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MKSAP17
Dermatology
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Chapter03:CommonRashes
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Previous:TherapeuticPrinciplesinDermatology

CommonRashes

EczematousDermatoses
Eczematousdermatitisisatypeofinflammationcharacterizedbyinflamed,dry,red,itchyskin.The
termseczemaanddermatitisareoftenusedinterchangeably.Therearemultipletypesofeczematous
dermatoses(Table7).
Table7.OpeninNewWindowTypesofEczematousDermatoses
Atopic
dermatitis

Aspecifictypeofeczematousdermatitisthatisgeneticallydrivenandoftenaffects
areassuchastheantecubitalandpoplitealfossaetypicallypresentsinchildhood

Allergic
contact
dermatitis

AtypeIVhypersensitivityreactiontoanallergenthatcomesintocontactwiththe
skin

Irritant
contact
dermatitis

Inflammationcausedbyadirectcausticorirritanteffectofachemical

Xerotic
eczema

Extremelydryskinthatresultsininflammationandpruritus

Nummular
dermatitis

Anacuteandextremelypruriticdermatitischaracterizedbycoinshapedplaques

Stasis
dermatitis

Anacuteinflammationoftheskincausedbychronicvenousstasis

Inalltypesofeczematousdermatoses,patientsshouldbetoldtotakeshortshowersorbathsinwarm
(butnothot)water,useamildsoap,andapplymoisturizerliberallywithin3minutesofgettingoutof
thebathtub.Theskinlosesthehydrationgainedfrombathingwithin3minutes,andifmoisturizeris
delayedlongerthanthis,theskinbecomesdrierthanitwasbeforebathing.Therearenewer
moisturizerscontainingceramidesthatmayprovideextrabenefitinhealingtheskinbarrier.
Washcloths,buffpuffs,loofahs,andotherabrasivecleaningimplementsshouldbeavoidedinpatients
witheczematousdermatitisbecausetheycaninappropriatelyexfoliatetheskin.Theymayalsoactas
fomitesandharborsourcesforinfection,especiallywithrepeateduse.

AtopicDermatitis
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RelatedQuestion
Question63
Atopicdermatitis(AD)ischaracterizedbyxerotic,pink,scalyskinandismostcommonlyseenon
theperiocularareas,posteriorneck,antecubitalandpoplitealfossae,wrists,andankles(Figure1).
Therashoftenwaxesandwanes.ManypatientswithADhaveadefectiveskinbarrierbecauseofa
mutationinfilaggrin,whichisaproteinthathelpstheepidermisprovideabarrieragainstallergens
andirritants.Therefore,patientswithafilaggrinmutationoftenhavedry,scalyskinandareathigher
riskforcontactdermatitis.PatientswithADalsohavedownregulatedinnateimmunity,andtherefore
theirskinislocallyimmunosuppressedandmoresusceptibletoinfection.Becauseoftheimpaired
barrier,thecirculatingLangerhanscellsintheskinaremoreeasilyincontactwithenvironmental
antigens,andpatientsaremorelikelytobecomesensitizedtoenvironmentalallergenssuchasdust
mites,ragweedpollen,andanimals.Theyarealsomorelikelytobecomesensitizedtochemicalsput
ontotheirskinleadingtocontactdermatitis.StaphylococcalcolonizationofADisverycommon.
Whentheskinisscratched,therearebreaksintheepidermisthatcanbecomeinfected,asevidenced
byhoneycoloredcrusting,oozingerosions,andpustules.Foodallergiesareanuncommoncauseof
flaresinAD,andbloodandskinIgEtestsfortheseallergenshavehighfalsepositiverates.
Therefore,randomfoodtestingwithoutareliablehistoryofflaringwithaparticularfoodcanleadto
inappropriatefoodavoidanceandpatientfrustration.
Figure1.OpeninNewWindow

Subacuteeczemaoftheflexuralfoldsshowingerythemawithcruststypicalofatopicdermatitis.

