DP05: A tough row to hoe: treating a novel recalcitrant facial rash

Wajeeha Khan,¹ Naomi Carson,² Aparna Sinha³ and Natalie Stone⁴

¹Chapel Allerton Hospital, Leeds, UK; ²Department of Cellular Pathology Severn Pathology, North Bristol NHS Trust, Bristol, UK; ³Department of Dermatology, Bristol Royal Infirmary, Bristol, Bristol, UK; and ⁴St Woolos Hospital, Newport, UK

Facial discoid dermatosis (FDD) is a recalcitrant rash confined to the face, which most commonly affects young females. Classically, FDD does not respond to conventional treatments and histologically resembles the pattern seen in pityriasis rubra pilaris (PRP). It is a newly recognized condition, first reported in 2010. We present two cases of FDD that were different in some respects from the already reported cases, and also present a literature review. A 30-year-old fit-and-well woman presented with an increasing number of red–brown, itchy and scaly plaques starting on her nose and later spreading to cover her whole face over a 3-year period. She was initially treated empirically with topical hydrocortisone, followed by clobetasone butyrate, which did not help. Skin biopsy revealed features in keeping with a diagnosis of PRP. Patch test found a relevant positive reaction to 2-bromo-2-nitropropane contained in her vitamin E face cream. Routine blood tests, as well as antinuclear antibody, anti-dsDNA and angiotensin-converting enzyme were all within the normal ranges. After getting no relief from topical corticosteroids, we commenced her on topical calcitriol, which seemed to reduce the scale and thickness of plaques. She was able to camouflage it and was happy with the outcome. A 42-year-old woman presented with a 10-year history of scaly red–brown patches and plaques on her cheeks, neck and chest during her first pregnancy, which had worsened following her second pregnancy 5 years later. She had been initially treated for psoriasis with clobetasone butyrate cream and Dovonex®, and subsequently for actinic keratosis with Efudix® cream without success. A previous biopsy had revealed a subtle corneal split and perivascular lymphocytic infiltrate. Repeat biopsy showed features of follicular plugging, checkerboard, alternating parakeratosis, parafollicular parakeratin and mild acanthosis with broad rete ridges seen in both samples and in keeping with PRP. Treatment with mometasone furoate 0·1% ointment provided resolution of some areas and improvement of others. Use of tacrolimus 0·1% ointment 2–3 times a week helped to some degree but did not maintain resolution. New areas continued to occur that responded to mometasone furoate 0·1% ointment. We report two cases of FDD in patients with type 1/2 skin type. Features enabling clinicians to make a diagnosis are the fixed nature of plaques, their slow progressive nature, clinical features that do not fully fit with seborrhoeic dermatitis, psoriasis, discoid lupus erythematosus, actinic keratosis or pemphigus foliaceous. A corneal split can be seen in FDD on histology alongside the features of PRP. Patch testing may be necessary to exclude any other contributing factors. None of the other cases reported in literature describe an association with pregnancy, but in one of our patients the rash started and was subsequently aggravated with pregnancy. The treatment of FDD cannot be generalized and needs to be tailored on a case-by-case basis.