- Email: [email protected]
Evaluation and management of the “Red Face”
SECTION
EDlTORS:
KALMAN
L. WATSKY,
I Evaluation and Management of the “Red Face”
M.D.
330 Orchard Street, Suite 311, New Haven, CT 06511, Tel: 203-789-4045, Fax: 203-789-3744, EmaiL. Kwats!&&zt.net.
MARTI
JILL
ROTHE,
Patricia G. Engasser,DanielJ. Hogan, LeslieA. Stewart, andKath yn A. Zug
M.D.
Dept. ofDermatology, U Corm Health Center, Fannington, CT 06032, Tel: 860-679-4176, Fax 860-679-1267, EmaS [email protected].
ADVICE & DISSENT addresses relevant issues in contact dermatitis through panel discussions or point/counterpoint debates. We look forward to input from the readership, including suggestions and commentary.
Patients presenting with a “red face” challenge clinicians to consider a broad differential diagnosis that includes contact dermatitis. The diagnosis may be obscured or complicated by underlying actinic damage or rosacea. Unraveling this Gordian knot to arrive at a precise and accurate diagnosis takes patience and practice. The collective experience of our invited group of expert clinicians sheds light on this process. Copyright o 1999 by W. B. Saunders Company
w
ASKED 4 EXPERTS for their approach to the evaluation and management of patients with “red faces.” Dr. Patricia Engasser is a Clinical Professor at the University of California San Francisco and Stanford Medical Centers. Dr. Daniel Hogan is Chief of Dermatology and Professor of Medicine and Pediatrics at the Louisiana State University Shreveport Medical School. Dr. Leslie Stewart is a Clinical Assistant Professor at the University of Colorado Health Sciences Center. Dr. Kathryn Zug is an Assistant Professor at Dartmouth Hitchcock Medical Center.
What isyour dzxerential diagnosis of the Yedface? Dr. Engasser: It is a long list that includes atopic dermatitis, seborrheic dermatitis, psoriasis, rosacea, perioral dermatitis, drug reaction, photosensitivity, fungal or HIV infection, contact dermatitis, contact urticaria, irritant contact syndrome, photocontact dermatitis, airborne contact dermatitis, or a combination of the above. Occasionally, collagen vascular disease can also present this way, dermatomyositis more frequently than lupus. Dr. Hogan: Many Caucasians, particularly in the Southern states, have actinic poikiloderma of the face and neck with prominent erythema from
l
From the Uniuersity of Cali@nia at San Francisco, San Francisco; the Stanford Medical Center, Palo Alto, CA; the Louisiana State Universi& Shreuepoti Medical School, Shreveport, LA; the Universi& of Colorado Health Science Center, Denuer, CO; and the Dartmouth Hitchcock Medical Center, Lebanon, NH. No repn‘nts auailable. Copyright 0 1999 &y W.B. Saunders Company 1046-199x~1004-0012$10.00/0
236
American
Journal
of Contact
Dermatitis,
VoL 10, No 4 (December),
1999:flp
236-239
Evaluation
and Management
age 20 years onward. My differential diagnosis for less obvious causes in adults includes rosacea, perioral dermatitis, and allergic contact dermatitis (ACD). Seborrheic dermatitis commonly coexists with all 3 and may be mimicked by ACD. Dermatitis limited to the eyelid is often due to atopic dermatitis and, less frequently, ACD. Photocontact dermatitis is rare in my experience. Other important considerations are early cutaneous lupus erythematosus and tinea facei. Dr. Stewart: My differential diagnosis includes rosacea, steroid rosacea, seborrheic dermatitis, atopic dermatitis, allergic or irritant contact dermatitis, photodermatitis, contact urticaria, lupus, dermatomyositis, and polycythemia rubra Vera. Dr. Zug: If there is patchy erythema, itch, and edema, then contact dermatitis tops my list. Most troublesome are patients who remain unimproved despite being on a very strict, limited facial care regimen; in these cases the diagnosis is commonly atopic or seborrheic dermatitis. However, always think about photoallergic contact dermatitis and photoaggravated eczema. Of course, rosacea and lupus should be in the differential.
