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Simple cases
Case 52
50-year-old woman complains for erythema and swelling in face for 1 week
History
Did you change cosmetics before these changes started?
That's a hard question. I use lots of different cosmetics, and I love trying new ones.
This answer is a prototype of a common response and does not help us. If a cosmetic product is responsible, then which one? Such changes can also appear without any connection to cosmetics.
Have you every had any other skin problems?
I had acne as a teenager.
This doesn't help us much. Almost everyone had acne as a teenager.
Do you take any medications?
I took Bactrim for a urinary tract infection for a few days.
Medications, especially antibiotics, can cause photosensitivity reactions. Is there a connection? The next question will help.
Do you have similar changes on other sun-exposed surfaces?
No, I was out a lot in a T-shirt and shorts and my arms and legs are fine.
This makes a photosensitivity reaction unlikely, but not impossible.
Have you noticed anything else?
I feel a bit tired and have trouble getting going in the morning.
Is the patient depressed or is there is an organic basis for her problems. Further questionsask about personal and family problems, but also about muscle tenderness and weakness, as well as joint pain.
Have you gotten a lot of sun in the past days?
I love the mountains and I may have overdone it recently.
This question casts suspicion on UV light, suggesting phototoxicity or photosensitivity.
Lesion
Choose the right efflorescences:
This skin disease usually doesn't involve the epidermis. Sometimes the edema is so intense that vesicles do develop, but not yet.
Typical for this disease is a red-violet periorbital erythema with edema (heliotrope eyelids).
Another typical finding is small violaceous papules over the interphalangeal joints (Gottron papules).
Telangiectases are new small blood vessels; in this disease they are common in the nail fold skin.
Diagnosis
Choose the right diagnosis:
Rosacea has a much slower course, and usually features pustules, as well as erythema and papules.
Allergic contact dermatitis appears even more rapidly with more acute epidermal changesvesicles and scales.
Periorbital edema is an atypical feature. Here we see no evidence of sclerosis with thickening and loss of skin markings.
The swollen red-violet eyelids (heliotrope eyelids), digital papules (Gottron papules) and muscle weakness are classic.
Therapy
Choose the right therapy(ies):
Dermatomyositis is a photosensitive dermatitis, so this is a must.
Acceptable treatment for pruritus but other measures always needed.
The mainstay of therapy, especially with muscular involvement.
Important to avoid side effects of corticosteroids, and for those cases who do not respond to the first line agent.
