DIFFERENTIAL DIAGNOSES OF COMMON RASHES

Purpose: Help the participant become a more efficient physician. Goal: Enable the participant to feel more comfortable and secure in correctly diagnosing the etiology of the dermatologic lesion in patients presenting with a skin rash. Objectives: At the end of this seminar, the participant should be able to: 1. Describe rashes as lesions in scientific terminology 2. Define the path physiology of each type of rash described 3. Identify the most likely etiology of rashes from common historical and physical presentations 4. List the infectious causes of skin rashes 5. Recognize life threatening causes of rashes 6. Formulate treatment plans specific for etiologic agent causing the rash

I.

Dermatologic Terms A. Primary lesions

1. 2. 3. 4. 5. 6. 7. Macule Patch Papule Nodule Tumor Plaque Vesicle circumscribed, flat color change, not palpable large macule >1.5 cm elevated, solid lesion <0.5 cm larger papule >0.5 cm larger nodule >2cm superficial, circumscribed, elevated, solid area >0.5cm papule filled with fluid vesicle filled with leukocytes and fluid large vesicle >0.5 cm Firm, edematous plaque caused by water in the dermis

8. Pustule 9. Bulla 10. Wheal

B.

Secondary lesions
1. Scales 2. Crusts 3. Erosion 4. Ulcer 5. Fissure excess dead epidermal cells dried serum and cellular debris focal loss of epidermis focal loss of epidermis and dermis linear, defined, crack into epidermis and dermis

6. Atrophy 7. Scar 8. Lichenification

thinning of epidermis or dermis connective tissue connecting dermis thickened epidermis

II.

Dermatitis (Eczema)- inflammatory process of both epidermis and dermis

A. Contact dermatitis: response to external agent in specific area or pattern 1. Primary irritant a. usually repeated exposure b. area of exposure only c. remove agent, protect skin, decrease inflammation, no oral steroid 2. Allergic contact (Rhus) a. Sensitization reaction b. red, pruritic, sharply demarcated, shape of contact, area of contact c. antihistamines, drying agents, topical steroids, oral steroids 1. fluorinated much more potent and cause thinning of skin, telangectasias, and other problems 2. dont use fluorinated steroids on face, groin, or babies 3. nonfluorinated-hydocortisone, Elocon, Westcort B. Atopic Itch that rashes 1. Interaction with IgE 2. face with circumoral sparing, extensors, flexural areas, lechenification, dry skin, increased palmar markings, Dennies line (folds lower lids), and allergic shiners 3. control itch (ASA), moisturize, bathe cool water, Cetaphil, Burrows Aveeno, guard against bacterial overgrowth C. Neurodermatitis (lichen simplex chronicus) 1. scratching or rubbing leads to lichenfication-only in areas patient can reach 2. extremities, nape, anogenital areas, central lichenfication with surrounding less 3. steroid creams D. Stasis 1. chronic ankle edema occludes lymphatics which sclerose small vessels leading to hyperpigmented, thick and scaling areas 2. around ankles 3. prevent and treat the ankle edema, compression, antibiotics if needed E. Xerosis (dry skin)

1. lack of water in stratus corneum, worse in winter 2. any area of the body 3. hydrate and lubricate-eucerin, alpha-keri, oils 4. water, air dried is most drying of agents 5. creams have more water than ointments, lotions have more water than creams, and ointments stay on better but feel greasy F. Dyshidrosis 1. dysfunction of sweat glands giving recurrent crops of vesicles that develop into scales and dryness 2. palms and soles, between fingers, differentiate from id reaction 3. Topic steroids G. Nummular Eczema 1. etiology 2. coin shaped, pruritic, any area of body 3. topical steroids

III.

