What is the diagnosis and management for a patient presenting with a burning, raised, and dry facial rash?

Facial Rash: Burning, Raised, and Dry

For a burning, raised, and dry facial rash, start immediately with hydrocortisone 1% cream applied 3-4 times daily to the affected areas, combined with liberal emollient use at least twice daily, while ruling out secondary infection and avoiding common irritants. 1, 2

Initial Clinical Assessment

Examine the patient for these specific diagnostic features to guide management:

• Assess body surface area (BSA) involvement to determine severity grading, as this drives treatment intensity 3
• Look for signs of secondary infection: crusting, weeping, honey-colored discharge, pustules, or increased warmth 1, 4
• Evaluate for blistering or oral mucosal involvement, which may indicate more severe conditions requiring urgent dermatology consultation 3
• Document pruritus severity and timing, as itching is the hallmark of inflammatory dermatoses 1
• Review medication history to rule out drug-induced photosensitivity or other medication-related causes 3
• Identify aggravating factors including recent irritant exposures, temperature extremes, new skincare products, or stress 1

Immediate Treatment Protocol

Topical Corticosteroid Therapy

Apply hydrocortisone 1-2.5% cream to affected facial areas 3-4 times daily as first-line treatment. 1, 4, 2

• For facial involvement specifically, use only low to moderate potency corticosteroids due to the face being thin-skinned with high risk for atrophy 1
• Never use very potent corticosteroids on the face except under dermatologist supervision for severe, recalcitrant cases, and then only for maximum 2 weeks 1
• Ointment formulations are preferable to creams for better moisture retention on dry skin 4

Essential Emollient Therapy

Apply emollients liberally at least twice daily, most effectively within 3 minutes after bathing to trap moisture. 1, 4

• This is foundational therapy and must not be omitted, as emollient neglect is a common cause of treatment failure 1
• Use hypoallergenic moisturizing creams or ointments to smooth the skin and prevent further dryness 3
• Avoid alcohol-containing lotions or gels, as they worsen xerosis 3, 1

Skin Care Modifications

Implement these protective measures immediately:

• Replace regular soap with soap-free cleansers or dispersible cream cleansers to prevent removal of natural skin lipids 1, 4
• Use lukewarm water for bathing, limiting duration to 5-10 minutes 4
• Pat skin dry gently rather than rubbing after washing 4
• Apply hypoallergenic sunscreen daily with at least SPF 30 (PABA-free, UVA/UVB protection) to all exposed facial areas 3
• Keep fingernails short to minimize excoriation from scratching 1, 4

Assessing for Secondary Infection

If the patient fails to respond to initial treatment within 1-2 weeks or shows signs of infection, obtain bacterial swabs immediately. 1, 4

Signs requiring bacterial culture:

• Crusting, weeping, or honey-colored discharge 1, 4
• Pustule formation 1
• Worsening despite appropriate anti-inflammatory treatment 4

If bacterial infection is confirmed, start oral antibiotics (such as flucloxacillin) for at least 2 weeks while continuing topical corticosteroids. 1, 4

Grading Severity and Escalation

Grade 1 (BSA <10%)

• Continue hydrocortisone 1% as prescribed 3
• Emphasize emollient use and skin irritant avoidance 3
• Monitor weekly for improvement 3

Grade 2 (BSA 10-30% or limiting instrumental activities)

• Consider holding any potential causative medications if drug-induced etiology suspected 3
• Add oral antihistamines (loratadine 10 mg daily for daytime; diphenhydramine 25-50 mg for nighttime if sleep disturbed) 3, 1
• May escalate to medium-potency topical corticosteroids (mometasone furoate 0.1% or betamethasone valerate 0.1%) for non-facial areas only 3
• For facial areas, continue low-potency corticosteroids only 1

Grade 3 (BSA >30% with moderate/severe symptoms or limiting self-care)

• Hold any suspected causative agents immediately 3
• Consult dermatology urgently to determine appropriateness of continuing treatment 3
• Initiate oral prednisone 1 mg/kg/day with tapering over at least 4 weeks, only under specialist guidance 3

Critical Pitfalls to Avoid

• Steroid phobia leading to undertreatment: Educate patients that appropriate-potency corticosteroids used correctly are safe and necessary 1
• Using very potent corticosteroids on the face: This causes atrophy, telangiectasia, and perioral dermatitis 3, 1
• Omitting emollients: This is the most common cause of treatment failure 1
• Continuous corticosteroid use without breaks: Implement "steroid holidays" when possible to prevent side effects 1
• Manipulating or picking at lesions: This increases infection risk 3
• Abrupt discontinuation of moderate-to-high potency corticosteroids: This causes rebound flare 4
• Overlooking signs of infection: Infection can worsen despite appropriate anti-inflammatory treatment 4

When to Refer to Dermatology

Refer urgently if any of the following occur:

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks 1
• Suspected eczema herpeticum (grouped vesicles or punched-out erosions requiring immediate acyclovir) 1
• Diagnostic uncertainty after initial evaluation 1
• Need for systemic therapy or phototherapy 1
• Requirement for continuous ultra-potent corticosteroids beyond 4 weeks 1
• Grade 3 or higher severity with BSA >30% and moderate-to-severe symptoms 3