Photo Quiz
A Persistent Facial Rash
BENSON KOON WEE YEO, MBBS, and HONG LIANG TEY, MBBS, MRCP, National Skin Centre, Singapore
The editors of AFP wel- A 46-year-old woman presented with a facial
come submissions for rash that had worsened over nine months.
Photo Quiz. Guidelines for
preparing and submitting She had been treated with several topical
a Photo Quiz manuscript corticosteroids and topical antibiotics, which
can be found in the improved her symptoms only temporarily.
Authors’ Guide at http:// She was taking no other medications. There
[Link]/afp/photo
quizinfo. To be considered were no specific triggers or contacts, and she
for publication, submis- had no significant medical history.
sions must meet these Examination revealed annular plaques with
guidelines. E-mail submis-
a raised erythematous border on the forehead
sions to afpphoto@aafp. Figure 1.
org. Contributing editor (Figure 1) and both cheeks (Figure 2). Other
for Photo Quiz is John E. areas of her body were not affected.
Delzell, Jr., MD, MSPH.
A collection of Photo Quiz- Question
zes published in AFP is Based on the patient’s history and physical
available at [Link] examination findings, which one of the fol-
[Link]/afp/photoquiz.
lowing is the most likely diagnosis?
❑ A. Acne rosacea.
❑ B. Acute cutaneous lupus
erythematosus.
❑ C. Atopic dermatitis.
❑ D. Dermatomyositis.
Figure 2.
❑ E. Tinea faciei.
Figures reprinted with permission from the National Skin
Centre. See the following page for discussion.
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Photo Quiz
Discussion
The answer is E: tinea faciei. Tinea faciei, Summary Table
or dermatophytosis, is a common condition
that results from a dermatophyte infection Condition Characteristics
of the superficial epidermis. Papulosquamous
Acne rosacea Erythematous papules, pustules, and telangiectasias
plaques with an annular scaly edge should on the cheeks, forehead, and nose; flushing and
increase the clinical suspicion of tinea infec- redness with consumption of spicy foods or alcohol
tions, particularly if they persist despite treat- are common
ment with steroids. After the application of Acute cutaneous Erythematous patches or plaques on the malar
steroids, scaling and other clinical features of lupus eminence and nasal bridge in a typical “butterfly”
tinea infection may disappear, leading to tinea erythematosus configuration; most common on sun-exposed
areas; systemic signs and symptoms of lupus
incognito. Tinea pedis and tinea cruris are the erythematosus may be present
most common superficial fungal infections. Atopic Eczematous morphology; most common on the flexor
However, tinea faciei accounts for about 3 to dermatitis surfaces of the extremities; often associated with
4 percent of tinea corporis cases. It is more a history of other atopic diseases (e.g., asthma,
common in females and children, accounting allergic rhinitis)
for about 19 percent of all superficial fungal Dermatomyositis Periorbital, symmetrical, violaceous patches
infections in children.1 (heliotrope rash); proximal muscle weakness
A fungal infection can be confirmed using Tinea faciei Papulosquamous plaques with an annular, scaly edge
a skin scraping of the lesion borders. A cul-
ture can identify the specific dermatophyte
species, although treatment is usually the same. The Atopic dermatitis, or endogenous eczema, is eczema-
fungal scraping and culture can produce false-negative tous instead of papulosquamous and is most com-
results, and sensitivity decreases after treatment with mon on the flexor surfaces of the extremities. Patients
steroids and antifungal medications.2 Rarely, a punch with the condition often have a history of other atopic
biopsy is needed to diagnose the infection or evaluate for diseases, such as asthma or allergic rhinitis. The rash
other possible causes. should respond to topical corticosteroids.
Most tinea infections can be treated with topical Dermatomyositis usually causes periorbital, sym-
antifungal medications. Systemic therapy should be metrical, violaceous patches (heliotrope rash), as well
considered for resistant, chronic, or extensive cases. Oral as symmetrical weakness in the proximal muscles.
antifungal medications should be used if the infection
Address correspondence to Benson Koon Wee Yeo, MBBS, at yeoben
involves hair or folliculitis because topical applications son@[Link]. Reprints are not available from the authors.
are unable to reach the depth of the hair follicles, where
Author disclosure: No relevant financial affiliations.
the dermatophytes reside.
Acne rosacea is a chronic inflammatory condition
affecting the cheeks, forehead, and nose. The condition REFERENCES
typically causes papules, pustules, and telangiectasias. 1. Lari AR, Akhlaghi L, Falahati M, Alaghehbandan R. Characteristics of
dermatophytoses among children in an area south of Tehran, Iran.
Flushing and redness often occur with consumption of Mycoses. 2005;48(1):32-37.
spicy foods or alcohol. 2. Levitt JO, Levitt BH, Akhavan A, Yanofsky H. The sensitivity and
Acute cutaneous lupus erythematosus usually involves specificity of potassium hydroxide smear and fungal culture relative to
erythematous patches or plaques on the malar eminence clinical assessment in the evaluation of tinea pedis: a pooled analysis.
Dermatol Res Pract. June 22, 2010. [Link]
and nasal bridge, resulting in the typical “butterfly” drp/2010/764843. Accessed January 28, 2013. ■
configuration. Systemic signs and symptoms of lupus
erythematosus may also be present. The rash is most
common in sun-exposed areas.
580 American Family Physician [Link]/afp Volume 87, Number 8 ◆ April 15, 2013
