Primary Care Rashes

https://www.umassmed.edu/globalassets/office-of-continuing-medical-education/pdfs/cme-primary-care-days/b2-common-rashes-in-the-primary-care-setting.pdf
Rash Identification:
• Viral sx - viral exanthem
• Asymmetric? Geometric? consider ACD
• Blisters? consider SJS/TEN
• Facial edema? OR Systemic involvement? consider DRESS = Drug reaction with eosinophilia and systemic symptoms rare,
potentially fatal, drug-induced hypersensitivity reaction that includes skin eruption, hematologic abnormalities (eosinophilia, atypical
lymphocytosis), lymphadenopathy, and internal organ involvement (liver, kidney, lung).

reference.medscape.com/slideshow/skin-rashes-6004772?fbclid=IwAR0Uaj974EnTTZFzP6sqhpzpP_WrdHZ0qh41eZafYnhwN83mUmsBj7-vBtk#11

KOH scraping.
herpes zoster: herpetiform vesicles, lymphadenopathy. Tinea corporis- scaly inflammatory or noninflammatory patches.
Vaccine lessens shingles 84-96% & PHN 88-91% (Trichophyton, microsporum, Epidermophyton dermatophytes).

VZV (chickenpox) Rash, low fever, pruritis, clear vesicle in red halo Molluscum contagiosum 2-6 mm firm, smooth, umbilicated
10-21 days post exposure. Then central umbilication & crusting. papules in clusters or widely distributed. Poxvirus. Face, neck,
Face/torso/scalp -> body. Resolves 5-10d. Adults- antiviral ASAP. arms, hands (shared towels, sports equip, toys) or genitals.
Avoid ASA (reye syndrome) & ibuprofen (severe 2ndary infections) Painless or pruritic & tender. Flesh colored, white, translucent,
. yellow. Self-limiting or Cryo, laser, curettage, or meds.

Intertrigo often with candida but

HFMD 2-10 mm erythematous macules become central gray oval vesicle. may be other fungi, bacteria, viruses. Common in DM,
Oral, volar & occ. buttocks rash.Coxsackie A16. PO 2-3 mm vesicle on red obese. May see maceration, crusting, fissures, pustules,
base. 3-7 d incubation (nasal/po/fecal contact). Rash, HA, F, pharyngitis, vesicles. Clinical dx or KOH scrape. Tx: cool/ dry; top
po ulcers, anorexia. Tx: antipyretics, anesthetics, supportive care. AF or abx, low-dose top steroids, barrier agent.

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5th/erythema infectiosum B19 human Parovirus 3 phases, mild prodrome. 1. 2-4 days slapped red cheeks. 2. 1-4 d. rash-
erythematous macular to morbilliform on extremity extensor surfaces. 3. Days to weeks rash fades & reticular lacy pattern. Droplet/
blood transmission. Incubation 4-14 (to 20) days. HA, F, runny nose then pruritic red cheeks then torso/ extremities.7-10 d self
limiting. May develop persistent arthropathy, gloves and socks syndrome (papular pruritic hands/feet), transient RBC production
cessation (aplastic crisis, chronic red cell aplasia, hydrops
fetalis, congenital anemia. Increased risk if HIV, SCD, thalassemia. Tx: supportive po analgesia, antihistamines, topical antipuritic
lotions.

Pityriasis rosea papulosquamous. Salmon

herald macule enlarges to fine scales & well demarcated 2-10 cm patch followed by torso/ extremity macular patches 0.5-1.5 cm along
cleavage lines. Lasts 6 weeks (4-8, rarely >8). Prob viral. Tx: symptom relief (topical steroids, po antihistamines).

Tinea capitis Scaly non-tender patchy alopecia starts as red scalp

papule posterior cervical lymph node. Superficial mycosis or dermatophytosis. Direct contact or shared brush, hat, or pets. Can
culture/scrape or PE dx. Tx: po antifungals griseofulvin, terbinafine, itraconazole x 4-8 weeks.

Cellulitis nonnecrotizing bacterial SSTI dermis & hypodermis. Strep pyogenes & staph
aureus. Rarely hematogeneous or metastic seeding. Chills, F, pain, edema, erythema, warmth. Poorly differentiated borders. If severe-
BC or culture lesions, CBC. May develop lymphangitis (streaking) & regional lymphadenpathy. Mild= OP dicloxacilin, cephalexin,
clindamycin, Augmentin. Facial cellulitis, immune compromised, failed OP tx, or severe=IV abx. INCREASING CA-MRSA

Impetigo (bullous or non-bullous) gm + (S Aureus, GABHS, MRSA) superficial epidermis. 2-5

mm macule/papule into a vesicle into 1 cm bulla & surrounding erythema. Ruptures honey-yellow-crusted papule or plaque.
Asymptomatic to pain/pruritis, lymphadenopathy. Transmission- anterior nares colonization or lesion direct contact. Dx: clinical. Tx:
topical abx: mupirocin (Bactroban), Retapamulin (Altabax).