l L+%atcluesto the diagnosis doyou lookfor in the patient’s history? Dr. Engasser: I approach these patients smiling with my eyes and ears wide open. Smiling is important because these patients are frustrated and unhappy; they want us to understand their plight. I tell them that the problem may be difficult to solve and that their active participation is paramount for success. I use a questionnaire to avoid skipping information from their medical or dermatologic history and to organize patients’ thoughts. We explore the duration and constancy of the erythema, accompanying symptoms, exacerbating and ameliorating factors, medications, topical treatments, hobbies, work and home environment. We review thoroughly skin care regimens and cosmetics. I complete the history by eliciting patients’ thoughts on causes and therapies. Lb-. Zug: Seasonal effects, past and present topical care, treatments, occupation, and hobbies are particularly important.
What investigations doyou peform inyour workup? Dr. Engasser: Patch, photopatch, and phototesting are often performed. Worksite visits may be
l
of the “Red Face”
237
necessary. Laboratory tests to assess for collagen vascular disease, potassium hydroxide examination, and skin biopsy may be required in some cases. Dr. Hogan: I usually limit patch testing to cases in which dermatitis is the primary lesion. I also frequently order a radioallergosorbent test (RAST) to rubber latex as I have found this positive when patch testing is negative and there is no other explanation for the red face except possible airborne contact to rubber latex even without urticaria or asthma symptoms. Less frequently, I perform photopatch testing or order a 24-hour urine for 5-hydroxyindoleacetic acid (5HIAA) to exclude carcinoid syndrome.” Dr. Stewart: Depending on my suspicions, I perform patch testing, photopatch testing, contact urticaria testing, tests for antinuclear antibody (ANA), complete blood count, and creatine phosphokinase. Dr. Zug: Clinical assessment of the probable diagnosis determines whether I do an AllA, phototesting, patch testing, zinc level, RAST, or prick tests for dust mites, and even therapeutic trial of treatment.
l Which allergensdoyou useforpatch tests?What is your protocol? Dr. Engasser: Necessary material safety data sheets (MSDS) are obtained; information from physicians, therapists, employers, and cosmetologists is gathered. On Mondays, we perform appropriate patch tests, consisting of the North American Contact Dermatitis Group (NACDG) extended series, all of the patient’s topical medications and personal care items, and when indicated, a photoallergen series and a steroid screening series. Additional allergens include cocamidopropylbetaine, plant materials, or Amerchol 101. On Tuesdays, we perform light testing. On Wednesdays and Fridays, we read and interpret the patch tests; open or prick tests are also carried out. Questionable positives may be repeated on the upper arms. If the cause is clear, we write out a plan of avoidance, and a return evaluation is scheduled. Dr. Hogan: In addition to the True test I frequently use the Chemotechnique Diagnostics cosmetic, sunscreen, and corticosteroid series, sesquiterpene lactone mix, gold sodium thiosulphate, and fresh leaves from nontoxic plants the patient has inside his or her house. After reviewing MSDS
238
Engasser
and the work history, I test for occupational allergens from Hermal or Chemotechnique Diagnostics. We perform photopatch testing using the Scandinavian photopatch test series in selected patients. Dr. Stewart: In addition to standard allergens, I test to Chemotechnique’s cosmetic series, ylangylang oil, narcissus oil, sandalwood oil, toluene sulfonamide formaldehyde resin, and sesquiterpene lactone mix. In addition, I also test the patient’s cosmetic and toiletry items. If the patient has been using topical steroids, I may add the corticosteroid series. Dr. Zug: All patients are tested to the North American screening series, plus all of their personal care products and appropriate dilutions of relevant occupational or avocation exposures (wood dust, vaporized materials, epoxies, ultraviolet cured acrylates). Then I consider things like topical corticosteroids, sunscreens, or shampoo ingredients. How use&l is patch testing? Dr. Stewart: In the setting of patchy eczematous facial eruptions, I find patch testing very helpful because those cases usually signify a cosmetic ACD. I still find it helpful to patch test patients with known underlying endogenous conditions like atopic dermatitis who appear worse than usual or are recalcitrant to therapy because they can have a superimposed contact dermatitis. Dr. Zug: Patch testing is very rewarding, and I think should be done if itching is prominent and in cases of persistent, unexplained dermatitis. It is not as helpful for patients who complain of burning and stinging. l
