Facial swelling and beard crusting

A man in his 40s presented to the emergency department with a 24 hour history of facial swelling, itching, and oozing after using black henna hair dye on his beard the previous day. He noticed itching five hours after washing it off. His GP had prescribed cetirizine and flucloxacillin, but the patient attended the emergency department the next day as he felt his symptoms were worsening. He was usually fit and well and did not take regular medications. He was allergic to seafood and had had a previous reaction to artificial henna hair dye.

On examination he had tight bilateral facial swelling extending from the top of his beard to beneath the lower border of the mandible. His mouth opening was limited to 1.5-2 cm, and golden crusting and pustules were present throughout his beard (fig 1). He displayed no signs of respiratory distress and had normal tongue mobility with no airway concerns. No obvious areas of fluctuance or dental pathology were noted on examination.