Facial edema

DIAGNOSIS:

The diagnosis of facial edema is evident upon inspection. Often disturbing to the patient, acute facial edema is a dermatological emergency.

Analysis of lesions, their context and the presence of occurrence of symptoms (fever) orient the diagnosis. Few additional tests are needed.

ETIOLOGY:

Common causes:

The three most frequent causes are firstly acute eczema and caustic dermatitis is not accompanied by constitutional symptoms and do not require hospitalization, and secondly angioedema and erysipelas if accompanied by constitutional symptoms and requiring hospitalization.

Acute eczema and dermatitis caustic:

Acute eczema:

Diagnosis:

The diagnosis is clinical, based on a pruritic edema, with an ill-defined erythema, vesicles or microérosions oozing, crusting, sometimes mélicériques.

There is no general signs. A impetiginisation possible.

The causative agent, often overlooked, is wanted for questioning.

Locations are evocative:

– Eyelid eczema nail polish and other cosmetic product;

– Eczema lobule ears branches glasses (nickel, dyes);

– Contact dermatitis of the lips with red lipstick at the mouth of musical instruments.

Treatment:

Treatment is based on the eviction of the offending allergen, the application of topical corticosteroids classically class III (Tridésonit®) in decreasing doses over a week Tridésonit® cream 1 application morning and evening on the lesions for two days, then application per day for two days and then every other day for four days and stop.

If impetiginisation, local antiseptics may be useful for a few days (chlorhexidine solution aqueuse® 1 application after the toilet for three days), more rarely systemic antibiotics (oral Pyostacine® 1 g / 3x / day for five days) .

Caustic dermatitis:

Diagnosis:

Edema is most important in eczema.

Superficial erosions and bubbles, oozing and painful, are also present.

There is no general signs.

The interrogation research projection in the previous hours of gases, irritants or caustic chemical liquids. The contact is accidental, during a work accident or, for example, when exposed to a self defense spray (tear gas).

Treatment:

The processing is identical to that of eczema.

We must not forget the legal measures in case of winning accident or assault (descriptive certificates, etc.).

Angioedema:

Diagnosis:

The angioedema (or angioedema) is the deepest form of urticaria which it may be associated. It requires emergency hospitalization (risk of glottal edema with respiratory distress,

hypotension, etc.).

The swelling is often unique, white or pink, often with normal epidermis.

It is accompanied by a sensation more to type of cooking pruritus. Areas with loose subcutaneous tissue (lips and eyelids) are most affected. The swelling is not painful.

Urgency is looking for mucosal involvement (glottis, tongue, soft palate), which can lead to respiratory distress and requiring emergency treatment.

General symptoms are possible, like digestive disorders (abdominal pain, diarrhea, vomiting) or hypotension.

The diagnosis is clinical, no further review is necessary.

The interrogation research the concept of pre-existing allergies or similar episodes, insect bites (Hymenoptera) of iodine injection, drug taking (penicillin, angiotensin converting enzyme inhibitors, angiotensin II receptor antagonists, etc. ) or food in the previous minutes.

However, it is not always possible to find a cause.

The occurrence of recurrent angioedema without urticaria, beginning in childhood, and the notion of family history hereditary angioneurotic edema suggest (cf. Edema).

Remember also that angioedema can be acquired (lupus, hematological malignancies cryoglobulinemia, especially with hepatitis C, etc.).

Treatment:

Treatment requires emergency hospitalization.

In severe forms, it is based on the injection of adrenaline (0.25 to 0.5 mg intramuscularly or subcutaneously) associated with resuscitation (filling with saline, oxygen or intubation, etc. .).

Antihistamines and corticosteroids are then injected to prevent the risk of recurrence (1 Polaramine® injectable bulb Solumedrol 1 mg / kg intravenously).

In less severe forms, use antihistamines and corticosteroids without adrenaline.

The relay per os can be done quickly, the decrease corticosteroids taking place on approximately 4-7 days.

A medical certificate describing the episode and the possible accountability of a substance is given to the patient.Foreclosure advice is given.

In allergic patients, a self-injection of adrenaline syringe (Ana-Help®) may be surrender.

Erysipelas:

Diagnosis:

This is an acute bacterial cellulitis due to bêtahémolytique streptococcus group A.