Papulosquamous Diseases (scaling papules that become plaques)

A. Psoriasis 1. red plaques with silvery scales 2. over elbows, knees, extensor surfaces, pitted nails, arthritis, Auspitz sign (pinpoint bleeding when scales are removed) 3. soft brush, topic steroids, tars, shampoos, UV light, PUVA, methotrexate B. Lichen Planus 1. inflammatory process after trauma 2. flat, polygonal, shiny papules with minimal scaling, can be linear-over wrists, forearms, inner thighs-may have oral lesions 3. no best treatment, steroid topically C. Pityriasis Rosea 1. etiology 2. begins as Herald patch to Christmas tree pattern trunk 3. no specific treatment, resolves on own in 6-12 weeks D. Seborrheic Dermatitis 1. bad dandruff vs. Pityrosporum ovale 2. greasy, red, scaling, irritation scalp, cheeks, central chest, back, eyebrows

3. topical steroids, shampoos, Selsun, Nizoral E. Ichthyosis 1. inheritable 2. fish scales, extensive, palms and soles spared 3. hydration and lubrication F. Secondary syphilis 1. treponerna pallidum 2. great imitator, symmetric, red and brown macules, palms and soles, darkfield, RPR, VDRL 3. antibiotic

IV.

Vesiculobullous Diseases
A. Pemphigus vulgaris 1. chronic, autoimmune (autoantibody then acantholysis), fatal if untreated (secondary infection) 2. oral blisters, then over face, trunk, extremities over weeks, symmetrical, easily broken blisters, Nikolsky sign (rub normal appearing skin and a blister develops), not on palms or soles, antibody titer 3. systemic steroids, gold B. Bullous pemphigoid 1. etiology 2. primary bulla or urticarial base with rings of bullae, symmetrical, flexural, intertriginous, can be on palms or soles 3. oral steroids C. Dermatitis herpetiformis 1. chronic, can be associated with Celiac Sprue, IgA mediated 2. small vesicles in groups, widespread, symmetrical scalp, butt, eyelids 3. Dapsone D. Epidermolysis Bullosa 1. inherited 2. blisters after minimal trauma 3. protect skin E. Herpes Simplex 1. DNA virus, lives in spinal ganglia, trauma, sun, stress 2. crop of blisters, into painful ulcer, lips, genitalia, Whitlow, Pap, or Tzanck

3. Acyclovir F. Chicken pox 1. DNA virus Herpes Zoster 2. central to peripheral, crops of vesicles, different stages same time 3. high dose acyclovir, anti-itch, burrows, zinc oxide G. Zoster 1. DNA virus Herpes Zoster 2. Pain then vesicles in neurodomal pattern, tip of nose 3. Acyclovir, Zostrix (capsaicin), pain meds, steroids, postherpetic neuralgia

V.

Erythemas
A. Reactive 1. Urticaria (wheals, hives) a. IgE mediated b. any allergen, food, stress, cholinergic, dermatographism, pressure, solar, cold c. Antihistamine, H2 blocker in chronic, epi if severe, <10% find etiology 2. Erythema Multiforme a. acute vascular inflammatory response to infection, drug, chemical, systemic b. target lesions, symmetrical, can be bullous, palms and soles, mucous membranes c. supportive, remove offender, steroids if severe 3. Erythema nodosum a. inflammatory disorder in sub Q fat lobules b. tender, red nodules, usually legs-infection, TB, sarcoid, drugs; SLE, BCP c. treat underlying process 4. Palpable purpura or petchaie a. injured, leaking blood vessel b. WATCH OUT FOR INFECTIOUS DISEASEmeningiococcemia, RMSF, disseminated candida, strep, HS purpura (Henoch-Schonlein) c. treat underlying process 5. Other infectious a. Erythrasma- Corynebacterium minutissimum, brown, scrotum and inner thighs, Woods light (coral red), topical erythromycin b. Erysipelas-strep, very red, warm, over cheeks, antibiotics c. Cellulitis- strep or staph, warm, red, tender, poorly demarcated borders, antibiotics

d. Intertiginous candida - yeast, moist areas, satellite lesions, antifungal creams B. Annular 1. Erythema chronicum migrans-lyme disease a. carried by tick b. spreading redness with central clearing, later arthritis c. antibiotics 2. Tinea Corporis-ringworm a. Trichophyton or Microsporum b. enlarges peripherally, clears centrally, KOH prep c. topical antifungals, towel down

VI.

