Pain in the face may either be due to local disease of any of the major structures of the face, or conditions affecting the innervation. The latter can occur anywhere between the posterior fossa and the ends of the trigeminal nerve. A good examination is not difficult, and quicker than most as undressing is not usually required.
COMMON
maxillary/frontal sinusitis
trigeminal neuralgia (TN)
dental abscess
temporomandibular joint (TMJ) dysfunction
shingles (herpes zoster)
OCCASIONAL
cluster headache (periodic migrainous neuralgia)
temporal arteritis
parotid: mumps, abscess and duct obstruction (stone/tumour)
upper cervical spondylosis
mandibular or maxillary osteitis or cyst
cellulitis
RARE
multiple sclerosis
atypical facial pain (may be linked with depression)
nasopharyngeal and lingual carcinoma
posterior fossa tumours
gummatous meningitis and tabes
glaucoma and iritis
LIKELY: none.
POSSIBLE: FBC, ESR/CRP, sinus X-ray.
SMALL PRINT: X-ray of TMJ, temporal artery biopsy, sialogram, CT/MRI scan.
FBC: WCC and ESR/CRP raised in infection; ESR/CRP raised in temporal arteritis and tumour (ESR more useful than CRP in suspected temporal arteritis).
X-rays: sinus X-ray of little help in acute sinusitis but may help in chronic pain to assess for possible chronic sinusitis or tumour; TMJ views and dental plain film for abscess likely to be arranged by dentist; parotid sialogram for stone/tumour.
Temporal artery biopsy: may be necessary to clinch diagnosis of temporal arteritis.
CT/MRI scan the only practical way to examine the posterior cranial fossa and Gasserian ganglion – a specialist investigation.
Don’t over-diagnose sinusitis – many URTIs will produce mild facial ache through a vacuum effect.
Remember that shingles can produce pain before the rash – in the acute onset of unexplained unilateral facial pain, warn the patient to report back to the doctor should a blistering rash develop.
Refer dental abscesses to a dentist without treating first, to ensure proper investigation, treatment and follow-up – and to encourage the patient to present to the correct agency in future.
If no obvious cause is found for persistent facial pain, refer to exclude sinister pathology.
Trigeminal neuralgia is usually idiopathic, but may have a serious underlying cause, especially if there is associated motor disturbance or other neurological symptoms or signs.
Temporal arteritis is a clinical diagnosis. If suspected, treat immediately with high-dose steroids to prevent blindness. ESR is for retrospective confirmation only.
If the eyeball is red and tender in frontal facial pain, consider glaucoma, iritis or orbital cellulitis. Refer urgently.
Out-of-hours dental treatment can be very hard for patients to access in the UK. You may find yourself ethically obliged to provide some form of treatment, but be sure to give the advice (and document it) that the patient should contact their own dentist as soon as the dental surgery is open. Send a copy of your clinical notes to the dentist as you would any other clinician. You should never feel pressured to work outside your areas of competence, so don’t hesitate to refer to the local hospital facio-maxillary team on call if you have any doubts about diagnosis or emergency management.
Unlike the other ‘skin’ chapters in this book, this section is presented according to the rash’s distribution. This is because it is a common presentation, one with a wide differential and one which causes the patient significant concern, largely because of the cosmetic impact. Occasionally, it can be caused by, or represent, significant pathology. Individual facial spots – such as basal cell carcinoma – aren’t considered here.
COMMON
acne
rosacea
seborrhoeic eczema
impetigo
perioral dermatitis
OCCASIONAL
chloasma
sycosis barbae
drug side effect – especially phototoxicity
infection, e.g. herpes zoster and simplex, cellulitis, chickenpox, slapped cheek
allergic eczema
acne excoriée
post inflammatory hypo- or hyperpigmentation
pityriasis alba
petechiae from coughing/vomiting/straining
other generalised skin diseases, e.g. psoriasis, vitiligo
RARE
Stevens–Johnson syndrome
SLE
mitral flush
tuberous sclerosis
lupus vulgaris
sarcoidosis
dermatomyositis
LIKELY: none.
POSSIBLE: FBC, ESR, autoantibody screen, CPK.
SMALL PRINT: viral or bacterial swabs, skin biopsy, muscle biopsy.
FBC: WCC raised in any infection; may be normochromic, normocytic anaemia in SLE.
ESR, autoantibody screen: ESR likely to be raised in infection and SLE; autoantibodies may be positive in the latter.
CPK: elevated in dermatomyositis.
Viral or bacterial swabs: to help diagnosis in obscure cases or if secondary infection suspected.
Skin biopsy; muscle biopsy: the former for suspected lupus vulgaris or sarcoidosis; the latter to confirm dermatomyositis.
Do not underestimate the possible impact of a facial rash on a patient’s life. The cosmetic effect may be devastating.
A therapeutic trial of antibiotics in acne may take up to 3 months to take effect – ensure the patient is aware of this.
Remember that impetigo may simply represent superinfection of an underlying skin problem, such as eczema, which will require treatment in its own right.
Check on OTC medication usage. In particular, remember that hydrocortisone 1% cream is available over the counter – inappropriate use might aggravate rosacea and perioral dermatitis.
