Facial psoriasis

What is facial psoriasis?

Facial psoriasis is a chronic skin condition in which there are one or more, persistent, thickened, red and dry patches on the face.

Psoriasis is a common chronic inflammatory skin disease that may affect any skin site. Facial involvement occurs at some time in about half those affected by psoriasis. Although it is usually mild, facial psoriasis is occasionally very extensive involving the hairline, forehead, neck, ears and facial skin.

It is extremely rare to have psoriasis occurring solely on the face. Most patients also have scalp psoriasis and they may also have moderate to severe psoriasis at other sites.

Patients with facial psoriasis often suffer from psychosocial problems due to the presence of unsightly red, scaly plaques on highly visible areas.

Facial involvement presents as a therapeutic challenge because facial skin is thin, sensitive and more complicated to treat.

What are the clinical features of facial psoriasis?

Facial psoriasis has various clinical presentations. There are three main subtypes:

• Hairline psoriasis
• Sebo-psoriasis
• True facial psoriasis.

Hairline psoriasis

• An extension of scalp psoriasis beyond the hairline onto facial skin
• Bright red, thickened plaques with variable white scale

Facial psoriasis 

Facial psoriasis 

Facial psoriasis 

Sebo-psoriasis

• Patchy involvement of the hairline
• Often affects the eyelids, eyebrows, nasolabial folds and beard area
• Salmon-pink, thin plaques with bran-like scale
• Usually associated with diffuse or patchy scalp psoriasis
• Psoriasis may or may not be present at other sites

Facial psoriasis 

Eyelid psoriasis 

Facial psoriasis 

True facial psoriasis

• Sharply demarcated, red, scaly plaques
• May affect any part of the face
• Plaques tend to be symmetrical
• Associated with psoriasis at other sites including ears, genitals, scalp, elbows, knees, and trunk
• Can be part of chronic plaque psoriasis, guttate psoriasis or erythrodermic psoriasis

Facial psoriasis 

Facial psoriasis 

Facial psoriasis 

See more images of facial psoriasis.

Symptoms of facial psoriasis

• Mild to intense itch
• Soreness and skin sensitivity, which are usually mild

What causes facial psoriasis?

The causes of facial psoriasis are the same as for psoriasis in general. Psoriasis is associated with inappropriate activation of the immune system resulting in inflammation and increased proliferation of skin cells. There is a genetic predisposition, but environmental influences are important, including stress, infection, injuries and certain medications.

Facial psoriasis may also be aggravated by:

• Ultraviolet radiation — some patients have photosensitivity where the psoriasis is aggravated by exposure to the sun
• Skin flora, particularly the yeast Malassezia
• Smoking.

What is the treatment for facial psoriasis?

There is no cure for facial psoriasis, but satisfactory control of the disease is possible for most patients using topical therapy. General skin care may include:

• Gentle non-soap cleansers
• Moisturisers
• Sunscreens, if required.

Corticosteroid creams

Mild or moderate strength topical steroids reduce inflammation and relieve itching. Side effects of corticosteroids restrict the potency and duration of use on the face. These include:

• Periorificial dermatitis (spotty acne-like rash around the mouth, nose and eyelids)
• Easy bruising and tearing of the skin
• Thin, transparent skin especially if the eyelids are treated
• Telangiectasia (enlarged blood vessels)
• Rarely, increased hair growth (hypertrichosis)
• Risk of glaucoma and cataracts from long-term use of potent steroid creams around eyelids.

Hydrocortisone is generally safe. More potent topical steroids are best used on the face for only a few days each month.

Topical calcineurin inhibitors

The topical calcineurin inhibitors pimecrolimus cream and tacrolimus ointment may be prescribed off-label for facial psoriasis and can be very effective. They are particularly useful on eyelid skin. In New Zealand, these preparations are not currently subsidised by PHARMAC (February 2019).

Other topical preparations

• Salicylic acid is a descaling agent found in many over-the-counter creams.
• The vitamin D analogues, calcipotriol/calcipotriene and calcitriol tend to irritate facial skin. Cream or gel formulations may be tolerated, especially in combination with topical steroids.
• Coal tar creams may cause staining and irritation.
• The topical phosphodiesterase-4 topical inhibitor, roflumilast, is approved for the treatment of plaque psoriasis (2022).
• Off-label use of the phosphodiesterase-4 topical inhibitor crisaborole has been shown to be effective for facial psoriasis.

Phototherapy

Sun exposure or prescribed phototherapy is often helpful for facial psoriasis.

It is unwise if there is photosensitivity or significant sun damage, such as solar/actinic keratoses or skin cancer.

Systemic treatment

Severe facial psoriasis sometimes warrants treatment with tablets or injections such as methotrexate, ciclosporin, acitretin or biologic agents. Patients should be under the care of an experienced dermatologist and should be carefully monitored.

What is the prognosis?

Facial psoriasis tends to persist, although its severity may vary with season, stress and other factors. It may be a marker of more severe disease with early-onset, long duration and more extensive plaques.