A 48-year-old man comes to the office for evaluation of a facial rash. He first noticed the rash approximately 3 months ago. It started on his forehead and eyebrows and has now progressed to involve his nose down to his chin. He has also noticed a lot of dandruff in his hair recently. The patient has no other medical problems and takes no medications. Skin examination findings are shown in the image below. Close examination shows greasy-looking, fine yellowish scales on an erythematous base. The trunk and extremities have no lesions. Which of the following is the most likely diagnosis?

Question

A 48-year-old man comes to the office for evaluation of a facial rash.  He first noticed the rash approximately 3 months ago.  It started on his forehead and eyebrows and has now progressed to involve his nose down to his chin.  He has also noticed a lot of dandruff in his hair recently.  The patient has no other medical problems and takes no medications.  Skin examination findings are shown in the image below.  Close examination shows greasy-looking, fine yellowish scales on an erythematous base.  The trunk and extremities have no lesions.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient with dandruff and a scaly rash involving the nasolabial folds has seborrheic dermatitis (SD). SD is a common inflammatory disease that affects the scalp (dandruff), face (eyebrows, nasolabial folds, and external ear canal/posterior ear), chest, and intertriginous areas. SD occurs in all ages but is most common in the first year of life and again at age 30-60. It is also associated with central nervous system disorders (especially Parkinson disease) and HIV. The diagnosis of SD is clinical, with typical findings characterized by pruritic, erythematous plaques with fine, loose, yellow, and greasy-looking scales. SD primarily affects areas with numerous sebaceous glands, although sebum production in affected patients is typically normal. Malassezia species may play a role in the pathogenesis of SD, and topical antifungal agents (eg, ketoconazole, selenium sulfide) are effective in treating this condition. (Choice A) Rosacea is characterized by erythema, edema, and telangiectasias affecting primarily the central face. Flushing and local discomfort can be triggered by hot or spicy foods, emotional stressors, or temperature fluctuations. Rosacea (Choice B) Psoriasis presents with well-circumscribed plaques covered with a thick, silvery scale. The lesions are typically worst at the extensor surfaces of the elbows and knees but may also affect the scalp and trunk. Psoriasis (Choice D) The classic butterfly rash of systemic lupus erythematosus appears as erythematous macules and plaques in sun-exposed areas of the face. The nasolabial folds are spared, and patients frequently have multisystem involvement (eg, fever, arthralgias). systemic lupus erythematosus (Choice E) Pityriasis versicolor (also called tinea versicolor) is characterized by hypopigmented, hyperpigmented, or erythematous macules or patches on the upper body. It is caused by Malassezia species yeast and is often most visible after extensive sun exposure due to tanning of the adjacent skin. Pityriasis versicolor Educational objective: Seborrheic dermatitis causes pruritic, erythematous plaques with a greasy scale that predominantly affect the scalp and face. It is most common in the first year of life and in middle age and can be associated with Parkinson disease and HIV. Topical antifungal agents are effective treatment. References: Seborrheic dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/22281892)

A 48-Year-Old Man Comes to the Office for Evaluation of a Facial