Common Rashes
Condition (link to pictures) |
Description/Symptoms |
Management |
|---|---|---|
| Morbilliform Drug Rash | Erythematous macules ➔ confluent papules Trunk ➔ extremities, symmetric Most common precipitants = antibiotics (beta-lactam antibiotics, sulfa drugs), allopurinol, AEDs, NSAIDs Sx: Pruritus, low grade fever |
Discontinue offending agent Topical Corticosteroids, wet wraps Antihistamines If eosinophilia, kidney/liver dysfunction, mucous membrane lesions or painful/dusky lesions, consider alternative diagnoses (DRESS, AGEP, SJS/TEN) |
| Erythema Multiforme | Abrupt onset of papular “target” lesions in symmetrical acrofacial sites, +/-mucosal involvement Usually precipitated by HSV Sx: Lesions can be painful, pruritic or swollen Systemic symptoms likely attributed to inciting infection (HSV, CMV, EBV, flu, COVID, etc) |
Oral antihistamines and/or topical steroids for itch Treat precipitating infections (HSV tx does not alter course of single episode, can help prevent future inf) Stop offending medications If recurrent, derm referral for prolonged antiviral course |
| Zoster | Reactivation of VZV leading to blistering, painful rash in dermatomal distribution Rash can last 3-4 weeks Sx: Painful pustular lesions with systemic symptoms including fever, headache and lymphadenopathy |
Best treatment is prevention (shingles vaccine in adults >50) Valacyclovir 1000 mg TID (if symptoms started w/in 72 hours and patient has new lesions) for 7 days OR acyclovir 800 mg 5x daily for 7 days Can be complicated by post-herpetic neuralgia, manage w/ early antiviral treatment, topical capsaicin, TCAs, gabapentin/pregabalin |
| Seborrheic Dermatitis | Inflammatory response to Malassezia yeasts Characterized by erythematous w/ yellowish and greasy scale of scalp, face, upper trunk, intertriginous areas Can be associated with HIV, Parkinson's disease and use of neuroleptic medications; consider rescreening everyone for HIV Chronic, relapsing (mildest form = dandruff) Sx: Usually non-pruritic |
Mild symptoms + isolated to scalp (i.e. dandruff) ➔ antifungal shampoo (Rx: ketoconazole 2%, OTC: selenium sulfide 2.5%) Moderate/severe symptoms w/ scale, inflammation and pruritus of the scalp➔ antifungal shampoo + 2 week high potency topical corticosteroid followed by 2x weekly use of high potency topical steroids |
Presentation depends on location Pedis: itchy erosions/scales between toes, hyperkeratosis/scale covering soles/sides of feet, vesiculobullous blisters of inner aspect of foot Capitis: partial hair loss, +/- erythema, +/- pustular lesions Curis: erythematous bilateral but asymmetrical rash with raised border and central clearing Onychomycosis Perform KOH preparation if possible to confirm diagnosis Sx: Can be itchy and erythematous or asymptomatic |
Treat all sources of tinea to prevent re-infection. Nystatin IS NOT effective treatment Pedis/Corporis/Cruris: if localized infection ok for topical antifungals (clotrimazole 1% BID until clinical resolution 1-4 weeks) Capitis: Oral griseofulvin (500-1000 mg daily for 4-6 weeks) or oral terbinafine (250 mg once daily for 4 to 6 weeks) Onychomycosis: Oral terbinafine (250 mg once daily for 6 weeks (fingernail) or 12 weeks (toenail)), topical therapy (efinaconazole, amorolfine, ciclopirox) |
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| Paronychia | Inflammation of the skin around a finger or toenail Can be associated with felon (painful abscess at the base of the toe/nail) or herpetic whitlow (viral cutaneous infection caused by HSV) Usually due to staph/strep or pseudomonas Sx: Pain at the site of the infection, can develop systemic infection leading to fever/chills/myalgias |