l Which diagnosis is most common& encounteredin your practice? Dr. Engasser: Quite often, atopic dermatitis, rosacea, or seborrheic dermatitis. In addition, these patients commonly suffer from corticosteroid dependence or cosmetic intolerance. By utilizing a simple regimen of skin care, they can avoid irritants, gradually repair their facial skin barrier, and clear. Dr. Hogan: Except for obvious rosacea, the most common diagnosis in my practice is perioral dermatitis. The majority of my patients with perioral dermatitis have used systemic or topical corticosteroids of increasing potency following se-
et al
vere flares. They require oral tetracycline and discontinuance of their topical corticosteroids. They may also need specific advice and psychological support. Dv. Stewart: I receive several referrals from fellow dermatologists to test for facial contact dermatitis. Rosacea is the most common red face diagnosis in my practice, followed by seborrheic dermatitis and then cosmetic allergic contact dermatitis. Dr. Zug: The most common diagnosis underlying a red face is rosacea and perioral dermatitis, but allergic contact and atopic dermatitis are close behind. How ojen doyou make a specijicdiagnosis? Dr. Stewart: In patients with patchy facial eczematous eruptions, more likely than not, I am able to identify culprit allergen(s) in their cosmetics or toiletries. The most challenging patients for me are those with a diffuse nonphotodistributed facial erythema with or without scaling. These patients often complain of itching or burning, but all patch testing and contact urticaria testing is frequently negative and there is no history of endogenous skin disease.
l
How doyou manage caseswith negative or nonspecijc tests? Dr. Engasser: We instruct patients to follow a simple, gentle skin care regimen that includes: 1) cleansing with water and possibly fragrance-free cleanser; 2) moisturizing with glycerin and rose water; and 3) fragrance-free shampoo. We do not restrict use of lipsticks and eye makeup, if the corresponding areas are uninvolved. Loose powder is allowable. Potent topical corticosteroids are eliminated. Hydrocortisone 1 to 2.5% ointment or cream (lotion for scalp) is substituted; occasionally, desonide is allowed. Sun protection with clothing and a physical sunscreen is initiated. If there is an element of rosacea or perioral dermatitis, oral tetracycline is begun. If patch, photopatch, and phototesting have not been fruitful but the patient is improving, a limited number of skin care products are added back 1 at a time after carrying out a repeat open application test (ROAT) for 1 to 2 weeks. Dr. Hogan: I recommend that patients wash their face with a mild cleanser such as Aquanil or Cetaphil and apply a bland moisturizer such as l
Evaluation
and Management
Lubriderm lotion once a day. Unless the diagnosis is dermatitis or lupus erythematosus, I do not prescribe topical corticosteroids for the face, as I have unmasked perioral dermatitis in many individuals using class 5 or 6 topical corticosteroids. For red flushed faces without papules or dermatitis, I will sometimes perform a therapeutic trial with topical metronidazole 0.75%, oral tetracycline or a similar antibiotic, or ketoconazole 2% cream for its beneficial effects on seborrheic and possibly facial atopic dermatitis. Dv. Stewart: If patch testing and contact urticaria testing are negative, I usually have the patient perform use tests to their toiletry products. It is not uncommon to encounter negative patch tests and positive ROAT to I of the patient’s products responsible for the eruption. I also discontinue use of cosmetic and toiletry products except for Vaseline petroleum jelly as a moisturizer and Free and Clear Shampoo for 2 weeks to observe whether they clinically improve off these products. Sometimes patients with negative patch and use tests respond to stopping use of their products. If all tests are negative, I recommend a daily cosmetic regime that causes minimal irritation including mild cleansers and bland emollients like petrolatum or vanicream. I also recommend performing use tests to any product before it is introduced.
of the “Red Face”
239
Dr. Zug: Even if there is no clear-cut unarguable diagnosis, I try to designate a working diagnosis as a guide for further therapeutic trials.
