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How to Approach a Patient with Rash

1. Learning Objective By the end of this lecture students will know Basic dermatological terms Important points in history and clinical examination Important Infectious causes of rash 2. Important Dermatological Terms 3. History The most important initial questions to ask patients with new rashes include the following: How long has the rash/lesion been present? How did it look when it first appeared, and how is it now different? Where did it first appear, and where is it now? What treatments have been used, and what was the response, this time and previously? 4. History What associated symptoms, such as itching or pain, are associated with the lesion? Are any other family members affected or have a similar complaint? Has the patient ever had this rash before? If so, what treatment was used/response? 5. What does the patient think caused the rash? Is anything new or different, ie, medications, personal care products, occupational or recreational exposures? 6. Physical Examination Type of lesion Shape of individual lesions

Arrangement of multiple lesions (eg, scattered, grouped, linear, etc.) Distribution of lesions Color Consistency and feel 7. Etiologies The Infectious causes of Rash are Bacterial Viral Fungal Parasitic 8. Bacterial Scarlet fever a. Group A streptococcus (GAS) infection b. Exotoxin (erythrogenic toxin)-mediated diffuse erythematous rash c. coarse, sandpaper-like, erythematous, blanching rash, which ultimately desquamates

9. Rash of Scarlet fever Accompanied by Strawberry tongue 10. Bacterial

Acute Rheumatic Fever a. Another Complication of group A streptococcal pharyngeal infection

b. Erythema marginatum i. Transient macular lesions with central clearing found on extensor surfaces c. Subcutaneous nodules often located over bony prominences 11. Bacterial

Mycoplasma Pneumonia a. It can present in following forms b. Mild erythematous maculopapular

c. Vesicular rash d. Erythema multiforme, or the Stevens-Johnson syndrome 12. 13. Target lesion of Erythema Multiforme Bacteria

Rocky Mountain spotted fever a. Tick-borne lethal disease

b. Rickettsia rickettsii c. Vector Dermacentor andersoni (Tick) d. Rash between the third and fifth days of illness

e. Begins on the ankles and wrists and spreads both centrally and to the palms and soles 14. 15. Bacteria

Lyme disease a. Tick-borne illness b. Spirochete Borrelia burgdorferi

c. Erythema Migrans in Early localized and Early disseminated stages of diease 16. Bacterial

Miscellaneous Causes a. Bacillus Anthracis b. Staph Aureus Scalded Skin Syndrome c. Pseudomonas Ecthyma Gangrenosum d. Acne Propionobacterium Acnes e. Mycobacterium species Skin abscess 17. Viral

Measles a. Paramyxovirus single stranded RNA virus


Blanching erythematous "brick-red" maculopapular rash

c. Beginning in the head and neck area and spreading centrifugally to the trunk and extremities d. 18. 19. Viral Fever, cough, coryza, and conjunctivitis

Chickenpox (Varicella) a. Varicella-zoster virus (VZV)

b. Classic vesicular lesions on an erythematous base c. Present in different stages from papules through vesicles to crusting 20. Rash of Varicella in different stages



Rubella (Post-natal) a. b. c. d. 22. Morbilliform Rash that resembles measles Low constitutional symptoms Prominent postauricular, posterior cervical, and/or suboccipital adenopathy Punctate soft palate macules, can be a helpful clue Morbilliform Rash of Rubella


Parvovirus a. Parvovirus B-19 causes Erythema Infectiosum (Fifth Disease) b. In children Slapped Cheek Pattern c. Joint involvement in Adults d. Rash is erythmatous on face and lace like pattern on limbs and trunks

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Slapped Cheek appearance of Parvovirus rash Viral

Miscellaneous a. Non polio enterovirus b. HHV 8 Immunocompomised c. HIV Occasional Rash in Initial Stages



Pityriasis Versicolor a. Malessezia Furfur, M globosa, M restricta b. Discrete serpentine hyper or hypo pigmented macules c. Chest, upper Back, Arms or and Abdomen d. Parasitic 27. 28. Cutaneous Leishmaniasis a. L.Tropica, L.Major, L. braziliensis etc b. Papular, nodular, or ulcerative lesions c. Parasitic 29. Cutaneous Larva Migrans a. Causes Include Nematodes importantly Ancylostoma etc b. Accidental penetration of Skin by larvae c. Erythematous, serpiginous, pruritic, cutaneous eruption



Scabies a. Sarcoptes Scabiei (Mite) b. Highly contagious c. Intense itching especially at Night d. Superficial burrows of scabies usually occur in the area of the hands, feet, wrists, elbows, back, buttocks, and external genitals

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Burrows of scabies on hand Summary

There are thousands of other causes of Infectious Skin conditions Most of them can be diagnosed and differentiated on History and Physical Examination only.