ContactDermatitis
Althoughcontactdermatitisiscommonandcausessignificantmorbidity,itisalsocurableby
avoidingthecausativechemical.Therearetwotypesofcontactdermatitis,allergicandirritant.
AllergiccontactdermatitisisatypeIVdelayedhypersensitivityreactiontoaspecificchemical.With
repeatedexposuretothechemical,apruriticeczematousdermatitisdevelopsontheexposedarea
(Figure2).Inexuberantcases,thelocalizedinflammationcanleadtoasecondaryidreaction,a
generalizedacutecutaneousreactioninwhichpinpointfleshcoloredtoredpapulesdevelopdiffusely
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onthebody.Idreactionsmaybecenteredontheinitialallergicsitebutmayalsoinduceuniform
monomorphoussmallpapulesespeciallyontheextensorarms,legs,orneck.Irritantcontact
dermatitisiscausedbyadirecttoxiceffectontheepidermisfromexposuretoachemicalsuchasa
cleaningagent,othercausticsubstances,orrepeatedwettinganddryingandisnotmediatedbythe
immunesystem.Forexample,overwashingwithharshsoapwilloftenleadtodry,irritatedskin,
whichisnotimmunemediated.
Figure2.OpeninNewWindow

Pinpointvesiclesonaredbaseontheantecubitalfossaarecharacteristicofacutecontactdermatitis.

CausesofAllergicContactDermatitis
RelatedQuestions
Question9
Question24
UrushiolisanallergenintheToxicodendron(formerlyclassifiedasRhus)genusofplants.Examples
oftheseplantsincludepoisonivy,poisonoak,andpoisonsumac.Typicallythisrashpresentswith
geometriclinesorsplattersofredpapulesandvesicles,especiallyonexposedareas.Iftheurushiol
resinoxidizestotheskin,itwillturnblackandisoftenmistakenforaspiderbite(blackdotpoison
ivy).
Nickelmetalallergyisalsoverycommon,especiallywiththeincreasinglyfrequentpracticeof
piercing.Nickelistypicallyfoundinjewelry,belts,orsnaps,includingtheinsidebuttononjeans,
whichrubsagainstthelowerabdomen.
Neomycinandbacitracinarecommonlyusedoverthecountertopicalantibioticsthatwithrepeated
use,especiallyonabradedorlaceratedskin,canleadtocontactsensitization.Patientsandphysicians
oftenmistakethisforawoundinfection,butiftheareaisitchyandthereisageometric,sharply
borderedpattern,acontactallergyshouldbesuspected.Transdermalmedicationssuchasclonidineor
buprenorphinehavealsobeenassociatedwithallergiccontactdermatitis.
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Fragrancessuchaseugenol,geraniol,andcinnamicaldehydearecommoncausesofcontact
dermatitiswhenusedinperfumesandcolognesaswellasinsoapsandmoisturizers.Contact
dermatitistoaerosolizedfragranceswillpresentinanairbornepattern(involvingtheface,especially
theeyelidsneckandarms).Patientswhoareallergictofragrancesinsoapsandmoisturizerswill
haveamorediffuseeruptiononthetrunkandextremities.
Rubberandchemicalsusedintheprocessingofrubbercanbefoundinlabelsoremblemson
clothing,nonslipgrips,gloves,orotherworkplaceexposuresandmayalsocausecontactallergies.
PlantmaterialssuchasteatreeoilandbalsamofPeru,aswellasotherorganicingredients,have
becomemorepopularaspeoplearechoosingtousemoreorganicproducts.Thesecanbepotent
allergensandgounnoticedbypatientswhoareoftenusingthemastopicalagentstotreataprimary
skineruption,resultinginsecondarysensitization.
Therearemanyotherallergens,includingpreservativesinmedicinesandsoaps.Whenanobvious
causativeagentcannotbeidentified,epicutaneouspatchtestingcanbeveryhelpful.Thistest
involvesputtingsmallcommerciallyavailableconcentrationsofthepotentialcausativechemicalson
theback.Theallergensareremovedafter48hours,andtheareasareevaluatedforarashat48hours
andagainat72or96hours.Thedecisionaboutwhichallergenstoapplyisbasedonthedistribution
ofthecontactdermatitis.Oftenthecausativeagentisnoteasytoidentifypriortotesting.For
example,apatientmaydeveloparashbecauseofirritationorrubbingfromanewpairofshoesand
thenapplytopicalmedicationsormoisturizersanddevelopasecondarycontactdermatitisonthe
originalrash.Therefore,mostpatientsaretestedusingastandardpanelofthemostcommonly
describedallergens.Epicutaneouspatchtestingisnotthesameasscratchorpricktesting,whichis
usedtoidentifyimmediatetypeIIgEmediatedwhealandflareresponses.