Suggested Readings Berne
B, Ros AM: Seven years experience of photopatch testing with sunscreen allergens in Sweden. Contact Dermatitis 38:61-64, 1998 Lotti T: Menchini G, Teofoli P: The challenge of airborne dermatitis. Clin Dermatol 16:27-31, 1998 Amin S, Tanglertsampan C, Maibach HI: Contact urticaria syndrome: 1997. Am J Contact Dermat 8:15-19, 1997 Draelos ZK: Sensitive skin: Perceptions, evaluation, and treatment. Am J Contact Dermat 8:67-78, 1997 Rhodes LE, Parslew RA, Ashworth J: Outcome of facial rashes with nonspecific histological features: A long-term follow-up of 64 cases. J Cutan Pathol22: 160-163, 1995 Hogan DJ: Perioral dermatitis. Cm-r Probl Dermatol 22:98-104, 1995 Dooms-Goossens A: The red face: Contact and photocontact dermatitis. Clin Dermatol 11:289-295,1993 Rebora A, Rongioletti F: The red face: Seborrheic dermatitis. Clin Dermatol 11:243-251, 1993 Mirensky YM: The red face: Atopic dermatitis. Clin Dermatol 11:235-242, 1993 Rebora A: The red face: Rosacea. Clin Dermatol225-234,1993 Ducombs G, Benezra C, Talaga P, et al: Patch testing with the “sesquiterpene lactone mix”: A marker for contact allergy to compositae and other sesquiterpene lactone containing plants. A multicentre study of the EECDRG. Contact Dermatitis 22:249-252, 1990 Maibach HI, Engasser P: Management of cosmetic intolerance syndrome. Clin Dermatol6:102-107, 1988
EDlTORS:
KALMAN
L. WATSKY,
I Evaluation and Management of the “Red Face”
M.D.
330 Orchard Street, Suite 311, New Haven, CT 06511, Tel: 203-789-4045, Fax: 203-789-3744, EmaiL. Kwats!&&zt.net.
MARTI
JILL
ROTHE,
Patricia G. Engasser,DanielJ. Hogan, LeslieA. Stewart, andKath yn A. Zug
M.D.
Dept. ofDermatology, U Corm Health Center, Fannington, CT 06032, Tel: 860-679-4176, Fax 860-679-1267, EmaS [email protected].
ADVICE & DISSENT addresses relevant issues in contact dermatitis through panel discussions or point/counterpoint debates. We look forward to input from the readership, including suggestions and commentary.
Patients presenting with a “red face” challenge clinicians to consider a broad differential diagnosis that includes contact dermatitis. The diagnosis may be obscured or complicated by underlying actinic damage or rosacea. Unraveling this Gordian knot to arrive at a precise and accurate diagnosis takes patience and practice. The collective experience of our invited group of expert clinicians sheds light on this process. Copyright o 1999 by W. B. Saunders Company
w
ASKED 4 EXPERTS for their approach to the evaluation and management of patients with “red faces.” Dr. Patricia Engasser is a Clinical Professor at the University of California San Francisco and Stanford Medical Centers. Dr. Daniel Hogan is Chief of Dermatology and Professor of Medicine and Pediatrics at the Louisiana State University Shreveport Medical School. Dr. Leslie Stewart is a Clinical Assistant Professor at the University of Colorado Health Sciences Center. Dr. Kathryn Zug is an Assistant Professor at Dartmouth Hitchcock Medical Center.