Erythematous macules/papules
A. Drug reaction 1. Morbilliform a. Ampicillin in mom, PCN, sulfa, Dilantin, barbiturates b. Discrete, symmetricl, trunk outwar, spares palms and soles c. Remove drug, supportive 2. Photosensitivity- exaggerated sunburn B. Infectious 1. Candida- satellite lesions 2. Measles- rubeolla, Koplike spots, conjunctivitis, begins at scalp line, fine desquamation 3. Rubella- laboratory diagnosis, arbovirus, adenopathy, sicrete on extremities, looks like scarlet fever 4. Roseolla infanatum- fever but feels and looks good, rash develops when fever breaks 5. Erythema infectiosum- 5th disease, paravovirus, slapped cheek 6. Coxsackie virus and echo virus- nondescript, viral hand, foot and mouth disease C. Infestations 1. Chiggers- redbug or harvest mite, severe itch, edge of clothes, burrows solution, anti-itch 2. Fleas- reaction to bite, itch, burrows solutions, anti-itch 3. Scabies- mites, burrows, between fingers and toes, beltline, excoriations, pruritic, shaves skin, Eliminate (permethrine), Kwell (lindane) D. Kawasaki mucocutaneous lymph node syndrome 1. Etiology

2. Fever, conjunctivitis, stomatis, palms and soles, desquamation, nodes, myocarditis, arthritis, pericarditis, hepatic, nephritis, coronary artery vasculitis 3. ASA

VII. Other Infections

A. Fungal 1. Tinea capitis- Trichophyton or Microsporum, hair loss with scaling and black dot hairs broken, kerion, KOH prep, oral antifungal (griseofulvin or ketaconizole) for 4-6 weeks. 2. Tinea pedis same fungi, intertriginous, instep, scaling soles, moccasin distribution, keep dry, avoid shoes, topical antifungals. 3. Tinea versicolor pityrosporum furfur, brown of fawm colored, scales, hypopigmented in summer, KOH, Selsun, antifungals, Tinver. 4. Deep Fungi a. Sporotrichosis rose thorn, nodules up lymphatics, antifungals. b. Blastomycosis warty plaque studded with peripheral pustules, antifungals. B. Leprosy 1. Mycobacterium leprae 2. Immigrants, asymptomatic plaque granuloma, numb waxy 3. Dapsone C. Pustular 1. Impetigo strep or staph (bullous), superficial erosion with honey colored crust, dicloxacillin, erythromycin, cephalosporin mupirocin. 2. Furunculosis staph, boils, antibiotic X 3 months, Neosporin in nares, antibacterial soaps. 3. Folliculitis staph, hair follicles, mupirocin or oral antibiotics, pseudomonas hot tubs. D. Viral

1. Warts any site, destructive method to treat symptom. 2. Molluscum contagiosum- pox virus, unbilicated pearl with cheesy core, freeze or remove core.

VIII. Pigment Disorders

A. Vitiligo 1. Autoimmune 2. Any area of the body 3. Psoralens + UV light (PUVA) B. Chloasma (mask of pregnancy) 1. Hoemonal (BCP) 2. Cheeks and nose 3. Depigment with hydroquinone C. Seniles (solar) lentigines liver spots 1. Age, sun 2. Multiple, discrete, tan, face or hands 3. Retin A followed by hydroquinone D. Mongolian spots 1. Congenital 2. Usually buttocks, back, and legs 3. No treatment necessary E. Halo nevus benign, disappears on own

IX. Rheumatologic Diseases

A. Discord lupus 1. Autoimmune 2. Sharply demarcated, red, atrophic center plaque, malar areas 3. Hypo or Hyperpigmented B. Systemic lupus 1. Autoimmune 2. Malar redness and edema (butterfly rash), alopecia C. Morphea (localized scleroderma) localized, thick skin, plaques, ivory colored D. Sarcoid erythema nodosum, waxy papules on face, eyelids and nares