HandDermatitis
RelatedQuestion
Question67
Handdermatitisischaracterizedbyinflamed,scaling,andsometimesfissuredskinonthepalmaror
dorsalhand(Figure3).Themostcommoncausesareoverwashing,allergicorirritantcontact
dermatitis,AD,dyshidroticeczema(pompholyx),andtinea.Repeatedorextendedwashingwithsoap
causeshanddermatitisbyfriction,removaloftheprotectiveskinbarrier,andirritationfromthe
surfactantpropertiesofthesoap.Peoplewhoarerequiredtorepeatedlywashtheirhands(suchas
medicalprofessionals)orthosewhowashrepeatedlybecauseofobsessivecompulsiveorautism
spectrumdisordersoftenhaveextremelypronouncedhanddermatitis.Thistypeofirritantdermatitis
willbeespeciallymarkedonthedorsalhandswherethestratumcorneumisthinnerthanthatofthe
palms.Manychemicalsfoundincommonproductscancauseallergiccontactdermatitis.
Hairdressers,rubberworkers,healthcareworkers,orothersexposedtomanydifferentchemicals
haveahigherriskofbecomingsensitized.Allergiccontactdermatitismanifestswithextremeitching
andredness.Dyshidroticeczema(pompholyx)isanextremelyitchyeruptionofsmallvesiclesonthe
sidesofthefingersandpalmsthatcanoccurfromfrequentwettinganddrying,sweating,allergies,or
asareactiontotineapedis.ADtypicallyaffectsthehands,butotherareasmayoftenbeaffectedas
welltherefore,theentirebodyshouldbeexamined.Patientswhowearringsoftenhavesoapand
watertrappedunderneaththeringafterwashing.Thisleadstoanirritantdermatitis.Removingthe
ringpriortowashingormakingsurethatnosoaporwaterresidueisleftundertheringafterwashing
areeffectivepreventivemeasures.
Figure3.OpeninNewWindow

Dyshidrotichandeczema,characterizedbyacuteepisodesofanintenselypruriticeruptiononthe
palms.

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Therapyforhanddermatitisstartswithidentifyingacause.Forirritanthanddermatitis,avoidingthe
irritantbywashingless,moisturizingmore,andwearingcottonglovesinsideofrubbergloveswhen
aroundchemicalsorduringactivitiessuchasdishwashingcanpreventdevelopmentofarash.If
rubberglovesarewornalone,thehandsoftensweatandthewateristrappedagainsttheskin,leading
tofurtherflaresofdyshidrosis.Topicalpetrolatumjellyisaninexpensiveandeffectivewayof
repairingthedamagedskinbarrier.Atopicalglucocorticoidmaybenecessaryforashortperiod
whilethetriggersareidentifiedoriftheskinisveryinflamed.Allergiccontactdermatitis,AD,and
dyshydroticeczemacanallbetreatedthesamewaybutnearlyalwaysrequireashortcourseof
topicalglucocorticoidsforsymptomrelief.Tineamanuum,afungalinfectionthatcharacteristically
involvesthehands,isoftenrecalcitranttotopicaltherapybecausetheinfectioninvolvesananatomic
sitewithverythickstratumcorneumoftentopicalkeratolyticagentsareaddedtohelpantifungal
agentspenetratetheskin,andsomepatientsrequireoralmedications.

XeroticEczema
Xeroticeczema,alsocalledasteatoticeczemaorwinteritch,ischaracterizedbyverydryskinthat
uponcloseexaminationmaybeslightlyfissured.Typicalareasincludetheanteriorshins,trunk,back,
andarms(Figure4).Theeruptionisextremelypruritic.Aggressivemoisturization,alongwith
changingtosoapsthatcontainlesssurfactant,maybeallthatisneededtotreattheeczema.
Figure4.OpeninNewWindow

Extensivefinescalingwithminimalerythemaonthebackinapatientwithseverexeroticeczema.