What isyour dzxerential diagnosis of the Yedface? Dr. Engasser: It is a long list that includes atopic dermatitis, seborrheic dermatitis, psoriasis, rosacea, perioral dermatitis, drug reaction, photosensitivity, fungal or HIV infection, contact dermatitis, contact urticaria, irritant contact syndrome, photocontact dermatitis, airborne contact dermatitis, or a combination of the above. Occasionally, collagen vascular disease can also present this way, dermatomyositis more frequently than lupus. Dr. Hogan: Many Caucasians, particularly in the Southern states, have actinic poikiloderma of the face and neck with prominent erythema from
l
From the Uniuersity of Cali@nia at San Francisco, San Francisco; the Stanford Medical Center, Palo Alto, CA; the Louisiana State Universi& Shreuepoti Medical School, Shreveport, LA; the Universi& of Colorado Health Science Center, Denuer, CO; and the Dartmouth Hitchcock Medical Center, Lebanon, NH. No repn‘nts auailable. Copyright 0 1999 &y W.B. Saunders Company 1046-199x~1004-0012$10.00/0
236
American
Journal
of Contact
Dermatitis,
VoL 10, No 4 (December),
1999:flp
236-239
Evaluation
and Management
age 20 years onward. My differential diagnosis for less obvious causes in adults includes rosacea, perioral dermatitis, and allergic contact dermatitis (ACD). Seborrheic dermatitis commonly coexists with all 3 and may be mimicked by ACD. Dermatitis limited to the eyelid is often due to atopic dermatitis and, less frequently, ACD. Photocontact dermatitis is rare in my experience. Other important considerations are early cutaneous lupus erythematosus and tinea facei. Dr. Stewart: My differential diagnosis includes rosacea, steroid rosacea, seborrheic dermatitis, atopic dermatitis, allergic or irritant contact dermatitis, photodermatitis, contact urticaria, lupus, dermatomyositis, and polycythemia rubra Vera. Dr. Zug: If there is patchy erythema, itch, and edema, then contact dermatitis tops my list. Most troublesome are patients who remain unimproved despite being on a very strict, limited facial care regimen; in these cases the diagnosis is commonly atopic or seborrheic dermatitis. However, always think about photoallergic contact dermatitis and photoaggravated eczema. Of course, rosacea and lupus should be in the differential.
l L+%atcluesto the diagnosis doyou lookfor in the patient’s history? Dr. Engasser: I approach these patients smiling with my eyes and ears wide open. Smiling is important because these patients are frustrated and unhappy; they want us to understand their plight. I tell them that the problem may be difficult to solve and that their active participation is paramount for success. I use a questionnaire to avoid skipping information from their medical or dermatologic history and to organize patients’ thoughts. We explore the duration and constancy of the erythema, accompanying symptoms, exacerbating and ameliorating factors, medications, topical treatments, hobbies, work and home environment. We review thoroughly skin care regimens and cosmetics. I complete the history by eliciting patients’ thoughts on causes and therapies. Lb-. Zug: Seasonal effects, past and present topical care, treatments, occupation, and hobbies are particularly important.
What investigations doyou peform inyour workup? Dr. Engasser: Patch, photopatch, and phototesting are often performed. Worksite visits may be
l
of the “Red Face”
237
necessary. Laboratory tests to assess for collagen vascular disease, potassium hydroxide examination, and skin biopsy may be required in some cases. Dr. Hogan: I usually limit patch testing to cases in which dermatitis is the primary lesion. I also frequently order a radioallergosorbent test (RAST) to rubber latex as I have found this positive when patch testing is negative and there is no other explanation for the red face except possible airborne contact to rubber latex even without urticaria or asthma symptoms. Less frequently, I perform photopatch testing or order a 24-hour urine for 5-hydroxyindoleacetic acid (5HIAA) to exclude carcinoid syndrome.” Dr. Stewart: Depending on my suspicions, I perform patch testing, photopatch testing, contact urticaria testing, tests for antinuclear antibody (ANA), complete blood count, and creatine phosphokinase. Dr. Zug: Clinical assessment of the probable diagnosis determines whether I do an AllA, phototesting, patch testing, zinc level, RAST, or prick tests for dust mites, and even therapeutic trial of treatment.
