FACE
Facial rash
Atopic eczema
Signs
- •
Dry, itchy, erythematous thickening of facial skin ( Fig. 15.1 ).
Fig. 15.1
Look for
- •
Staphylococcal blepharitis.
- •
Vernal and atopic keratoconjunctivitis.
- •
Early-onset shield-like cataract.
- •
Keratoconus.
- •
Retinal detachment.
Acne rosacea
Signs
- •
Erythema and papules on the glabella, cheeks, nose and chin ( Fig. 15.2 ).
Fig. 15.2
Look for
- •
Chronic posterior blepharitis.
- •
Recurrent chalazion.
- •
Peripheral keratitis.
Sarcoidosis (lupus pernio)
Signs
- •
Violaceous lesions with a predilection for the nose ( Fig. 15.3 ).
Fig. 15.3
Look for
- •
Uveitis.
- •
Retinal periphlebitis.
- •
Fundus granulomas.
- •
Dry eye.
- •
Conjunctival granulomas.
Systemic lupus erythematosus
Signs
- •
Erythematous rash involving the cheeks and bridge of the nose with a ‘butterfly’ distribution ( Fig. 15.4 ).
Fig. 15.4
Look for
- •
Dry eye.
- •
Peripheral ulcerative keratitis.
- •
Scleritis.
- •
Retinopathy.
Dermatomyositis
Signs
- •
Extensive erythematous rash ( Fig. 15.5 ).
Fig. 15.5
Look for
- •
Violaceous (heliotrope) eyelid rash and periorbital oedema.
- •
Dry eye.
- •
Scleritis.
- •
Retinopathy.
Tuberous sclerosis (adenoma sebaceum)
Signs
- •
Red papules on the cheeks and nose ( Fig. 15.6 ).
Fig. 15.6
Look for
- •
Fundus astrocytomas.
Xeroderma pigmentosum
Signs
- •
Bird-like facies, and cutaneous atrophy, scaling and pigmentation with a propensity to malignant change ( Fig. 15.7 ).
Fig. 15.7
Look for
- •
Eyelid and conjunctival malignancies.
- •
Dry eye.
Facial pigmentary changes
Port wine stain (naevus flammeus)
Signs
- •
Sharply demarcated, usually unilateral, soft, purple patch which occurs in patients with Sturge–Weber syndrome ( Fig. 15.8 ).
Fig. 15.8
Look for
- •
Episcleral haemangioma.
- •
Diffuse choroidal haemangioma.
- •
Glaucoma.
- •
Heterochromia iridis.
Naevus of Ota (oculodermal melanocytosis)
Signs
- •
Unilateral hyperpigmentation of deep facial skin, most frequently in the distribution of the 1st and 2nd divisions of the trigeminal nerve ( Fig. 15.9 ).
Fig. 15.9
Look for
- •
Episcleral hyperpigmentation.
- •
Heterochromia iridis.
- •
Iris mammillations.
- •
Trabecular hyperpigmentation and glaucoma.
- •
Fundus hyperpigmentation.
- •
Uveal melanoma.
Lack of facial expression
Myotonic dystrophy
Signs
- •
Bilateral facial wasting with hollow cheeks, sagging jaw and ptosis ( Fig. 15.10 ).
Fig. 15.10
Look for
- •
Early-onset shield-like cataract.
- •
Light-near dissociation of pupils.
- •
Mild pigmentary retinopathy.
Myasthenia gravis
Signs
- •
Myasthenic involvement of muscles of facial expression and ptosis ( Fig. 15.11 ).
Fig. 15.11
Look for
- •
Ophthalmoplegia, particularly involving elevation.
Systemic sclerosis
Signs
- •
Shiny tight facial skin due to subcutaneous fibrotic changes, nasal deformity and vertical furrowing of perioral skin ( Fig. 15.12 ).
Fig. 15.12
Look for
- •
Eyelid scarring.
- •
Dry eye.
- •
Retinopathy.
Parkinsonism
Signs
- •
Sweaty and greasy face with mild lid retraction ( Fig. 15.13 ).
Fig. 15.13
Meretoja syndrome
Signs
- •
Bilateral facial palsy ( Fig. 15.14 ).
Fig. 15.14
Look for
- •
Corneal lattice dystrophy type 2.
Möbius syndrome
Signs
- •
Bilateral facial paresis with the mouth constantly held open ( Fig. 15.15 ).
Fig. 15.15
Look for
- •
Esotropia.