E. Dermatomyositis periorbital edema, eyelids blue-red (heliotrope), reticulated eruption trunk and extremities, flat papules over knuckles (Gottons papules), oral steroids

X. Systemic Diseases
A. Tuberous Sclerosis 1. Autosomal dominant 2. Seizures, MR, adenoma sebaceum (papules cneral face and nares) ash leaf macules at birth B. Von Recklinghausens 1. Autosomal dominant 2. Caf-au-lait spots >6, axillary freckles, neurofibromas C. Sturge-Weber vascular anomaly skin, eye, and meninges, port wine stain (nevus flammus) D. Peutz-Jeghers 1. Autosomal dominant 2. Polyposis and GI bleeds, freckles on and around lip

TOPICAL STERIODS Classification of topical steroids preparations by potency *

LOW POTENCY Alclometasone dipropionate Hydrocortisone base/acetate 0.5% Hydrocortisone 0.05% Cortisporin** (crm) base/acetate 2.5% Aclovate (crm, oint) Anuso10HC (crm) Mantadil* (crm) Hytone (crm, lotion, oint) Dexamethasone Hydrocortisone base/acetate 1% Nutracort (lotion) Phosphate 0.1% Corticaine Max Strength (crm) NeoDecadron** (crm) Cortisporin** (oint) Triamcinalone acetonide 0.025% Hytone (crm, lotion, oint) Flucinolone acetonide 0.01% Nutracort (crm, lotion) Aristocort (crm) Synalar (crm, soln) Aristocort A (crm) Vytone** (crm) Kenalog (crm, lotion, oint) Triamcinolone acetonide 0.2% Kenalog (aerosol) INTERMEDIATE POTENCY Desonide 0.05% DesOwen (crm, lotion, oint) Tridesilon (crm, oint) Desoximetasone 0.05% Topicort-LP (emollient crm) Fluocinolone acetonide 0.025% Synalar (crm, oint) Flurandrenolide 0.05% Cordran (crm) Flurandrenolide 0.25% Cordon (oint) Fluticasone propionate 0.005% Cutivate (oint) Hydrocortisone butyrate 0.1% Locoid (crm, oint, soln) Hydrocortisone valerate 0.2% Westcort (crm, oint) Mometasone furoate 0.1% Elocon (crm, oint) Prednicarbate 0.1% Dermatop (emollient crm) Triamcinolone acetonide 0.1% Aristocort (crm, oint) Aristocort A (crm, oint) Kenalog (crm, lotion, oint) Triamcinolone acetonide 0.2% Kenalog (aerosol)

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HIGH POTENCY Amcinonide 0.1% Cyclocort (crm, lotion, oint) Betamethasone dipropionte, augmented 0.05% Diprolene AF (crm) Desoximetasone 0.05% Topicort (gel) Desoximetasone 0.25% Topicort (emollient crm, oint) Diflorasone Diacetate 0.05% Florone (crm, oint) Florone E (emollient crm) Psorcon (crm) Flucinonide 0.05% Lidex (crm, gel, oint, soln) Lidex-E (emollient crm) SUPER HIGH POTENCY Fluocinolone acetonide 0.2% Synalar HP (crm) Halcinonide 0.1% Halog (crm, oint, solution) Halog-E (emollient crm) Triamcinolone acetonide 0.5% Aristocort (crm, oint) Aristocort A (crm) Kenalog (crm, oint)

Betamethasone dipropionate, Clobetasol propionate 0.05% Flurandrenolide 4 mcg/sq cm Augmented 0.05% Temovate (crm,gel, oint, emollient Cordran (tape) Diprolene (oint, gel) crm, scalp application) Halobetasol propionate 0.05% Cordran (tape) Diflorasone diacetate 0.05% Psorcon (oint) Halobetasol propionate 0.05% Ultravate (crm, oint)

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