l Which allergensdoyou useforpatch tests?What is your protocol? Dr. Engasser: Necessary material safety data sheets (MSDS) are obtained; information from physicians, therapists, employers, and cosmetologists is gathered. On Mondays, we perform appropriate patch tests, consisting of the North American Contact Dermatitis Group (NACDG) extended series, all of the patient’s topical medications and personal care items, and when indicated, a photoallergen series and a steroid screening series. Additional allergens include cocamidopropylbetaine, plant materials, or Amerchol 101. On Tuesdays, we perform light testing. On Wednesdays and Fridays, we read and interpret the patch tests; open or prick tests are also carried out. Questionable positives may be repeated on the upper arms. If the cause is clear, we write out a plan of avoidance, and a return evaluation is scheduled. Dr. Hogan: In addition to the True test I frequently use the Chemotechnique Diagnostics cosmetic, sunscreen, and corticosteroid series, sesquiterpene lactone mix, gold sodium thiosulphate, and fresh leaves from nontoxic plants the patient has inside his or her house. After reviewing MSDS
238
Engasser
and the work history, I test for occupational allergens from Hermal or Chemotechnique Diagnostics. We perform photopatch testing using the Scandinavian photopatch test series in selected patients. Dr. Stewart: In addition to standard allergens, I test to Chemotechnique’s cosmetic series, ylangylang oil, narcissus oil, sandalwood oil, toluene sulfonamide formaldehyde resin, and sesquiterpene lactone mix. In addition, I also test the patient’s cosmetic and toiletry items. If the patient has been using topical steroids, I may add the corticosteroid series. Dr. Zug: All patients are tested to the North American screening series, plus all of their personal care products and appropriate dilutions of relevant occupational or avocation exposures (wood dust, vaporized materials, epoxies, ultraviolet cured acrylates). Then I consider things like topical corticosteroids, sunscreens, or shampoo ingredients. How use&l is patch testing? Dr. Stewart: In the setting of patchy eczematous facial eruptions, I find patch testing very helpful because those cases usually signify a cosmetic ACD. I still find it helpful to patch test patients with known underlying endogenous conditions like atopic dermatitis who appear worse than usual or are recalcitrant to therapy because they can have a superimposed contact dermatitis. Dr. Zug: Patch testing is very rewarding, and I think should be done if itching is prominent and in cases of persistent, unexplained dermatitis. It is not as helpful for patients who complain of burning and stinging. l
l Which diagnosis is most common& encounteredin your practice? Dr. Engasser: Quite often, atopic dermatitis, rosacea, or seborrheic dermatitis. In addition, these patients commonly suffer from corticosteroid dependence or cosmetic intolerance. By utilizing a simple regimen of skin care, they can avoid irritants, gradually repair their facial skin barrier, and clear. Dr. Hogan: Except for obvious rosacea, the most common diagnosis in my practice is perioral dermatitis. The majority of my patients with perioral dermatitis have used systemic or topical corticosteroids of increasing potency following se-
et al
vere flares. They require oral tetracycline and discontinuance of their topical corticosteroids. They may also need specific advice and psychological support. Dv. Stewart: I receive several referrals from fellow dermatologists to test for facial contact dermatitis. Rosacea is the most common red face diagnosis in my practice, followed by seborrheic dermatitis and then cosmetic allergic contact dermatitis. Dr. Zug: The most common diagnosis underlying a red face is rosacea and perioral dermatitis, but allergic contact and atopic dermatitis are close behind. How ojen doyou make a specijicdiagnosis? Dr. Stewart: In patients with patchy facial eczematous eruptions, more likely than not, I am able to identify culprit allergen(s) in their cosmetics or toiletries. The most challenging patients for me are those with a diffuse nonphotodistributed facial erythema with or without scaling. These patients often complain of itching or burning, but all patch testing and contact urticaria testing is frequently negative and there is no history of endogenous skin disease.
