Rashes/Dermatology Jackie Weaver-Agostoni, DO, MPH UPMC Shadyside Director, Osteopathic Family Medicine Residency 1/28/17
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History Length of symptoms Initial appearance and location Changes/Spread Treatments tried and response Associated symptoms Sick contacts History of similar symptoms and treatment New exposures
History PMHx Medications Family history Social history- occupation, hobbies
Lesion Morphology Macule nonpalpable Ex: vitiligo, cafe au lait, petechiae
Lesion Morphology Papule palpable, </= 5 mm
Lesion Morphology Plaques - Large >/= 5 mm superficial flat lesions
Lesion Morphology Pustules small purulent-filled papules Vesicles small < 5 mm papules containing serous material Bullae large >/=6 mm vesicles
Lesion Morphology Nodules palpable, discrete lesions >/= 6 mm Tumors = large nodules
Lesion Morphology Cysts enclosed lined cavities filled with liquid/semisolid material Telangiectasia dilated superficial blood vessel Wheals - hives
Diagnostic Techniques KOH Prep!! Fungal Tzanck smear!! HSV!! VZV Wood s Lamp!! Tinea!! Erythrasma!! Vitiligo!! Melasma!! Porphyria
Melanoma Risk factors!!!!!!!! Moles: Atypical, total # > 50 Red hair and freckling Severe sunburn, especially in childhood First degree relative Prognosis!!!! Breslow s classification (tumor thickness) and lymph node spread No staging workup needed if lesion < 1 mm thickness as low risk
Irritant Contact Dermatitis Xerosis, fissures, erythema, eczematous eruption Change frequently Increase air exposure Protective ointment!! Petroleum Jelly!! A and D ointment!! Desitin
Diaper Candidiasis Satellite lesions Antifungal creams, frequent diaper changes Usually lasts about 10 days
Rhus Dermatitis Lasts 1-2 weeks Linear Lesions Blister fluid can NOT spread the inflammation Remove source, wet dressings (Burow s solution), Class I topical glucocorticoid if non-bullous Blisters may require oral Prednisone (1-2 week taper). Do NOT remove the tops.
Miliaria Crystallina Miliaria- Heat rash Eccrine sweat duct occlusion Vesicles filled with clear fluid Asymptomatic Cool water compress and proper ventilation
Pityriasis Rosea Benign and self-limiting Herald patch- trunk or proximal extremities Christmas tree distribution Reach their maximum number in 1-2 wks. Clears in 1-3 months More papular/vesicular in kids
Molluscum Contagiosum Virus Umbilicated, flesh-colored, dome-shaped papules Autoinnoculation, scratching, touching Most self-limited in 6-9 months Curettage, cryosurgery, tretinoin (not very effective), salicylic acid, cantharidin Physical expression of lesion rather than tx with phenol worked just as well with less scarring
Primary Herpes Simplex HSV-1 Kids- typically start around or in mouth Respiratory droplets, direct contact with active lesion, virus-containing fluid (saliva) Primary infection with more lesions than recurrence Uniform in size vs. herpes zoster Lasts 2-6 wks Acyclovir (Zovirax)
Erythema Multiforme Acute, immune-mediated Target-like lesions Can have mucosal disease (erosions, bullae) Virus typical cause (HSV, mycoplasma pneumonia in kids) Medications, autoimmune dz, malignancy Usually self-limited over couple weeks Young adults Symmetrical, extensor surfaces, centripetal spread
Stevens-Johnson Syndrome Commonly triggered by medications!! Allopurinol, antibiotics, antipsychotics and anti-epileptics, analgesics and NSAIDs Fever and mucocutaneous reaction followed by necrosis and sloughing of epidermis Starts as erythematous or purpuric macules and placques < 10% body surface (vs. Toxic Epidermal Necrolysis)
Varicella Chicken Pox Contagious 2 days before rash, and until all lesions crust Trunk " face and extremities All phases present Dew drop on a rose petal March-May Complications: secondary infection, encephalitis, Reye s syndrome, pneumonia Symptomatic tx, antivirals (Acyclovir approved)within 24 hrs Immunization- 80% effective
