About Butterfly Malar Rash

What Is a Malar Rash?

A malar rash (often called a butterfly rash) is a pattern of skin discoloration across both cheeks and the bridge of the nose. It may be flat or slightly raised and may feel smooth, rough, or scaly. Depending on skin tone, a malar rash can appear pink, red, purple, brown, or darker than the surrounding skin. A lupus-related malar rash often spares the folds that run from the nose to the corners of the mouth, but appearance alone cannot identify the cause. Rosacea, cutaneous lupus, seborrheic or contact dermatitis, sunburn or other photosensitive reactions, dermatomyositis, and skin infections can look similar. A healthcare professional—sometimes a dermatologist or rheumatologist—should evaluate a new, persistent, recurrent, painful, or otherwise concerning facial rash.

Causes and Risk Factors of a Malar Rash

A malar-pattern rash is a clinical sign rather than a single disease. Possible causes and look-alike conditions include:

Cutaneous lupus erythematosus [eh-ruh-thee-muh-toh-suhs], including the acute malar eruption that can occur with systemic lupus erythematosus (SLE).
Rosacea, which may also cause flushing, visible small blood vessels, burning or stinging, and acne-like bumps.
Dermatitis, including seborrheic dermatitis and irritant or allergic contact dermatitis.
Photosensitive reactions, including sunburn and reactions related to certain medicines.
Less common causes, such as dermatomyositis, pellagra, and bacterial skin infections such as erysipelas or cellulitis.

Risk factors and triggers depend on the cause. Examples include:

Personal or family history of lupus or another autoimmune disease may increase suspicion for cutaneous lupus, but family history alone does not diagnose it.
Ultraviolet light can trigger or worsen cutaneous lupus and can also flare rosacea.
Rosacea triggers vary and may include heat, sun exposure, hot drinks, spicy foods, alcohol, exercise, stress, and irritating skin-care products.
Some medicines can cause photosensitivity or lupus-like reactions; medication changes should be discussed with a healthcare professional.

Because the causes differ, there is no single set of modifiable risk factors for every malar-pattern rash. Noting timing, sun or heat exposure, new medicines or products, and associated symptoms can help a clinician identify the cause. Do not stop a prescribed medicine without medical advice.

Malar Rash Symptoms

Features of a malar-pattern rash can include:

Discoloration across the cheeks and bridge of the nose that may be pink, red, purple, brown, or darker than the surrounding skin.
A flat, slightly raised, smooth, rough, or scaly surface.
Itching, burning, tenderness, or pain, although a lupus-related malar rash may cause little discomfort.
Worsening after ultraviolet exposure; rosacea may also flare with heat or other individual triggers.

Other findings may help distinguish the cause:

Rosacea may cause flushing, visible small blood vessels, acne-like papules or pustules, eye irritation, or skin thickening.
Bacterial skin infection may cause rapidly spreading redness, warmth, swelling, marked tenderness, fever, or chills.
Dermatitis may be itchy or scaly and may involve the folds beside the nose.

If lupus is the cause, symptoms outside the skin may include:

Joint pain, stiffness, or swelling.
Unexplained fatigue or fever.
Mouth or nose sores, hair loss, or other sun-sensitive rashes.
Chest pain with breathing, leg swelling, foamy or bloody urine, headaches, confusion, or seizures, which require prompt medical assessment.

Seek prompt medical care for a rapidly spreading, hot, swollen, or very painful facial rash; fever or chills; eye pain or vision changes; facial swelling; trouble breathing; or other severe symptoms. Otherwise, arrange an evaluation if the rash is new, persistent, recurrent, or accompanied by joint, kidney, chest, or neurologic symptoms.

Malar Rash Diagnosis

Diagnosis of a malar rash begins with the rash pattern, medical history, exposures, medicines, and associated symptoms. There is no single test that diagnoses every malar-pattern rash.

History and skin examination: The clinician asks about onset, sun and heat exposure, triggers, new medicines or skin products, eye symptoms, infection symptoms, and signs of autoimmune disease. The distribution of the rash—including whether it involves or spares the folds beside the nose—can provide clues but is not diagnostic by itself.
Testing guided by the suspected cause: Rosacea is usually diagnosed clinically. If lupus is suspected, testing may include a complete blood count, kidney and liver tests, urinalysis and urine protein measurement, antinuclear antibody (ANA), disease-specific antibodies such as anti-double-stranded DNA and anti-Smith, and complement levels.
Skin biopsy: A dermatologist may obtain a small skin sample when the diagnosis remains uncertain or cutaneous lupus is suspected. In selected cases, direct immunofluorescence may provide additional information.
Infection evaluation: A rapidly spreading, warm, tender rash with fever may require urgent examination and, when appropriate, tests for bacterial infection.

Inflammatory markers such as ESR or CRP are nonspecific and cannot diagnose lupus. A positive ANA is also not diagnostic by itself and may occur in healthy people; results must be interpreted with symptoms, examination findings, and other tests. A malar rash is not ordinarily “staged.” Clinicians instead assess the diagnosis, skin severity, and whether an underlying condition affects other organs.

Malar Rash Treatment Options

Treatment for a malar rash depends on the diagnosis; treatments for one cause may be ineffective or harmful for another. A clinician should confirm the cause before prescription treatment is started.

For lupus-related malar rash:

Strict photoprotection, including shade, protective clothing, and broad-spectrum, water-resistant sunscreen with SPF 30 or higher.
Prescription topical corticosteroids or topical calcineurin inhibitors for selected skin lesions; choice and duration depend on the site and severity.
Antimalarial medicines such as hydroxychloroquine for more extensive or persistent cutaneous lupus, with clinician-directed monitoring.
Other systemic immunomodulating or immunosuppressive medicines when skin disease is severe or lupus affects internal organs. NSAIDs may help some joint or muscle symptoms but do not treat the malar rash itself.

For rosacea-related malar rash:

Gentle skin care, daily sunscreen, and identification and avoidance of individual triggers.
Prescription topical medicines may include metronidazole, azelaic acid, or ivermectin for acne-like bumps; other topical medicines can reduce persistent facial redness.
Oral doxycycline or other clinician-selected therapy may be used for more extensive inflammatory or eye-related disease. Laser or light therapy may help persistent visible blood vessels or redness.

For bacterial infection-related malar rash:

Cellulitis or erysipelas generally requires prompt medical assessment and prescription systemic antibiotics. Treatment choice depends on severity, location, allergy history, and local resistance patterns; severe illness may require hospital care.

General self-care while awaiting diagnosis may include:

Use broad-spectrum, water-resistant sunscreen with SPF 30 or higher, reapply as directed, and add hats, protective clothing, and shade.
Use a gentle cleanser and fragrance-free moisturizer, and avoid scrubbing or applying new irritating products to inflamed skin.
Keep a record of possible triggers and take photographs that show how the rash changes over time.

Avoid using leftover antibiotics or applying prescription steroid creams to the face unless a healthcare professional recommends them. Do not start, stop, or change prescription medicines without medical advice. Follow-up may be needed to monitor skin response and, when lupus is suspected, possible effects elsewhere in the body.