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NummularDermatitis
Nummulardermatitisischaracterizedbyround(notannularorringlike)scalingplaquesthatare
intenselyitchy(Figure5).Theskinissoinflamedthatpinpointvesiculationfromserum
accumulatingintheinflamedskinoftenoccursandcansimulateinfection.Tineacorporiscanbe
differentiatedfromnummulardermatitisbecausetherashoftineacorporisisoftenannularwithat
leastapartiallyclearedcenterandscalingattheperiphery.Psoriasisisoftenlocatedontheelbows,
knees,scalp,orinterglutealcleftbuthaslarger,thickerwhitescale.Allergiccontactdermatitiscan
alsopresentwithsmall,round,intenselyitchyplaques.Thepatientthereforeshouldbeaskedifthe
locationoftherashalignswithanyoutsidecontactant(forexample,metalfromabeltorchair)orif
anythingisbeingapplied(forexample,neomycin,bacitracin,herbalmoisturizers,orteatreeoil)that
mayhelptodifferentiatetherashofnummulardermatitisfromthatofallergiccontactdermatitis.
Nummulardermatitisisoftenrecalcitranttotherapyandmayrequirepotenttopicalglucocorticoid
treatment.
Figure5.OpeninNewWindow

Nummulardermatitisischaracterizedbyextremelypruriticroundorovalpatchesofeczematous
dermatitis,consistingofpapules,scaling,crusting,andoftenserousoozing.Mostlesionsappearon
thetrunkorlegsandare2to10cmindiameter.

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StasisDermatitis
RelatedQuestion
Question15
Stasisdermatitismanifestswithred,inflamedskinonthelowerlegsinpatientswithvenousstasisor
othercausesoflowerextremityedema.Decreasedvenousdrainageresultsinvenoushypertension
andincreasedvascularpermeabilityandedema.Becausetheshinsareoftenoneofthedriestpartsof
thebodyandareeasilyexcoriated,dermatitisinthisarearelatedtovenousstasisiscommon.Thered
areaontheanteriorshinsinpatientswithstasisdermatitisisoftenbilateralandwarmtothetouchbut
typicallyisnottender(Figure6).Althoughstasisdermatitiscansimulateinfection,cellulitisusually
isnotpresent.Patientswilloftenhaveanormalleukocytecountandbeafebrile.Conversely,cellulitis
isalmostalwaysunilateralandisusuallyaccompaniedbyfeverandleukocytosis.Therapyincludes
optimizingtotalbodyfluids,usingcompressionstockings,elevatingthelegs,andapplyingfrequent
emollients.Topicalglucocorticoidssometimeshelpifseverepruritusorinflammationispresent.
Figure6.OpeninNewWindow

Stasisdermatitiscausingerythematous,pebbly,oozingplaquesonthebilaterallowerlegsofapatient
hospitalizedforcellulitis.

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KeyPoints
Foodallergiesareanuncommoncauseofflaresinatopicdermatitisroutinefoodtesting
withoutareliablehistoryofflaringwithaparticularfoodshouldbeavoided.
AllergiccontactdermatitisisatypeIVdelayedhypersensitivityreactiontoaspecificchemical,
andepicutaneouspatchtestingcanhelptoidentifythecausativeallergen.
Handdermatitisischaracterizedbyinflamed,scaling,andsometimesfissuredskinonthe
palmarordorsalhandandismostcommonlycausedbyoverwashing,allergicorirritant
contactdermatitis,atopicdermatitis,dyshidroticeczema(pompholyx),andtinea.
Stasisdermatitisissometimesconfusedwithcellulitishowever,patientswithstasisdermatitis
donothavetenderskin,willhaveanormalleukocytecount,andwillbeafebrile.

PapulosquamousDermatoses
Papulosquamousdermatosesarecharacterizedbyscalingpapulesandplaquesduetoinflammationof
theepidermis.

Psoriasis
Psoriasisisachronicinflammatorydermatosisthatmanifestswithscaling,variablypruriticplaques
thatmayberecalcitranttotopicaltherapy(Figure7andFigure8).Atotalof1%to2%ofthe
populationisaffected,andthereisageneticpredispositiongiventhat50%ofoffspringwillhave
psoriasisifbothparentsareaffected.Theincidenceofpsoriasispeaksataroundage20yearsand
againatage60years.Therearemanydifferentpatternsofpsoriasis(Table8).Patientswithpsoriasis
haveincreasedinflammatoryTh1,Th17,andTh22cells.Thislikelyexplainswhypsoriasismaybe
consideredtobeamultisysteminflammatoryresponseratherthanbeinglimitedtotheskin.Atotalof
6%to11%ofpatientswithpsoriasisalsohavepsoriaticarthritis.Psoriaticarthritiscanbesevereand
debilitating(seeMKSAP17Rheumatology).Patientswithpsoriasis,especiallythosewhohave
widespreaddisease,haveanincreasedriskofmyocardialinfarctionandothermajorcardiovascular
events.Emergingdatasuggestthatpsoriasismaybeassociatedwiththemetabolicsyndrome,and
somehaveshownlinksbetweenpsoriasisanddiabetesmellitus,hypertension,andhyperlipidemia.
Therefore,patientswithpsoriasisshouldbemonitoredmorecloselyforcardiovasculardiseaseand
otherassociatedriskfactors.Psoriasisseemstobemorecommoninobesepatientsandthosewho
smoke.Weightlossmayleadtoimprovement.Smokingtobaccomayworsenpsoriasis,andpatients
shouldalsobecounseledagainstsmokingespeciallybecauseoftheelevatedriskofcardiovascular
disease.Patientswithpsoriasisoftenperceivethattheirdiseasehasgreaterimpactontheirlivesthan
moreseveremedicalconditionssuchashypertensionanddiabetes,andmanyfeelthattheirskin
conditionisundertreated.
Figure7.OpeninNewWindow

