Painful rash on face

Diagnosis: Erysipelas

Erysipelas is an acute superficial cellulitis with lymphatic involvement. It is characterized by the abrupt onset of a warm, erythematous rash with a sharply demarcated, indurated, elevated margin. There are no suppurative foci; sometimes, however, there are bullae or vesicles.

In facial “butterfly” erysipelas (which this patient had), the plaques may involve the eyelids, cheeks, nose, and forehead. Upon palpation, the skin is hot and tender. As the process develops, the color becomes a dark, fiery red and vesicles appear at the advancing border and over the surface. Associated regional lymphadenopathy may be present. There is no necrosis.¹

Most cases are caused by the Streptococcus species—usually group A (Streptococcus pyogenes)—and groups B, C, and G. (Erysipelas is occasionally caused by Staphylococcus aureus.) After prodromal symptoms that last for 4 to 48 hours and include malaise, chills, fever, anorexia, and vomiting, more red, tender firm spots develop.

Predisposing conditions for erysipelas include disruption to the skin barrier as a result of trauma, lymph stasis (prior radiation, mastectomy, saphenous vein harvest, lymphadenectomy), injection drug use, ulcers, wounds, dermatophytic infections, and edema. Toe intertrigo is perhaps the most common site for pathogen entry. The source of infection in facial erysipelas, however, is often the nasopharynx.^2,3

Differential diagnosis includes cellulitis, rosacea

The differential diagnosis for erysipelas include cellulitis, rosacea, lupus erythematous “butterfly rash,” and seborrheic dermatitis.

Cellulitis is associated with skin erythema, edema, and warmth in the absence of underlying suppurative foci. Lymphangitis and inflammation of regional lymph nodes may occur. Vesicles, bullae, and ecchymoses (or petechiae) may also be present.⁴

Rosacea is a disorder that occurs in middle-aged and older adults, and is more common in women.⁵ It is characterized by symmetrical vascular dilation on the central face, including the nose, cheek, eyelids, and forehead. Facial erythema and telangiectasias—typically on the cheeks—are also present, as well as late papules and pustules.⁶ There are no comedones, which you would see with acne vulgaris.⁶ Rosacea is made worse by heat or sunlight, emotional stressors, and drinking alcohol or eating spicy foods.

Lupus erythematous “butterfly rash” is characterized by a macular confluent erythema over the cheeks and bridge of the nose with fine scaling, erosions, and crusts. It appears in approximately half of patients with systemic lupus erythematosus, usually after sun exposure.^7,8