The location of the face is now less frequent than that of the legs. Edematous closet appears in hours, preceded by fever with chills. It is limited by a peripheral bead, red, infiltrated, hot and painful. Often unilateral, there were more frequent cheekbones. There may be a few vesicles, scales or crusts mélicériques area.

Fever is often greater than 38 ° C. 5 There are no signs of severe sepsis.

We must seek a gateway (sub-nasal crack or sub-auricular wound, etc.).

Complete blood count (CBC) Research leukocytosis neutrophils.

Blood cultures are rarely positive and the door samples are often disappointing.

Generally tare (alcoholism, diabetes, etc.) is to be found.

Treatment:

Treatment requires hospitalization. It is based on the same antibiotics as for leg erysipelas (intravenous penicillin G 6x 4 million units / day, intravenous amoxicillin 1 g / 3x / day). The par-intravenous treatment is relayed after 48 hours of apyrexia orally, for a total of fifteen days of treatment.

The front door is processed. Recurrence is less frequent than in the leg erysipelas.

Other causes:

Other causes, varied and less frequent, may be responsible for the onset of facial edema.

General edematous syndrome:

Diagnosis:

A general edematous syndrome can cause localized swelling of the eyelids. This is mostly a morning predominance edema, primarily related to renal disease (nephrotic syndrome, acute glomerulonephritis).

Treatment:

Treatment is based on the treatment of kidney disease hospitalization.

Superior vena cava syndrome:

Diagnosis:

Recall facial swelling at the superior vena cava syndrome (edema in head and neck cape, filling supraclavicular hollow chest collateral venous circulation).

The main cause is lung cancer in humans.

Treatment:

This is a therapeutic emergency. The patient was transferred to the hospital after call of 15.

Nasal oxygen therapy, an incision and diuretics (Lasilix® 40 to 80 mg IVD) and anticoagulants (Lovenox ® 100 anti-Xa IU per 10 kg weight subcutaneously in the absence of renal failure or Calciparine® subcutaneously) may be administered before the transfer.

TRAPS:

Diagnosis:

This is an exceptional disease. TRAPS, familial periodic fever autosomal dominant, may cause edema of the face. In addition it fever, one aspect of pseudoérysipèle members, myalgia and ophthalmologic involvement (conjunctivitis).

Treatment:

Since this syndrome is due to a mutation of TNF receptor á, it was logical to propose Embrel® (2 sc injections per week) but the results are disappointing. Corticosteroids are partially effective. Currently we tend to try the inhibitors of interleukin-1 monoclonal antibodies (Anakinra®).

Infections:

Viral infections:

* Zona:

Diagnosis

Zoster ophthalmic territory may cause facial swelling. Classically, it is rather the prerogative of elderly or immunocompromised.

Edema is unilateral, localized to a métamère.

Pain type burns before the eruption, the occurrence of bouquet vesicles on erythematous base and crusts are in favor of the diagnosis. The diagnosis is clinical.

Different territories can be achieved:

– Frontal branch with involvement of the upper eyelid and forehead;

– Lacrimal branch with reaching the outer half of the upper eyelid, the temporal region and the bulbar conjunctiva;

– External nasal branch: bridge of the nose, inner corner of the eye, conjunctiva;

– Internal nasal branch: Ala, anterior part of the partition.

Recall that shingles can cause facial palsy and an ophthalmic disease is systematically sought, especially for infringement of the nasal branch.

Ophthalmological opinion is requested doubt, urgently, especially in the presence of signs of keratitis or uveitis.

Shingles can be confirmed by the Tzanck testing or local levy PCR herpes virus (diagnostic group) in doubtful cases.

Immunosuppression underlying (age, HIV) should be investigated.

Treatment

The treatment is detailed in Chapter vesicles. It is mainly based on Valaciclovir (Zelitrex®).

* Other viruses:

Swelling of the face slapped occurring in a child, often accompanied by a rash daisy chain members is to check for infection Parvovirus B 19. oculonasal catarrh preceding a sign of Koplick, erythema confluence trunk with healthy skin intervals is for a measles.

Bacterial infections:

* Staphylococcal malignant:

The classic malignant staphylococcal infection of the face, life-threatening, is not seen practically.

After handling a boil on the upper lip or nasolabial fold (within a line joining the labial commissure and the outer corner of the eye) suddenly appears an inflammatory closet, indurated in burgundy and painful . This extensive closet quickly with turgidity of the superficial venous system, sometimes topped pustules. An indurated cord corresponding to the thrombosed veins is present. It is accompanied by general signs of severe sepsis (high fever, chills, fatigue, hypotension, confusion, oliguria, etc.).