Scalingpapulesandplaquesofpsoriasiscoalescentontheelbowandextensorforearm.
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Figure8.OpeninNewWindow

Scalingpatchwithpustulesattheedgetypicalofapustularflareofpsoriasis.

Table8.OpeninNewWindowTypesofPsoriasis

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Psoriasis
vulgaris

Red,thick,scalingplaquesconcentratedontheelbows,knees,ankles,shins,andtrunk

Inverse
psoriasis

Red,thinplaqueswithvariableamountofscaleintheaxillae,underthebreastsor
pannus,interglutealcleft,andperineum

Sebopsoriasis

Red,thinplaquesinthescalp,eyebrows,nasolabialfolds,centralchest,andpubic
area

Guttate
psoriasis

0.5to2cmredplaquesthateruptsuddenlyonthetrunkoftenafteragroupA
streptococcalinfection

Nailpsoriasis Indentationsandoilspotsofteninvolvingmultiplenails
Thechoicefortherapyforpsoriasisisbasedprimarilyonlocationandseverity.Topicaltherapyisthe
preferredchoiceforlocalizeddiseaseandusuallyconsistsofintermittentpulsesofmediumtohigh
potencytopicalglucocorticoidseitheralternatingwithorinconjunctionwithtopicalvitaminD
analoguesorkeratolyticagents.Atypicalregimenforflaresoflocalizeddiseasemightbeamedium
potencyglucocorticoidappliedonceortwiceadayontheweekdaysandatopicalvitaminD
analogueappliedonceortwicedailyonweekends.Topicalglucocorticoidsappliedcontinuouslypose
ahigherriskofatrophyandstriae,sohavingsteroidholidaysafewdayseachweekmayallowthe
medicationstobeusedmoresafelyovertime.ThevitaminDanalogueshavesomebenefitin
psoriasisbutdonotcausethesamesideeffectsasglucocorticoids.Ointmentsandcreamsare
preferredonthebody,whereassolutionsandfoamsaremoreappropriateforthescalp.Calcineurin
inhibitorsareusedtopicallyofflabelforinversepsoriasis(psoriasisintheperineum,axillae,or
underthebreasts).
Patientswithpsoriasiscoveringmorethan10%bodysurfaceareaorthosewithpsoriaticarthritis,
recalcitrantpalmoplantarpsoriasis,pustularpsoriasis,orpsoriasisinchallenginganatomicareas
(groin,scalp)maybeconsideredforsystemictherapy.Systemicagentsincludephototherapy,
traditionalsystemicagents(retinoids,methotrexate,cyclosporine),orbiologicagents,mostoften
tumornecrosisfactor(TNF)inhibitorsandinterleukin12orinterleukin23inhibitors.Phototherapy
doesnotcauseimmunosuppressionbutrequiresmultiplevisitsperweekphototherapydoesnot
impactpsoriaticarthritis.Theremaybealongtermriskofskincancerassociatedwithlighttherapy,
althoughthisisprimarilyariskwithpsoralenultravioletA(PUVA)phototherapy,solighttherapy
maybesaferinpatientswithdarkerskintypeswhohavelowerinitialrisk.Systemictherapywith
retinoids,methotrexate,orcyclosporinehasbeenusedformanyyearsinappropriatepatients.TNF
inhibitorsandinterleukin23inhibitorsarealsoFDAapprovedalternativesforpsoriasis.Therapy
withanyofthesystemicagentsshouldbeguidedbyaclinicianexperiencedintheiruse,including
appropriateevaluationforcontraindicationsandcarefulmonitoring.Theimpactofthesetreatments
onthepsoriasisassociatedcomorbiditiesisasyetunknown.