l
How doyou manage caseswith negative or nonspecijc tests? Dr. Engasser: We instruct patients to follow a simple, gentle skin care regimen that includes: 1) cleansing with water and possibly fragrance-free cleanser; 2) moisturizing with glycerin and rose water; and 3) fragrance-free shampoo. We do not restrict use of lipsticks and eye makeup, if the corresponding areas are uninvolved. Loose powder is allowable. Potent topical corticosteroids are eliminated. Hydrocortisone 1 to 2.5% ointment or cream (lotion for scalp) is substituted; occasionally, desonide is allowed. Sun protection with clothing and a physical sunscreen is initiated. If there is an element of rosacea or perioral dermatitis, oral tetracycline is begun. If patch, photopatch, and phototesting have not been fruitful but the patient is improving, a limited number of skin care products are added back 1 at a time after carrying out a repeat open application test (ROAT) for 1 to 2 weeks. Dr. Hogan: I recommend that patients wash their face with a mild cleanser such as Aquanil or Cetaphil and apply a bland moisturizer such as l
Evaluation
and Management
Lubriderm lotion once a day. Unless the diagnosis is dermatitis or lupus erythematosus, I do not prescribe topical corticosteroids for the face, as I have unmasked perioral dermatitis in many individuals using class 5 or 6 topical corticosteroids. For red flushed faces without papules or dermatitis, I will sometimes perform a therapeutic trial with topical metronidazole 0.75%, oral tetracycline or a similar antibiotic, or ketoconazole 2% cream for its beneficial effects on seborrheic and possibly facial atopic dermatitis. Dv. Stewart: If patch testing and contact urticaria testing are negative, I usually have the patient perform use tests to their toiletry products. It is not uncommon to encounter negative patch tests and positive ROAT to I of the patient’s products responsible for the eruption. I also discontinue use of cosmetic and toiletry products except for Vaseline petroleum jelly as a moisturizer and Free and Clear Shampoo for 2 weeks to observe whether they clinically improve off these products. Sometimes patients with negative patch and use tests respond to stopping use of their products. If all tests are negative, I recommend a daily cosmetic regime that causes minimal irritation including mild cleansers and bland emollients like petrolatum or vanicream. I also recommend performing use tests to any product before it is introduced.
of the “Red Face”
239
Dr. Zug: Even if there is no clear-cut unarguable diagnosis, I try to designate a working diagnosis as a guide for further therapeutic trials.
Suggested Readings Berne
B, Ros AM: Seven years experience of photopatch testing with sunscreen allergens in Sweden. Contact Dermatitis 38:61-64, 1998 Lotti T: Menchini G, Teofoli P: The challenge of airborne dermatitis. Clin Dermatol 16:27-31, 1998 Amin S, Tanglertsampan C, Maibach HI: Contact urticaria syndrome: 1997. Am J Contact Dermat 8:15-19, 1997 Draelos ZK: Sensitive skin: Perceptions, evaluation, and treatment. Am J Contact Dermat 8:67-78, 1997 Rhodes LE, Parslew RA, Ashworth J: Outcome of facial rashes with nonspecific histological features: A long-term follow-up of 64 cases. J Cutan Pathol22: 160-163, 1995 Hogan DJ: Perioral dermatitis. Cm-r Probl Dermatol 22:98-104, 1995 Dooms-Goossens A: The red face: Contact and photocontact dermatitis. Clin Dermatol 11:289-295,1993 Rebora A, Rongioletti F: The red face: Seborrheic dermatitis. Clin Dermatol 11:243-251, 1993 Mirensky YM: The red face: Atopic dermatitis. Clin Dermatol 11:235-242, 1993 Rebora A: The red face: Rosacea. Clin Dermatol225-234,1993 Ducombs G, Benezra C, Talaga P, et al: Patch testing with the “sesquiterpene lactone mix”: A marker for contact allergy to compositae and other sesquiterpene lactone containing plants. A multicentre study of the EECDRG. Contact Dermatitis 22:249-252, 1990 Maibach HI, Engasser P: Management of cosmetic intolerance syndrome. Clin Dermatol6:102-107, 1988