- •
Limitation of abduction.
- •
Horizontal gaze palsy.
Facial spasm
Essential blepharospasm
Signs
- •
Periodic bilateral involuntary spasm of the orbicularis oculi and upper facial muscles temporally rendering the patients functionally blind ( Fig. 15.16 ).
Fig. 15.16
Facial hemispasm
Signs
- •
Brief unilateral spasm of the orbicularis oculi and facial muscles ( Fig. 15.17 ).
Fig. 15.17
Facial hirsutism
Cushing syndrome
Signs
- •
Also moon face and hyperpigmentation ( Fig. 15.18 )
Fig. 15.18
Look for
- •
Bitemporal hemianopia due to adenoma (Cushing disease).
- •
Cataract.
Acromegaly
Signs
- •
Coarse facies ( Fig. 15.19 ).
Fig. 15.19
Look for
- •
Bitemporal hemianopia due to a pituitary adenoma.
- •
Optic atrophy.
- •
Angioid streaks.
Turner syndrome
Signs
- •
Webbed neck ( Fig. 15.20 ).
Fig. 15.20
Look for
- •
Keratoconus.
- •
Blue sclera.
- •
Cataract.
Porphyria cutanea tarda
Signs
- •
Bullous skin eruptions and scarring ( Fig. 15.21 ).
Fig. 15.21
Look for
- •
Cicatrising conjunctivitis.
- •
Scleritis.
Fair complexion and blond hair
Oculocutaneous albinism
Signs
- •
Pale skin and blond hair ( Fig. 15.22 ).
Fig. 15.22
Look for
- •
Nystagmus.
- •
Iris transillumination.
- •
Pale fundus and foveal hypoplasia.
- •
Anomalous chiasmal nerve fibre pathway.
Homocystinuria
Signs
- •
Coarse fair hair and malar flush (see Fig. 10.16 ).
Look for
- •
Ectopia lentis.
- •
Myopia.
- •
Retinal detachment.
Saddle-shaped nose
Congenital syphilis
Pathogenesis
- •
Osteitis of the nasal bone ( Fig. 15.23 ).
Fig. 15.23
Look for
- •
Interstitial keratitis.
- •
Pigmentary retinopathy.
Wegener granulomatosis
Pathogenesis
- •
Necrotising granulomatous vasculitis involving the nose ( Fig. 15.24 ).
Fig. 15.24
Look for
- •
Scleritis.
- •
Peripheral ulcerative keratitis.
- •
Orbital involvement.
- •
Nasolacrimal duct obstruction.
- •
Retinopathy.
Relapsing polychondritis
Pathogenesis
- •
Recurrent inflammatory swelling, destruction and collapse of nasal cartilage ( Fig. 15.25 ).
Fig. 15.25
Look for
- •
Scleritis.
- •
Anterior uveitis.
Leprosy
Pathogenesis
- •
Destruction of the nasal bone and cartilage ( Fig. 15.26 ).
Fig. 15.26
Look for
- •
Madarosis.
- •
Anterior uveitis.
- •
Miosis.
- •
Iris atrophy.
- •
Keratitis.
- •
Scleritis.
MOUTH
Ulceration
Behçet disease
Signs
- •
Recurrent, painful aphthous stomatitis which may involve the buccal mucosa and the tongue ( Fig. 15.27 ).
Fig. 15.27
Look for
- •
Anterior uveitis with hypopyon.
- •
Panuveitis.
- •
Retinal vasculitis.
Reiter syndrome
Signs
- •
Transient painless ulceration ( Fig. 15.28 ).
Fig. 15.28
Look for
- •
Conjunctivitis.
- •
Acute anterior uveitis.
- •
Keratitis.
Stevens–Johnson syndrome
Signs
- •
Mucosal bullae and erosions associated with haemorrhagic crusting of the lips ( Fig. 15.29 ).
Fig. 15.29
Look for
- •
Cicatrising conjunctivitis.
Mucous membrane pemphigoid
Signs
- •
Mucosal blisters and superficial erosions ( Fig. 15.30 ).
Fig. 15.30
Look for
- •
Cicatrising conjunctivitis.
Pemphigus vulgaris
Signs
- •
Mucosal blisters and erosions ( Fig. 15.31 ).
Fig. 15.31
Look for
- •
Cicatrising conjunctivitis.
Secondary syphilis
Signs
- •
‘Snail-track’ ulcers ( Fig. 15.32 ).