KeyPoints
Psoriasiscanbeamultisysteminflammatoryresponselimitednotjusttotheskin,andpatients
whohavewidespreaddiseasehaveanincreasedriskofmyocardialinfarctionandothermajor
cardiovascularevents.
Topicaltherapyisthepreferredtreatmentforlocalizedpsoriasisandconsistsofintermittent
pulsesofmediumtohighpotencytopicalglucocorticoidseitheralternatingwithorin
conjunctionwithtopicalvitaminDanaloguesorkeratolyticagents.
Systemictherapy,suchasphototherapy,traditionalsystemicagents,orbiologicsshouldbe
reservedforsevere(>10%bodysurfacearea)psoriasis,psoriaticarthritis,orpsoriasis
unresponsivetotopicaltherapy.

LichenPlanus
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Lichenplanus(LP)isanacuteeruptionofpurple,pruritic,polygonalpapulesthatmostcommonly
developsontheflexuralsurfaces,especiallythewristsandankles(Figure9).LPcanalsooccurin
themucousmembranes(mouth,vaginalvault,andpenis)withwhiteplaquesthat,ifuncontrolled,
mayulcerate.Theeruptioncanalsodevelopinthenails,leadingtothickeninganddistortionofthe
nailplate.LPismostcommonlyidiopathicbutmaybeinducedbymedicationsorpossiblyinfection.
LPhasbeenreportedinupto20%ofpatientswithhepatitisCinfectioninsomestudies,butother
reportshavefailedtoshowanassociation.MedicationsimplicatedincausingLPorlichenoiddrug
reactionsaregoldsalts,captopril,hydrochlorothiazide,andhydroxychloroquine.
Figure9.OpeninNewWindow

Lichenplanuspresentingashyperpigmentedpurple,pruriticpolygonalpapulesandplaquesonthe
ventralwrists.

LPtendstoremitafter1to2yearswithorwithouttherapybutmaylastlonger,especiallyiferosive.
Therapywithpotenttopicalglucocorticoidsisofteneffectiveinlesseningthelesionsanddecreasing
pruritusbutmaynotbecurative.ErosiveLPthatisactiveformanyyearsmaydegenerateinto
squamouscellcarcinomaasaresultofchronicinflammationthereforetherapytocontrolerosiveLP
isveryimportant.Systemicglucocorticoids,systemicretinoids,andphototherapycanbeconsidered
fortreatmentofsevereorrecalcitrantLP.

KeyPoints
Lichenplanusisanacuteeruptionofpurple,pruritic,polygonalpapulesthatmostcommonly
presentsontheflexuralsurfacestopicalglucocorticoidsareofteneffectiveatdecreasingthe
sizeofthelesionsandtheassociateditchbutmaynotbecurative.
Systemicglucocorticoids,systemicretinoids,andphototherapyshouldbereservedforsevere
orrecalcitrantlichenplanus.

PityriasisRosea
RelatedQuestion
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Question31
Pityriasisrosea(PR)isareactiveeruptionofunknowncause,althoughsomeexpertshavesuggested
anassociationwithapreviousviraleruption.Itismorecommonlyseeninthespringandfallandhas
apredilectionforyoungadults.Clinically,PRoftenpresentswithonescalingpatchthatisafew
centimeterswide(heraldpatch)andistypicallymistakenforanareaoftineacorporisorcontact
dermatitis.Many0.5to2.0cmredscalingpatchestheneruptalongtheskincleavagelinesina
Christmastreedistributiononthebackafewdayslaterandlast1to3months(Figure10).The
eruptionisoftenmildlypruritic.Theclinicalappearanceofscalingpapulesandplaquesissimilarto
thatofsecondarysyphilis,althoughPRtypicallysparestheface,palms,andsoles,whereastherash
ofsecondarysyphilisoftenaffectsthepalmsandsoles.Testingshouldbeperformedifthereisany
clinicalconcernforsyphilis.TherapyforPRischallenging,althoughthereareofflabelreportsofthe
useofsunlight(allowingthepatienttotanwithnaturallightwithoutburning),phototherapy,and
systemicmacrolideantibiotics.Topicalglucocorticoidsandantihistaminesmayhelpwiththe
pruritus.
Figure10.OpeninNewWindow

Pinkmaculeswithacollarofscaleconsistentwithpityriasisrosea.

