The face is widely exposed to the surrounding environment and is also a region that comes into frequent contact with the hands. As a result, contact dermatitis presenting on the face may be from a causative agent that had direct, indirect or airborne contact. The face is also the most common site of photocontact dermatitis.1 Therefore, the face is a highly complex region and can be difficult to assess. Paying close attention to characteristic patterns may provide clues to identifying the specific allergen.
Facial contact dermatitis has a fairly well defined group of frequent offending allergens. Using a regional approach helps simplify this list into three main categories.
The first category, scalp-applied allergens, was reviewed in the initial paper of this series. Please refer to the scalp paper for further details of this group.
The second category to be considered is aerosolized contact allergens (aeroallergens). The term aeroallergen should not be restricted to things like animal dander, dust mites and pollens, which more frequently drive Type I hypersensitivity reactions. Aeroallergens also include fragrances (Figure 1), plant allergens and things that become temporarily aerosolized during the repair or manufacturing process (Figure 2).
Aeroallergens have been classically reported to present as facial dermatitis with a distinct cut off along the shirt collar. Aeroallergens are also sometimes contributors to a phototoxic or photoallergic reaction. Sparing under the chin or behind the ears is a clue to photoexacerbation. Patients with aeroallergen-driven facial dermatitis frequently have an underlying atopy. The “headlight sign,” which refers to the presence of facial dermatitis that dramatically spares the nose, may be useful clinically to suggest such patients2 (Figure 3). It has been reported in patients with atopic dermatitis and neurodermatitis.
The third category is directly applied facial allergens. In a study performed by the North American Contact Dermatitis group, females more frequently presented with facial contact dermatitis secondary to cosmetic-associated allergens.3 Common sources among both females and males include moisturizers, sunscreens, hair products and fragrances.1,3 In general, cosmetic-related dermatitis favors a bilateral facial distribution. It is often patchy and diffuse. Predilection for the periphery of the face involving the pre-auricular, submental and mandibular region should direct consideration toward scalp-applied allergens, like shampoos, conditioners and hair dyes, as well as wash-off products like facial cleansers (Figure 4). This sign was introduced in the first paper of this series and is known as a rinse-off pattern. A predominantly central facial distribution (forehead, cheeks and chin) suggests makeup, moisturizers or jewelry (Figure 5).
A unilateral rash with patchy distribution along the mid- to lower-cheek of the lateral face is suggestive of a nickel or chromate allergy from cell phones4,5 (Figures 6 and 7). An individual who had bilateral, symmetrical presentation of contact dermatitis due to simultaneous use of two cellphones was recently reported.7
Other potential nickel sources should be considered, such as eyewear. A bilateral rash on the upper cheek where the lower rims of eyewear potentially make contact with the skin is suggestive of an allergy to worn-out metal in eyewear1,6 (Figures 8 and 9).
Rubber is another common cause of contact dermatitis and rubber-induced rashes often present according to the shape of the offending object. Scuba diver face masks and swimming goggles produce a bilateral, symmetrical pattern that follows the outline of the product.1 Rubber cosmetic sponges will cause a patchy distribution with an asymmetrical pattern, but may vary depending on the patient.1
Table 1 summarizes the above regional contact dermatitis patterns in table format.
Patients with a known allergy to commonly used topical medicaments for acne, rosacea, seborrhea, psoriasis or actinic keratoses can be particularly challenging to treat. Table 2 and Table 3 highlight useful topical medicaments that are minimally allergenic.8
Ms. Huynh is with the Center for Dermatology Research and the department of dermatology at Wake Forest University School of Medicine in Winston-Salem, NC.
Drs. Sheehan and Zirwas and Mr. Chung are with the Center for Dermatology Research at Wake Forest University School of Medicine.
Dr. Feldman is with the Center for Dermatology Research and the departments of dermatology, pathology and public health sciences at Wake Forest School of Medicine.
Disclosure: The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, L.P. Dr. Feldman has received research, speaking and/or consulting support from Galderma, Abbott Labs, Warner Chilcott, Aventis Pharmaceuticals, 3M, Connetics, Roche, Amgen, Biogen, Stiefel, GlaxoSmithKline and Genentech. Dr. Zirwas receives consulting support from Coria Labs, Taro Pharma and SmartPractice. Dr. Sheehan, Ms. Huynh and Mr. Chung have no conflicts to disclose.