Measles Rubeola Droplets Cough, coryza, conjunctivitis Koplik s spots- blue-white spots with red halo on buccal mucosa Downward spread Morbilliform (confluent elevated maculopapules)
Hand-Foot-and-Mouth Disease Coxsakievirus A16 Oral-oral and fecal-oral routes Warmer months Linear vesicles on palms and soles Self-limited 7-10 days Symptomatic treatment 1st trimester may cause spontaneous abortion
Scarlet Fever Strep pyogenes Downward spread Circumoral pallor, pinpoint papules, sandpaper Pastia s sign- linear petechiae in skin folds Desquamation of palms and soles Beau s lines- transverse grooves on all nails several wks after rash gone PO abx- PCN, e-mycin
Rubella German measles, 3-day measles Respiratory spread 1st trimester " congenital rubella synd.!! Cataracts, deafness, heart defects, bone damage, neurologic issues including mental retardation Immunization- do not get pregnant for at least 1 month following Downward spread Pinkish or rosy-red macules or maculopapules No treatment required- rash fades in 1-2 days
Erythema Infectiosum Parvovirus B19 Fifth disease Slapped cheek Lacy eruption on trunk and extremities 2-day prodrome Respiratory spread Symptomatic treatment Rash lasts approx 10 days Risk to pregnant women- fetal death
Roseola Infantum Exanthem subitum, sixth disease HHV-6 6 mo.- 4y/o High fever (103-106 degrees) " rash Pale-pink, almond shaped, macules Symptomatic tx.
Kawasaki Syndrome Mucocutaneous lymph node syndrome Multisystem vasculitis Fever plus at least 4: bilateral conjunctivitis, red lips/pharynx/ strawberry tongue, erythema palms or soles, edema of hands or feet, desquamation, rash (erythematous exanthem), cervical lymphadenopathy Cardiovascular sequelae Tx: ASA, Gamma globulin
Rocky Mountain Spotted Fever!! Palms and Soles!! Tick-borne disease Rickettsia rickettsii!! Southeastern and south central states!! Spring and early summer!! Rash typically between 3 rd and 5 th day!! Early treatment
Meningococcemia Petechial Rash- discrete 1-2 mm lesions can coalesce into larger purpuric/ecchymotic lesions Trunk and lower body Mucus membranes- hemorrhage
Scabies Direct contact Nocturnal itching Burrows, vesicles or pustules on palms/soleshighly characteristic in infants More widespread in kids- face and scalp involvement (vs adults) Permethrin, Lindane (?safety re: neurotoxicity, Ivermectin, sulfur (?safe), Crotamiton (60% cure vs 89% with permethrin) Launder contaminated items
Lupus Butterfly Rash- spares nasolabial fold!! After sun exposure!! Can precede systemic symptoms Discoid lesions more inflammatory- scar!! If DLE alone, rarely anti-ro ab and normal or low titer ANA Tx: Topical glucocorticoids, antimalatial drugs
Psoriasis Etiology- genetic, other (smoking, obesity, etc) Arthritis, nail involvement Tx: Topical, Phototherapy, Systemic
Henoch-Schonlein Purpura 2-10 y/o Palpable purpura of legs and buttocks, abdominal pain, GI bleed, arthralgia, hematuria Widespread vasculitis Prognosis based on renal involvement Usually benign and self-limited IgA deposition on biopsy Corticosteroids/dapsone
Tinea
Erythema migrans
Secondary Syphilis
References Habif, Thomas P. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. Mosby. Dermatology (Chapter 8) in Zitelli, Basil J. and Holly W. Davis. Atlas of Pediatric Physical Diagnosis, 4th edition, Philadelphia: Mosby Inc., 2002. Pp 257-314. ONLINE Sites Ely JW, Stone MS. The Generalized Rash: Part I and Part II. Differential Diagnosis. AFP, March 2010. http://www.aafp.org/ http://www.pediatrics.wisc.edu/education/derm/tutorials.html http://dermatlas.med.jhmi.edu/derm/ http://www.dermnet.com/ http://www.meistermed.com/moremeister/dermmeister/index.htm!! Free dermatology photo atlas for your PDA http://www.uptodate.com