Parents are sensitised to non blanching rashes. They can be reassured that such a rash restricted to the face (indeed, restricted to the entire distribution of the superior vena cava) is not due to meningitis.
A complaint of dramatic facial ‘sunburn’ in the elderly may well represent a phototoxic reaction – check the drug history.
Beware the acute onset of unilateral unexplained facial erythema with mild oedema, especially in an elderly patient. This may well be the start of cellulitis or herpes zoster.
Warn patients with facial zoster or herpes simplex infection near the eye to report any ocular problems.
Acne excoriée may be a marker of significant psychiatric pathology.
This section looks at ‘internal’ causes of facial swelling rather than superficial skin conditions which are dealt with elsewhere (see p. 387). This problem is usually a major concern to the patient because of the disfigurement, which it is impossible to hide. The causal conditions are often very painful too.
COMMON
mumps (viral parotitis)
angioneurotic oedema (allergy)
dental abscess
trauma (especially fractured zygoma)
salivary gland stone
OCCASIONAL
bacterial parotitis
cellulitis (including orbital)
masseteric hypertrophy (caused by bruxism)
dental cyst
myxoedema
herpes zoster (may be swelling rather than blistering initially)
RARE
parotid tumour
maxillary or mandibular sarcoma
Cushing’s syndrome
nasopharyngeal carcinoma
Burkitt’s lymphoma
LIKELY: facial X-ray (if trauma).
POSSIBLE: TFT (if patient looks myxoedematous).
SMALL PRINT: FBC, ESR/CRP, sialogram.
Plain facial X-ray important in trauma (view may depend on site). Also may reveal rare cases of bony tumour.
TFT, FBC, ESR/CRP: TFT will reveal hypothyroidism; WCC raised in infective process; ESR/CRP raised in infection and tumour.
Parotid sialogram will show obstruction of duct (stone, tumour).
New gruff voice with diffuse facial swelling should prompt investigation for likely hypothyroidism.
Don’t over-diagnose mumps in children: since the advent of MMR vaccination, this is becoming more uncommon; cervical adenitis is much more likely.
Whenever possible, direct patients with dental problems directly to the dentist, who will be able to prescribe any necessary antibiotics and analgesics.
Painless, progressive facial swelling suggests tumour or dental cyst. Urgent oral surgical referral is indicated.
Bloodstained nasal discharge in association with a unilateral facial swelling is an ominous sign suggesting malignancy.
Severe angioedema may cause respiratory tract obstruction: treat vigorously as for anaphylactic shock.
Orbital cellulitis requires urgent assessment and intravenous antibiotics.
Parotid swelling with a facial palsy suggests parotid tumour with involvement of the facial nerve.
Suspected herpes zoster in the ophthalmic division of the trigeminal nerve requires urgent antiviral treatment and ophthalmological referral.
Facial ulcers and blisters present much earlier than similar lesions elsewhere on the body because of the cosmetic disfigurement. Smaller lesions, especially basal cell carcinomas, are often picked up coincidentally by the doctor when the patient attends for some unrelated matter. (NB: For rashes confined, or largely confined, to the face, see Facial rash, p. 153.)
COMMON
impetigo
herpes simplex virus (HSV)
herpes zoster
basal cell carcinoma (BCC)
keratoacanthoma
OCCASIONAL
squamous cell carcinoma (SCC)
ulcerating malignant melanoma and lentigo maligna (Hutchinson’s freckle)
drugs (e.g. barbiturates)
acne excoriée
ulcerating dental sinus
RARE
dermatitis artefacta
tuberculosis
pemphigus
Actinomyces
primary syphilitic chancre or tertiary syphilitic gumma
cutaneous leishmaniasis
cancrum oris
Acute lesions very rarely require investigation; chronic lesions pose more of a diagnostic problem. In such cases, biopsy, or excision biopsy, is the gold standard test. Cytology after scraping the lesion with a scalpel blade may be helpful in diagnosing basal cell carcinoma. Syphilis serology may very rarely be useful if primary or tertiary syphilis is suspected.
Remember that herpes simplex can occur on the face at sites other than the lip. The appearance of the lesions and their recurrent nature should provide the diagnosis.
‘Rodent ulcer’ is a kinder term than basal cell carcinoma, especially for small lesions, as it is less likely to arouse unnecessary anxiety. Nonetheless, impress upon the patient the importance of attending the appointment with the specialist.
Patients with herpes zoster are at risk of a number of anxieties because of the existence of various ‘old wives’ tales’ about shingles. Establish any fears and take time to explain the natural history of the condition, including the possibility of post-herpetic neuralgia.
In children with recurrent impetigo, consider an underlying condition – particularly eczema.
If in any doubt about the diagnosis, urgent dermatological referral for skin biopsy is indicated. Remember that chronic facial ulceration is rarely benign.
Ulceration in a previously abnormally pigmented area of skin suggests advanced local malignancy.
Beware attempting excision biopsy of facial lesions unless specially trained. Areas of cosmetic importance can be medico-legal minefields.
Ask about foreign travel: leishmaniasis develops from the bite of a Mediterranean or South American sandfly.
Beware of herpes zoster or simplex developing around the eye: significant complications may follow, so treat and follow up carefully and obtain an ophthalmological opinion if necessary.