SeborrheicDermatitis
RelatedQuestion
Question47
Seborrheicdermatitisisaninflammatoryscaling,itchydermatosisthatmostcommonlyaffectsthe
scalpbutcanalsoaffecttheeyebrows,nasolabialfolds,chin,centralchest,andperineum
(Figure11).SeborrheaisthoughttobeanoverreactionofthebodytocommensalMalasseziayeasts
thatliveontheskin.Seborrheaischaracterizedbywaxy,scaling,redpatches.Therashoftenstartsin
pubertyandwaxesandwanesovermonthsandyears.Therashonthefaceisverycommon,
especiallyintheelderly,inimmunosuppressedpatients(particularlyinpatientswithHIVinfection),
andinpatientswithneurologicdisorderssuchasParkinsondisease.Patientswilloftenthinktheyjust
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haveconsistentlydryskinonthefacehowever,thedistributionofascalingrashontheeyebrows
andnasolabialfoldsextendingontothecheeksandchinistypicalofseborrheaandoftendoesnot
respondtomoisturizationonly.
Figure11.OpeninNewWindow

Erythematousplaqueswithdryscaleoccurringinthebeardareaandnasolabialfoldscharacteristicof
seborrheicdermatitis.

Seborrheacanbetreatedwithoverthecounterseleniumsulfideorzincpyrithioneshampoosthatare
latheredintotheskinandallowedtoworkforafewminutesandthenwashedout.Ketoconazole
shampooandtopicalketoconazolecreamarealsoveryeffective.Whentheskinismoreinflamed,a
shortcourseoflowpotencytopicalglucocorticoidscanbeused,butpatientsshouldbewarned
againstcontinuedusearoundtheeyestoavoidsideeffects.

DrugReactions
RelatedQuestion
Question40
Therearemanydifferentmanifestationsofmedicationreactionsintheskin.MorbilliformortypeIV
hypersensitivityreactionsarethemostcommonandmanifestaspinktoredmaculesandpapules
(oftencalledmaculopapular)thatareoftenverypruritic(Figure12).Thetypicalonsetiswithin7to
14daysofstartingthemedication,butifexposureisrecurrent,itmaybefaster.Thetherapyistostop
themedicationandtreatsymptomaticallywithantihistaminesandmediumpotencytopical
glucocorticoidsforabrieftimewhilethereactionresolves.Patientsshouldbewarnedtoalerttheir
clinicianiftheydevelopfevers,skinpain,blisters,pustules,ormucousmembraneinvolvement.
Figure12.OpeninNewWindow

Blanchableerythematouspatchesonthetrunkinapatientwithamorbilliformdrugeruption.
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Drugreactionwitheosinophiliaandsystemicsymptoms(DRESS)syndrome(ordrug
hypersensitivitysyndrome[DHS])isaseveredruginducedhypersensitivitysyndromecharacterized
byapapulareruption,facialedema,lymphadenopathy,internalorganinvolvement,andhematologic
abnormalitiessuchaseosinophilia,lymphocytosis,orthrombocytopenia.Themostcommon
implicateddrugsareallopurinol,sulfonamides,anticonvulsantagents,andminocycline.DRESSis
managedbydiscontinuingthecausativemedicationimmediatelyandprovidingsymptomatic
supportivecare.Systemicglucocorticoidsshouldbegivenbecauseofthehighriskofendorgan
damage.ForamoredetaileddiscussionofDRESSorDHS,seeDermatologicUrgenciesand
Emergencies.
Acutegeneralizedexanthematouspustulosis(AGEP)isanacuteeruptionofpinpointpustulesthat
oftenstartsontheheadandneckandextenddown.Thepustulesaresominutethatsometimesonly
theresultantpeelingisnoted(Figure13).AGEPiscausedbyvariousmedications(mostcommonly
antibiotics,especiallypenicillins,cephalosporins,andmacrolides)orviruses.Thelistofcausative
drugsislongandevergrowingandincludessuchhardtoidentifytriggersascontrastdyeand
dialysates.Therefore,ifAGEPissuspected,theclinicianshouldobtainathoroughhistoryofall
possibleexposures.GenerallyAGEPbeginswithin48to72hoursofbeginninganewdrug,which
mayhelpidentifytheculprit.Patientswillusuallyhaveafever,andlaboratoryresultswillshow
leukocytosisandoccasionallyexcessbands.Thediseaseselfresolveshowever,itmayresultin
extensivepeeling,whichmaybealleviatedbytheuseofemollients.
Figure13.OpeninNewWindow

Pinpointpustulesonabackgroundoferythemainapatientwithacutegeneralizedexanthematous
pustulosis.

