Clinical Conundrum: Navigating Erythematous Facial Rash in a middle-aged woman

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We present a clinical case involving a 62-year-old female patient with a prior diagnosis of hypothyroidism and psoriasis vulgaris. The patient sought emergency medical care due centrofacial and periocular edema, erythema, and pain. The onset of the current episode occurred less than 24 hours before admission, commencing as a right-sided malar rash that rapidly disseminated. Notably, the patient's medical history revealed a recent periorificial (nasal) psoriasis lesion treated with clobetasol ointment, identified subsequently as the likely point of bacterial entry.

In the differential diagnosis, prominent considerations included dermatomyositis and systemic lupus erythematosus, owing to the similarity in erythema distribution in both conditions, as well as the patient's age and gender. Systemic lupus erythematosus is characterized by a malar rash, also termed a butterfly rash, presenting as an erythematous flat or raised rash across the nose and cheeks, typically sparing nasolabial folds. Dermatomyositis is marked by the heliotrope rash, manifesting on the upper eyelid, across the cheeks, and the nasal bridge in a "butterfly" distribution.

Considering serological evidence of infection (neutrophilia and elevated C-reactive protein and erythrocyte sedimentation rate), the rapid onset of symptoms, and the observable skin manifestations (erythema, edema, and warmth), a diagnosis of facial erysipelas was established. The patient underwent a 10-day intravenous course of Ceftriaxone for antibiotic therapy and received prophylactic doses of enoxaparin to address the risk of cavernous sinus thrombosis. The patient exhibited favorable progress, ultimately experiencing complete recovery.