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Differential Diagnosis of Malar Rash

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A malar rash, characterized by erythema over the cheeks and bridge of the nose sparing the nasolabial folds, can be indicative of various underlying conditions. Accurate diagnosis requires consideration of the differential diagnoses, each with distinct clinical features, necessary investigations, and appropriate treatment strategies.

Differential Diagnosis of Malar Rash: Clinical Features, Investigations, and Treatment

Cause	Clinical Features	Investigations/Tests	Treatment
Systemic Lupus Erythematosus (SLE)	Butterfly-shaped rash across cheeks and nose. Photosensitivity. Joint pain and swelling. Oral ulcers. Renal involvement.	Antinuclear antibody (ANA) test. Anti-dsDNA and Anti-Smith antibodies. Complete blood count (CBC). Urinalysis for renal involvement. Skin biopsy if needed.	Nonsteroidal anti-inflammatory drugs (NSAIDs) for joint symptoms. Hydroxychloroquine for skin and joint manifestations. Corticosteroids for severe disease. Immunosuppressive agents (e.g., methotrexate, azathioprine) for organ involvement. Sun protection measures.
Rosacea	Flushing and persistent erythema on cheeks, nose, chin. Visible blood vessels (telangiectasia). Possible acne-like pustules. Burning or stinging sensations.	Clinical diagnosis based on physical examination. Dermatoscopy may aid in visualizing telangiectasia.	Topical metronidazole or azelaic acid. Oral antibiotics like doxycycline for inflammatory lesions. Laser therapy for persistent telangiectasia. Avoidance of known triggers (e.g., spicy foods, alcohol, extreme temperatures).
Dermatomyositis	Heliotrope rash (violaceous discoloration) on eyelids. Gottron's papules over knuckles. Muscle weakness, particularly proximal muscles. Mechanic's hands.	Creatine kinase (CK) levels elevated. Electromyography (EMG). Muscle biopsy. Magnetic resonance imaging (MRI) of muscles. Autoantibody testing (e.g., anti-Mi-2).	Corticosteroids as first-line therapy. Immunosuppressive agents (e.g., methotrexate, azathioprine). Physical therapy for muscle strengthening. Sun protection to prevent rash exacerbation.
Seborrheic Dermatitis	Greasy, yellow scales on cheeks, nose, and eyebrows. Redness and irritation. Commonly seen in infants (cradle cap) and adults.	Clinical diagnosis based on characteristic appearance.	Topical antifungal agents (e.g., ketoconazole). Topical corticosteroids for inflammation. Medicated shampoos containing zinc pyrithione or selenium sulfide. Avoidance of harsh skin products.
Allergic Contact Dermatitis	Erythematous rash with possible vesicles or pustules. Pruritus and burning sensations. Localized to areas in contact with allergens (e.g., cosmetics, metals).	Patch testing to identify specific allergens. Clinical history and examination.	Avoidance of identified allergens. Topical corticosteroids to reduce inflammation. Oral antihistamines for pruritus. Emollients to maintain skin barrier.
Erythroderma	Widespread redness and scaling of the skin. Possible systemic symptoms like fever and malaise. Variable distribution, can include malar areas.	Skin biopsy to determine underlying cause. Comprehensive laboratory evaluation (CBC, liver and kidney function tests). Patch testing if contact dermatitis is suspected.	Treat underlying cause (e.g., discontinuing offending agents). Topical emollients and corticosteroids. Systemic corticosteroids or immunosuppressants in severe cases. Supportive care to maintain skin integrity and prevent infection.
Periorbital Dermatitis	Redness and swelling around the eyes. Possible scaling or crusting. Commonly associated with use of cosmetics or topical steroids.	Clinical evaluation based on presentation. Patch testing if allergic contact dermatitis is suspected.	Avoidance of irritants and allergens. Topical corticosteroids or calcineurin inhibitors. Oral antihistamines for itching. Proper skincare regimen to restore skin barrier.
Pellagra	Dermatitis characterized by symmetric rash on sun-exposed areas, including the face. Diarrhea and dementia (the three D's). Photosensitivity and scaling.	Clinical diagnosis based on symptoms and dietary history. Niacin levels may be measured.	Niacin (vitamin B3) supplementation. Improvement of dietary intake. Treatment of any underlying conditions causing malabsorption.
Dermatitis Herpetiformis	Intensely itchy, blistering rash typically on elbows, knees, back, and buttocks. Sometimes involves the face with symmetrical distribution.	Skin biopsy with immunofluorescence. Serological tests for celiac disease (e.g., anti-tTG antibodies).	Gluten-free diet to manage underlying celiac disease. Dapsone for rapid symptom relief. Topical corticosteroids for localized symptoms.

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