Treatment of Red Flaky Skin on Bridge of Nose
The most likely diagnosis is seborrheic dermatitis, and first-line treatment consists of ketoconazole 2% cream applied twice daily for four weeks combined with gentle skin care measures, avoiding all alcohol-containing products on the face. 1, 2
Diagnostic Considerations
The bridge of the nose is a classic location for seborrheic dermatitis, which presents with erythematous, scaly patches and is characterized by greasy, yellowish scales rather than the thick silvery scales of psoriasis. 3 However, rosacea can also present with erythema on the central face including the nasal bridge, though it typically lacks the prominent scaling seen in seborrheic dermatitis. 4, 5
Key distinguishing features to assess:
- Seborrheic dermatitis: Greasy yellow scales, involvement of other seborrheic areas (scalp, eyebrows, nasolabial folds) 3
- Rosacea: Flushing episodes, telangiectasia, papules/pustules, minimal scaling 4, 5
- Psoriasis: Well-demarcated thick plaques with silvery scale, personal or family history of psoriasis 3
First-Line Treatment Protocol
Topical Antifungal Therapy
Apply ketoconazole 2% cream to the affected area twice daily for four weeks. 1 The FDA label specifically indicates this duration for seborrheic dermatitis, with reassessment needed if no clinical improvement occurs after the treatment period. 1
Essential Supportive Skin Care
- Use mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes to preserve natural skin lipids 3, 2
- Apply fragrance-free moisturizers containing urea (≈10%) or glycerin to damp skin immediately after cleansing to restore barrier function 3, 2
- Strictly avoid all alcohol-containing preparations on the face, as these markedly worsen dryness and trigger flares 3, 2
- Avoid perfumes, deodorants, and harsh soaps that strip natural lipids 3
Adding Anti-Inflammatory Treatment for Significant Inflammation
If prominent erythema and inflammation are present, add hydrocortisone 1% cream applied once or twice daily for a maximum of 1-2 weeks only. 2, 3 This is the only appropriate corticosteroid potency for facial use due to the high risk of skin atrophy and telangiectasia with stronger preparations. 3
Critical safety warning: Medium- or high-potency topical steroids (triamcinolone, mometasone, clobetasol) should never be used on facial skin due to unacceptable adverse effects including atrophy, telangiectasia, and tachyphylaxis. 3
Management of Pruritus
For moderate to severe itching:
- Apply topical polidocanol-containing lotions for symptomatic relief 3
- Consider oral antihistamines (cetirizine, loratadine, or fexofenadina) for additional relief 3, 2
When to Reassess or Refer
Reassess after 4 weeks of ketoconazole treatment. 1 If no clinical improvement occurs, the diagnosis should be redetermined. 1
Refer to dermatology if:
- Diagnostic uncertainty or atypical presentation 3
- Failure to respond after 4 weeks of appropriate first-line therapy 3
- Recurrent severe flares despite optimal maintenance therapy 3
- Suspected alternative diagnoses (psoriasis, contact dermatitis, rosacea) requiring specialized evaluation 3
Common Pitfalls to Avoid
- Do not use alcohol-based products on the face – these are the most common trigger for worsening symptoms 3, 2
- Do not use medium- or high-potency corticosteroids on facial skin – risk of permanent atrophy and telangiectasia is unacceptably high 3
- Do not continue topical corticosteroids beyond 2-4 weeks maximum on the face, even low-potency preparations 3, 2
- Do not use hot water for cleansing – use tepid water instead to prevent worsening dryness 3
- Do not confuse persistent mild itching with treatment failure – mild burning or itching from inflammation can persist for days after the condition improves 3
Alternative Diagnosis: If Rosacea is Suspected
If the presentation includes flushing, telangiectasia, or papules/pustules with minimal scaling, consider rosacea instead. 4, 5 In this case: