Intended for healthcare professionals

Endgames Picture quiz

Red in the face

BMJ 2010; 340 doi: (Published 28 January 2010) Cite this as: BMJ 2010;340:b5643
  1. Juber Hafiji, specialist registrar,
  2. Jonathan Batchelor, specialist registrar
  1. 1Department of Dermatology, Addenbrooke’s Hospital, Cambridge CB2 0QQ
  1. Correspondence to: J Hafiji juber.hafiji{at}

    A 76 year old woman with metastatic neuroendocrine carcinoma underwent laparotomy and ileocolic resection for small bowel obstruction. The postoperative course was complicated by an anastomotic leak so she returned to theatre for refashioning of the ileostomy. While recovering on the ward, she developed a grade IV sacral sore and the laparotomy wound became infected with meticillin resistant Staphylococcus aureus (MRSA).

    The organism was found to be sensitive to doxycycline, which was therefore started orally. The laparotomy wound began to heal well after three weeks of treatment. The patient however, developed a burning tingling rash on the left side of her face (figure), which was warm and tender to touch. She remained systemically well with no fever, facial swelling, or regional lymphadenopathy. She had no history of skin disease.


    • 1 How would you describe the physical signs?

    • 2 What is the differential diagnosis, and which is most likely in this patient?

    • 3 How would you manage this condition?


    1 How would you describe the physical signs?

    Short answer

    A florid eruption composed of a sharply demarcated erythematous macular patch on the left side of her face with complete sparing of the contralateral side.

    Long answer

    The term macule describes a well circumscribed flat alteration in the colour of the skin, less than 1 cm in diameter. It may be coloured—for example, pink or red owing to vasodilation and mild inflammatory changes; purple or yellow-brown from blood or haemosiderin; or brown, black, pale, or white owing to a disturbance in melanin synthesis. A patch is a flat lesion greater than 1 cm in diameter (a large macule), as …

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