1. Rashes/Dermatology Jackie Weaver-Agostoni, DO, MPH UPMC Shadyside
Director, Osteopathic Family Medicine Residency
3/5/16

2. Pre-Test #1

3. Pre-Test #2

4. Pre-Test #3

5. Pre-Test #4

6. Pre-Test #5

7. Pre-Test #6

8. Pre-Test #7

9. 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

10. History PMHx Medications Family history
Social history- occupation, hobbies

11. Lesion Morphology Macule – nonpalpable
Ex: vitiligo, cafe au lait, petechiae

12. Lesion Morphology
Papule – palpable, </= 5 mm

13. Lesion Morphology
Plaques - Large >/= 5 mm superficial flat lesions

14. Lesion Morphology Pustules – small purulent-filled papules
Vesicles – small < 5 mm papules containing serous material
Bullae – large >/=6 mm
vesicles

15. Lesion Morphology Nodules – palpable, discrete lesions >/= 6 mm
Tumors = large nodules

16. Lesion Morphology
Cysts – enclosed lined cavities filled with liquid/semisolid material
Telangiectasia – dilated superficial blood vessel
Wheals - hives

17. Diagnostic Techniques
KOH Prep
Fungal
Tzanck smear
HSV
VZV
Wood’s Lamp
Tinea
Erythrasma
Vitiligo
Melasma
Porphyria

18. Melanoma Risk factors Prognosis 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

20. Irritant Contact Dermatitis
Xerosis, fissures, erythema, eczematous eruption
Change frequently
Increase air exposure
Protective ointment
Petroleum Jelly
A and D ointment
Desitin

22. Diaper Candidiasis Satellite lesions
Antifungal creams, frequent diaper changes
Usually lasts about 10 days

25. 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.

27. Miliaria Crystallina Miliaria- “Heat rash”
Eccrine sweat duct occlusion
Vesicles filled with clear fluid
Asymptomatic
Cool water compress and proper ventilation

29. 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

31. 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

33. 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)

35. 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

37. 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)

40. 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

42. Measles Rubeola Droplets Cough, coryza, conjunctivitis
Koplik’s spots- blue-white spots with red halo on buccal mucosa
Downward spread
Morbilliform (confluent elevated maculopapules)

44. 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

46. 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

48. 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

50. 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

52. Roseola Infantum Exanthem subitum, sixth disease HHV-6 6 mo.- 4y/o
High fever ( degrees)  rash
Pale-pink, almond shaped, macules
Symptomatic tx.

54. 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

55. Rocky Mountain Spotted Fever
Palms and Soles
Tick-borne disease
Rickettsia rickettsii
Southeastern and south central states
Spring and early summer
Rash typically between 3rd and 5th day
Early treatment

56. Meningococcemia
Petechial Rash- discrete 1-2 mm lesions can coalesce into larger purpuric/ecchymotic lesions
Trunk and lower body
Mucus membranes- hemorrhage

59. Scabies Direct contact
Nocturnal itching
Burrows, vesicles or pustules on palms/soles- highly 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

60. 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

61. Psoriasis Etiology- genetic, other (smoking, obesity, etc)
Arthritis, nail involvement
Tx: Topical, Phototherapy, Systemic

63. 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

64. Tinea

65. Erythema migrans

66. Secondary Syphilis

67. 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., Pp
ONLINE Sites
Ely JW, Stone MS. The Generalized Rash: Part I and Part II. Differential Diagnosis. AFP, March 2010.
Free dermatology photo atlas for your PDA