Are the erythema and roughness on a young girl’s cheeks treatable?
A Photo Quiz to Hone Dermatologic Skills
Case: This 11-year-old girl is concerned about the persistent redness and roughness of her cheeks, which she has had since age 7 years. She is especially concerned about the social impact of these skin changes. The erythema is accentuated with exercise and anxiety, and the roughness becomes more pronounced in winter. The skin of her upper arms is similarly rough. Her mother has the same skin texture of the upper arms. The child has tried many over-the-counter topical medications with no success.
What is this eruption—and can treatment improve the look and feel of the patient’s skin?
Answer on next page
This young girl has striking erythema that is symmetrical, reasonably well demarcated, and prominent on both cheeks. I believe this facial rash best represents erythromelanosis follicularis faciei (EFF). This is also referred to as erythromelanosis follicularis faciei et colli when the neck is involved, although neck involvement is very rare in children. This condition is associated with follicular keratosis, which gives the skin the feel of fine sand paper; there is no associated scarring. The “roughness” of her upper arms is keratosis pilaris.
EFF is one of many facial eruptions characterized by follicular keratotic plugs. In my experience, the major morphological finding that differentiates these entities is the presence of scarring. Facial eruptions with scarring are grouped under the term “keratosis pilaris atrophicans” and occur, I have found, much less frequently than the nonscarring conditions. The 2 most common nonscarring conditions are keratosis pilaris and EFF. Erythema—the main feature in this patient—is absent in keratosis pilaris. It is typical for children to have both EFF and keratosis pilaris, as in this child.
The classic presentation of EFF—erythema and follicular keratosis of the cheeks—is shown here. Some patients may have increased pigmentation and report a burning sensation, which increases with the intensity of the erythema. In severe cases of EFF, the erythema may spread to the ears (the keratotic plugs are absent). The symptoms may worsen depending on the season; sun exposure does not appear to be a factor.
Unfortunately, EFF is very difficult to treat. The avoidance of detergent cleansers and the use of emollients are basic to my skin care recommendations. I will cautiously introduce the use of glycolic acid creams in an effort to reduce the follicular keratosis; however, this treatment often increases the erythema. Recently, I noted a significant decrease in both the erythema and keratosis in this child with the use of topical calcineurin inhibitors— pimecrolimus and tacrolimus.■