Malignant staphylococcal infection requires hospitalization emergency resuscitation (filling or positive inotropes, antibiotics intravenously).

* Localized infection:

Localized infection (ethmoid, chalazion, cyst manipulation) may cause local edema. Edema is inflammatory, moderate fever and general state.

Treatment is based on the local administration of antiseptics like chlorhexidine in aqueous solution possibly with systemic antibiotics (Pyostacine® 1 g / 3x / day for 7 days).

* Leprosy:

Leprosy can cause facial edema in the reversal reactions and its lepromatous. The patient stayed in an endemic area. There are more or less voluminous nodules, a leonine facies and depilation eyebrows.

Specialist advice is necessary to achieve the levies and start treatment.

This is based on multidrug therapy with rifampicin (600 mg / d), clofazimine (100 mg / d) and dapsone (100 mg / d) for twenty-four months at least. If reversion reaction, add an anti-inflammatory treatment (nonsteroidal anti-inflammatory drugs or corticosteroids).

Parasitic infections:

* Trichinosis:

Trichinosis is related to the ingestion of horse meat, pork or infested wild boar. The facial edema and periorbital fever is predominantly being accompanied by myalgia with muscle weakness, diarrhea.

Biologically, there is a significant eosinophilia and elevated muscle enzymes.

Serology is positive late into the fourth week.

The treatment comprises albendazole (Zentel®) at a dose of 10 mg / kg for 10 days. In case of general symptoms and severity of frank eosinophilia, systemic corticosteroids at a dose of 1 mg / kg for 7 to 15 days may be necessary.

* African trypanosomiasis:

African trypanosomiasis is not seen in France. The subject returned from an endemic area.

There hepatosplenomegaly with posterior cervical lymphadenopathy, sometimes pruritic erythematous skin lesions and fleeting.

The analysis of lymph node puncture juice or blood film will confirm the diagnosis.

The patient was transferred to an infectious disease.

Connective:

* Dermatomyositis:

Periorbital edema Liliace can be seen in dermatomyositis (think of an associated neoplasia): myalgia and axial deficit in muscle strength, Gottron papules, manicure sign, elevated CPK, pathologic capillaroscopy, specific muscle biopsy) .

* Systemic Lupus:

Edema wolf, lupus cheekbones can be seen in systemic lupus.

* Relapsing polychondritis and Wegener’s disease:

Infl ammation of the ear cartilage and nose can be seen in relapsing polychondritis.

Inflammation of the nose can be found mainly in relapsing polychondritis and Wegener’s granulomatosis.

Bites:

Edema and sometimes bullous lupus is seen on the bite area.

The examination must apply to find the concept of insect bite.

Treatment is based on the administration of topical antiseptics, type H1 oral antihistamines if significant pruritus (Clarityne® 1 tablet) and possibly corticosteroids on the same principle as eczema.

Photosensitivity:

The edema follows a normal or intense sun exposure. We must look for the same type of lesions on exposed areas (neck, back of the hands). The diffuse and symmetrical face with compliance sousmentonnier triangle is evocative.Erythema, vesicles or bubbles, can be observed.

When edema follows a normal sun exposure, look photosensitization: drug, contact with plants or perfumes associated with systemic disease (lupus, porphyria, etc.), a polymorphic light eruption or solar urticaria ( see photosensitivity).

Treatment depends on the etiology and is detailed in Chapter Photo-sensitivity. Remember that a clothing and cosmetic photoprotection (sunscreen type Photoderm® max SPF 50) is often needed, and that taking hydroxychloroquinine (Plaquenil® 200, 2 per day) may be useful as a preventive treatment 10-15 days prior to exposure and is to continue for the duration of the exposure.

Various causes:

We will not do that include:

– Sarcoidosis, Melkersson-Rosenthal syndrome;

– Lymphoma, sarcoma, angioma: subacute evolution of pre-existing lesions;

– Fractures clear diagnosis, significant edema with painful hematoma. With therapeutic emergency transfer to the hospital;

– Hypothyroidism: Classic moon face (other signs of hypothyroidism, TSH and T4 dosage);

– Hypercortisolism: Cushing’s syndrome or prolonged corticosteroids impregnation (telangiectasia, buffalo neck, skin atrophy).

Finally, sometimes no cause is found.