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Fixeddrugeruptions(FDE)arepurplepatchesthatoccurinthesamelocation(fixed)eachtimea
patientisexposedtothesamemedication.Severeeruptionsmayhavecentralbullae.Lips,genitals,
andhandsarecommonlyinvolved,butonlyonespotmaydevelopwiththefirstexposure.If
reexposed,however,theoriginalspotwillrecuralongwithnewareas.Commondrugculpritsinclude
overthecountermedicationssuchaspseudoephedrine,NSAIDs,sulfonamides,andotherantibiotics,
butthereisaverylonglistofmedicationsthatarefrequentlyresponsible.
Pigmentedpurpuricdermatosesarecharacterizedbylesionsthatlooklikepetechiaebutarearranged
intosmallpatchesorplaques(Figure14).Thelesionsaresometimesitchybutmaybeasymptomatic.
Thereisnoassociatedplateletabnormality.Thelesionsareoftencomparedtocayennepepperand
tendtoresolvewithsomerustcoloredpigmentation.Pigmentedpurpuramaybecausedbyexposure
tovirusesormedicationssuchasNSAIDs.Theeruptionisasymptomatic.Thereisnospecificwork
upindicatedandnosatisfactorilyconsistenttherapy.

KeyPoints
Seborrheacanbetreatedwithoverthecounterseleniumsulfideorzincpyrithioneshampoos
thatarelatheredintotheskinandallowedtoworkforafewminutesandthenwashedout
ketoconazoleshampooandtopicalcreamarealsoveryeffective.
Drughypersensitivitysyndrome(ordrugreactionwitheosinophiliaandsystemicsymptoms)is
aseverelifethreatening,idiosyncraticmedicationreaction.
Themostcommonmedicationscausingdrughypersensitivitysyndromearesulfonamides,
allopurinol,anticonvulsantagents,andminocycline.
Therapyfordrughypersensitivitysyndromeconsistsofstoppingthecausativemedication
immediatelyduetothehighriskofendorgandamage,systemicglucocorticoidsaretypically
needed.

Miliaria
RelatedQuestion
Question51
Miliariaiscolloquiallycalledheatrashorpricklyheatandischaracterizedbycloggingofthe
eccrinesweatglands.ThecloggingmaybepartiallyduetoovergrowthofStaphylococcus
epidermidis.Thelocationalongthesweatglandthatiscloggedwilldeterminewhattypeofmiliaria
isseen.Whentheglandiscloggedsuperficially,thereareminutepustulesthatarerupturedeasilyand
canbewipedoff(miliariacrystallina)(Figure15).Miliariarubracausesdeeperredpapulesand
somepustuleswhentheclogisdeeper,andmoreinflammationispresent.Miliariaisoftenseeninthe
settingoffeverandocclusion.Atypicalclinicalsituationisapatientwhoisimmobilized,eitherfrom
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painorfollowingsurgery,andsweatglandsareoccludedasaresult.Therapyisguidedtoward
coolingtheaffectedarea,allowingaircirculation.Iftheeruptionissevere,topicalantibioticssuchas
clindamycinsolutionorlowpotencytopicalglucocorticoidsmaybeused.
Figure15.OpeninNewWindow

Miliariacrystallinawithclear,fragilevesiclesbutnoinflammation.

AcantholyticDermatosis(GroverDisease)
Acantholyticdermatosis(Groverdisease)isabenignpruriticeruptionofpapulesorpapulovesicles
onthecentralchest,flanks,andback(Figure16).Itisoftenseeninmiddleagedtoelderlypatients
andmaybeinducedbysweatingorextremedrynessoftheskin.Theeruptionoftenflaresseasonally.
Acantholyticdermatosisistypicallyselflimited,buttherapywithtopicalglucocorticoidsor
moisturizersmaybeeffective.
Figure16.OpeninNewWindow

Apatientwithacantholyticdermatosis(Groverdisease)showingrecurrentoutbreaksofitchyred
bumpswithperipheralscaleontheback.

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ThiscontentwaslastupdatedinMarch2016.Moredetails

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Chapter03
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Questions
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