and in the past it was thought to be caused by alcohol consumption, but evidence of this relationship is lacking.

Picture 1C. Distorted, bulbous nose in a patient with rhinophyma.

Perioral dermatitis — presents as a rash around the mouth (nose or eyes can sometimes be involved as well) that, at a closer look are comprised of multiple, small, red bumps (picture 2). One interesting feature of perioral dermatitis is that it almost always spares the skin immediately adjacent to the lip borders (also called vermillion border). Another interesting fact is that steroid creams that are sometime mistakenly prescribed for this condition help only temporary but lead to worse outbreaks when stopped.

Perioral dermatitis is most often seen in young women, but can occasionally affect children and adolescents.

Picture 2. Small red bumps in a patient with perioral dermatitis. The skin nearest to the mouth is spared.

Seborrheic dermatitis presents as redness mixed with greasy yellow-white scaly patches. In people with darker skin, these scaly patches may have a gray or brown hue. Seborrheic dermatitis most commonly affects the scalp, which typically manifests as dandruff. When the face is affected, it typically hits the skin right below the hairline, around the nose, in the nasolabial folds, eyebrows, and behind the ears. (picture 3). One interesting feature of seborrheic dermatitis is that it usually gets better in the summer months and gets worse during cold and dry winter months.

Picture 3. Redness and yellow-white scaly patches in a patient with seborrheic dermatitis.

Atopic dermatitis or Eczema presents as rash that consists of red bumps and patches that may leak fluid and be crusty (picture 4). The two main features that help identify this disease are extreme itching and very dry skin. Itching may lead to scratching that causes more redness, swelling and raw appearance. Some people with atopic dermatitis may have dark circles an extra skin fold below the eyes (also called Dennie-Morgan folds). Many people suffering from atopic dermatitis also suffer from allergies and may have asthma.

Picture 4. Red patches around the eyes and extra skin folds in a patient with atopic dermatitis.

Contact dermatitis — is the result of contact with skin care products, cosmetics, or other substances. The areas involved depend on the sites where the irritants were applied and usually consist of red bumps and blisters (picture 5). The facial folds and the delicate skin of the eyelids are particularly susceptible. The typical complaints include severe itching and burning. When it is suspected it is very important to identify the reaction-causing substance.

Picture 5. Intense redness in the area where an irritant was previously applied.

Erysipelas — is a bacterial infection of the skin that presents as red, swollen, warm rash with sharp borders (picture 6). It is tender to touch and is often accompanied by fever, chills and malaise. If left untreated it can spread, with the most worrisome spread being towards the eye, where it can cause very serious infection. If suspected, immediate medical attention is necessary and antibiotics need to be prescribed right away.

Picture 6. Intensely red raised patch with sharp borders in a patient with erysipelas

Tinea faciei — is a fungal infection of the skin. The rash most frequently presents in patches on one side of the face and slowly increases in size (picture 7A). This disease is more prevalent in hot and humid climates. It prefers the areas of the face that aren’t covered with hair. However, in men, a similar type of fungal infection called tinea barbae has the opposite affinity and always occurs in the bearded area of the face (picture 7B).

Picture 7A. Oval red scaly patches, less red and scaly in the middle in a patient with Tinea Faciei
Picture 7B. Chronic inflammation in the bearded area of the skin in a patient with tinea barbae

Sun Poisoning (also known as Polymorphous light eruption (PMLE)) is a rash that usually appears 30 minutes to several hours after exposure to sunlight. It typically presents with dense clusters of small bumps and blisters or with red, raised rough patches (picture 8). Itching or burning are the most common complaints of sun poisoning. It is much more prevalent during spring, when the skin is not used to active sun. As the exposure increases into the summer months, the tolerance builds up and the eruptions tend to lessen.

Picture 8. Extreme sun poisoning

Phototoxic and photoallergic eruptions — these are rashes that are precipitated by a variety of drugs and chemicals, both ingested and applied to the skin that predispose our skin to excessive reactions to sun exposure. The typical example is when a person is prescribed an antibiotic such as Doxycycline and then gets exposed to sun. The response to sun exposure is amplified manifold because of the antibiotic. Making sure that you know about potential photosensitizing side effects of medications and chemicals that you take and avoid sun exposure.

Picture 9. Redness and blistering in a patient with phototoxic eruption.

2. Internal Diseases Affecting the Skin

The number of medical conditions that manifest with skin redness is enormous and would probably require a whole textbook to fully cover. Here we discuss two conditions that present with very distinct features. Again, if you have any concerns that you may have a serious medical problem please make sure to contact your health care provider right away.

Acute Cutaneous Lupus Erythematosus (aka Cutaneous Lupus). Systemic Lupus Erythematosus (SLE) is a serious disease that can affect many organs of the body and is triggered by over vigilance of immune system that starts attacking its own tissues. Patients with SLE may develop acute cutaneous lupus erythematosus, which often presents as a “butterfly rash” on the face that covers the cheeks and bridge of the nose (picture 10). The prominent telangiectasias of rosacea are not a feature of acute cutaneous lupus erythematosus. It rarely presents alone and is often accompanied by fevers, fatigue, joint pain, stiffness and swelling. If SLE is suspected, then immediate consultation with a medical professional is required.

Picture 10. Typical “butterfly rash” in a patient with Cutaneous Lupus.

Dermatomyositis is an inflammatory condition that is poorly understood. It presents with muscle weakness and a typical facial rash, called “heliotrope rash”, which is often the first sign of the disease. The rash is typically a dark red or a violet-colored, most commonly on the face and eyelids (picture 11). The rash, which can be itchy and painful, is often the first sign of dermatomyositis. It is important to mention that people with dermatomyositis are at increased risk of developing cancers, especially within the first five years of the diseases. Thus, it is imperative that this condition is managed by physicians with deep knowledge of this condition.

Picture 11. Dark red rash of the eyelids (heliotrope rash) in a patient with dermatomyositis.