Mystery Diagnosis: Face Rash
Lorraine is a 32-year-old administrative executive who develops a rash on her face after a summer excursion with her family in Hawaii. Is it a sunburn? Or is it something more serious?
Lorraine is a 32-year-old business administrator who came to see me for a sunburn she developed on her face after a one week summer excursion with her family in Hawaii. She doesn’t get out much, she tells me, as her career keeps her quite busy indoors. But she’s never had a burn like this before, and she is embarrassed to go back to work “looking like an apple,” she exclaims.
Well, it is summertime. And I know what that means—lots of time spent outdoors for my patients. It’s not an uncommon phenomenon during the hot summer months, especially here in sunny Southern California. My sunburn diagnoses are unfortunately more common than I’d like.
The History
If you’ve read my previous articles you may already be aware that doctors have a very structured evaluation process for each symptom at each visit (hence, why some visits are more time-consuming than you’d imagine). It first begins with the patient history. This initially entails perusing the patient chart for their past medical history and then gathering information about the present history (in this case the facial rash).
Lorraine is a very healthy young woman. She only suffers from adult acne, a very common diagnosis believe it or not, in addition to asthma since childhood. She very infrequently uses an as-needed rescue inhaler for her asthma, in addition to a daily antibiotic called minocycline for her acne.
She tells me that her rash began after sun exposure, while surfing the Hawaiian tides. She used to surf in her 20’s and couldn’t pass up the chance to ride the waves in one of the sport’s most sought-after hot-spots.
She tells me that she did indeed use sunblock, but that she could have made more of an effort to reapply every two hours as she knows she should.
The Exam
On exam, Lorraine has some mild diffuse “erythema” (doctor lingo for redness) on her chest and upper arms, but the worst sunrays seem to have struck her cheeks and nose. Thankfully, there is no blistering, the skin is dry, yet it is rather pain to the touch.
The Assessment
Given her recent sun exposure, and that she is a rather healthy young patient, sunburn does seem to be the most likely diagnosis. In addition, Lorraine is taking minocycline, which like many other acne treatment, is known to cause “photosensitivity” and increase the risk of sunburn.
“It completely slipped my mind!” Lorraine exclaims, as I reminded her that she should avoid the sun like the plague when being treated for acne with minocycline.
The Treatment
So after I have researched her past medical history, gathered the present history of current illness, examined Lorraine’s rash, and made my assessment, I then prescribe her my treatment recommendations. I advise her to:
- 1. Use water-resistant sunblock with SPF 30 or higher, with both UVA and UVB protection stated on the bottle and the ingredients titanium or zinc oxide (which block the sunrays best).
- 2. Avoid any further sun exposure.
- 3. Pick up a prescription for silver sulfadiazine cream (the cream often used to treat more concerning burns).
The Follow-Up
I didn’t expect to see Lorraine for the sunburn again, but she presented three weeks later with the same exact rash on her face. The burn on her arms and chest seem to have resolved, but the one on her face did not budge. It did not respond to the sunburn treatment I gave her, nor to the healing of time.
What else could cause a rash on the face induced by the sun?
Rosacea is a common skin disorder of the face, with a characteristic redness over the cheeks and central face. It can also be exacerbated by the sun. It is more common in lighter-complexioned women over the age of 30.
That sounds just like Lorraine. Medicine sometimes involves some trial and error using a process of elimination.
I prescribe Lorraine a topical antibacterial gel called “metronidazole,” first-line treatment for rosacea, and ask her to return if not improved after using this for a month.
Low and behold, Lorraine returns once again to follow-up in clinic in four weeks. And yep, you guessed it…she hasn’t had any improvement in her rash. She’s also still on that minocycline, which along with the metronidazole gel, should really zap that rosacea.
This time, I send Lorraine for a blood test to rule out some other less common causes of a rash on the face. And I finally have a surprising, less common answer for the red rash on her face. What is it?
The answer is Lupus. Lupus is an autoimmune disorder (when the body produces proteins that virtually attacks itself) that causes something called a “malar rash,” a particular rash in the distribution of a “butterfly” on the central face, with the center on the nose and the wings on the cheeks. This is a characteristic rash that can be confused with rosacea and sunburn. And like the two latter, it can also be triggered by the sun.
I then remember that Lorraine has also been taking minocycline, a medication that has also been associated with a Lupus-like condition called “drug-induced lupus.” That’s right: there are certain medications that can induce a milder, often reversible, version of Lupus. Besides minocycline, these medications include:
2nd and 3rd Line Antihypertensives:
Hydralazine
Diltiazem
Methyldopa
Anti-seizure drugs:
Phenytoin
Carbamazepine
Anti-microbials:
Rifampin (Antibiotic)
Nitrofurantoin (Antibiotic)
Terbinafine (Anti-fungal)
Isoniazid (treatment for active tuberculosis or its exposure)
Others:
Lithium
Procainamide
Chlorpromazine
Infliximab and etanercept
Much to her resistance, I asked Lorraine to discontinue the use of minocycline as a trial. And in several weeks, her “butterfly rash” had completely resolved.
In Lorraine’s situation, the Lupus symptom was induced by a drug and reversed upon discontinuation. But many patients with Lupus aren’t that fortunate.
What is Lupus? What are its symptoms and signs? How is it diagnosed?
Make sure to tune in next time to learn more about this mysterious disease that can manifest itself in more ways than one. Like Celiac disease, hypothyroidism, and syphilis, it can affect numerous organs, and hence present in numerous ways.
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Please note that all content here is strictly for informational purposes only. This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider. Please always seek a licensed physician in your area regarding all health related questions and issues.
Well, thanks again for listening to this episode of the House Call Doctor. If you have any future topic suggestions, you can email me at housecalldoctor@quickanddirtytips.comcreate new email. Have a healthy week!
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About the Author
Dr. Sanaz Majd is a board-certified Family Medicine physician who graduated from Drexel University College of Medicine in Philadelphia. Her special interests are women’s health and patient education.