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Erysipelas superficial into lymphatics, usually Group A Streptococci. Small

erythematous patch becomes well demarcated, indurated, shiny red plaque. Arthralgia, myalgia, HA, N. Severe = vesicles, bullae,
petichiae, frank necrosis. Clinical Dx. Tx 10-20 d po &/or parenteral abx. Usually PCN (alt. 1st gen cephalosporin or macrolide).

Folliculitis Pruritic pustules (or papules) on erythematous base on follicle of

face, scalp, neck, groin, genitals. S. Aureus, pseudomonas (hot tub/wet suits) maybe Gm – if on longterm abx. Self-limited; clinical dx
https://www.umassmed.edu/globalassets/office-of-continuing-medical-education/pdfs/cme-primary-care-days/b2-common-rashes-in-the-primary-care-setting.pdf

Drug exanthem Type IV hypersensitivity reaction;

Maculopapular 7-14 d after med is started, develops sooner with rechallenge. Morbilliform- symmetric distribution of erythematous
macules and papules, typically becoming confluent centrally. Lasts 1-2 weeks.

Urticaria Pruritic, edematous pink papules and plaques, many shapes, evanescent. May have
angioedema lasting 72 h. Acute < 6 weeks. Causes: URI (40%), drugs (9%), food (1%), idiopathic (50%), Autoimmune, infection. Tx:
ATC antihistamine trial Cetirizine 10mg, Loratadine 10mg, fexofenadine 180mg (no apple, orange, grape juice). Avoid aggravating
factors- ASA, NSAIDS, opiates. May add sedating antihistamine at hs Hydroxyzine 10-75 mg, Diphenhydramine 12.5-25mg; and H2
blocker (NOT monotherapy!): Ranitidine 150mg BID. crisis or angioedema po Prednisone. USUALLY don’t need steroids.

Stasis dermatitis BLE skin inflammation (itching, scaling, hyperpigmentation,

ulceration, excoriation, crusting, lichenification) d/t chronic venous insufficiency. May be worsened by dry skin, topical abx, lanolin,
preservatives, fragrances, irritant dermatitis, exudates macerate surrounding skin, bacterial colonization. S/S: Edema, hemosiderin
staining, acute lipodermatosclerosis- subfascial edema devolves to chronic lipodermatosclerosis, venous ulcers. Tx: Compression
stockings, lifestyle changes, calf exercises, top corticosteroids, emollients.

Allergic contact dermatitis (ACD) (Acute/chronic) Delayed contact hypersensitivity, Previous sensitization; Gold standard is patch
testing. Well demarcated erythematous, scaly plaques or blisters. Linearity suggests plant contact. Triggers: Poison ivy, sumac, oak;
nickel; Abx (Bacitracin, neomycin); Fragrance; topical steroids. Tx: Acute: mid to high potency topical steroids; OTC Burow’s
solution (Domeboro); Prednisone if significant facial involvement or widespread/ severe. Chronic top steroids, allergen elimination,
derm referral for patch testing.

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Psoriasis Start at any age, may be pruritic. Well demarcated plaques. Varied redness &
scale. Common- elbows, knees, lumbosacral back, umbilicus, scalp, nails, ears; Sometimes- hands, feet, flexural, genitals; Rarely- face
Aggravated by: infection, stress, alcohol, smoking, certain meds, season. Tx: Assess for joint disease & CV risk factors. Derm referral.
Topical steroids, Phototherapy- NBUVB.

Leukocytoclastic vasculitis (LCV) small-vessel vasculitis causes microscopic changes affecting the skin and
internal organs. Inflammation and necrosis of blood vessels usually r/t circulating immune complexes. S/s: Classic palpable purpura
(raised/ non-blanching), usually lower extremities, pruritis/ burning. May have Myalgia, arthralgia, F, abd pain, cough, V,
hematochezia/ melena, numbness, weakness. Etiology: Meds, malignancy, connective tissue diseases, Infection- Staph, Strep, HCV;
Cryoglobulinemia; Henoch Schonlein purpura; Idiopathic. Workup: In depth H&P, ROS, guaiac, BUN, Cr, UA (minimally!), treat
underlying cause; Topical steroids or po steroids if systemic disease or progressive, ulcerative disease. Usually self-limited. Dx: can
confirm with a skin biopsy.

Woods Lamp:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3440273/
Bacterial
Pseudomonas species: green in folliculitis and infected burn wounds.
Corynebacterium minutissimum: coral red in erythrasma.
Propionibacterium acnes: orange-red in comedones.

Fungal
Tinea versicolor: Malassezia furfur yellowish-white or copper-orange.
Pityrosporum folliculitis: Bluish-white in a follicular pattern.
Tinea capitis: Fluoresces in less than 5% of cases in US; blue-green (most Microsporum species), occasionally dull yellow
(Microsporum gypseum) and dull blue (Trichophyton schoenleinii).

Porphyrias Which samples fluoresce (always red-pink)?: red blood cells, urine, teeth, gallstones, or feces.

Diagnostic confirmation of Woods Lamp Results:

Pigment disorders: biopsy.
Bacterial infections: culture.
Fungal infections: potassium hydroxide microscopy, culture.2
Porphyrias: urine testing for porphobilinogen and 5-aminolevulinic acid, genetic testing