If no abscess formation, can manage with soaking affected digit in warm water and antiseptics (chlorhexidine soaks TID) with mupirocin applied after soaking If abscess present ➔ I&D + culture Antibiotics indicated if symptoms not improving after I&D or systemic symptoms (dicloxacillin 250-500 mg QID, cephalexin 500 mg QID) for 5 day duration If risk factors for MRSA ➔ Bactrim 1-2 DS tablets BID If oral flora present ➔ augmentin 875/125 mg BID |
| HSV | Present as clusters of 2-3 mm umbilicated clear or hemorrhagic vesicles persisting for 5-10 days usually preceded by localized tingling/burning Type 1 most commonly associated with oral lesions, Type 2 w/ genital lesions Diagnose with viral culture of swab from vesicle or serologic testing (may be positive and not causing symptoms) Sx: Lesions are painful, can be associated with mild malaise and fever |
No cure, following initial infection immunity develops but does not prevent against further attacks Tx w/ topical therapy for mild infections For initial infection: Valacyclovir 500 mg BID 3-5 d, acyclovir 200 mg 5x/d for 5 days For recurrent infections: oral valacyclovir 500 mg BID for 3 days or 1 g daily for 5 days OR Acyclovir 800 mg BID for 5 days For suppressive therapy: oral valacyclovir 500 mg or 1 g daily |
Candida: |
Balanitis: inflammatory versus infectious condition of the glans penis. Most commonly infectious cause (candida versus dermatophytosis) Sx: penile soreness, dysuria, itchiness, bleeding and erythema of the glans Candidal balanitis associated with white, curd-like exudate Intertrigo: erythematous/macerated plaques with peripheral scaling, often associated with superficial satellite papules or pustules Affects skin below breasts or under abdomen, armpits, groin and web spaces between fingers/toes |
Balanitis: attention to genital hygiene with retraction of foreskin and cleansing for prevention/therapy Clotrimazole cream BID for 7-14 days Intertrigo: Prevention with moisture-free skin, can use talcum powder to assist in intertriginous areas Topical antifungal agents (clotrimazole 1% cream BID for 4 weeks, 1% ointment BID for 2 weeks) Oral fluconazole or itraconazole for severe, generalized and/or refractory cases |
Pityriasis versicolor: Superficial fungal skin infection caused by Malassezia Hypo/hyperpigmented or erythematous macules/patches or thin plaques most common on upper trunk, upper extremities Sx: usually asymptomatic Pityriasis rosacea: Self-limiting rash (6-10 weeks) characterized by large circular/oval “herald patch” found on chest/abdomen or back followed by small scaly oval red patches on back and chest (sometimes described in Christmas tree pattern) Sx: vary from mild to severe itching. ⅔ of patients have flu-like symptoms prior to rash onset |
BPityriasis versicolor: Topical antifungal treatment with ketoconazole 2% shampoo (Daily for 3 days), selenium sulfide 2.25% shampoo or terbinafine 1% cream Pityriasis rosacea: Self-limiting disease therefore treatment is symptom management Apply daily moisturizing creams, avoid drying soaps Can trial medium potency topical steroids and oral antihistamines |
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(eczema) |
Lesions are pruritic, erythematous, +/- weeping/exudative, +/- blistering. Can become lichenified and scaly with fissuring over time. Most commonly occurs on neck, hands and flexural surfaces in adults Associated with atopic triad (asthma, eczema, and allergies) |
Avoid triggers (fabrics, chemicals, humidity, and dryness, foods) Daily skin hydration w/ emollients ointments > creams (take into consideration patient tolerability) Topical corticosteroids: Mild disease - hydrocortisone 2.5% BID until 3-5 d after skin clearance. Moderate disease - triamcinolone 0.1% or 0.025% Clobetasol cream for up to two weeks followed by mild steroids Skin and face folds treatment: Desonide 0.05% OR topical calcineurin inhibitors (tacrolimus 0.1% BID, discontinue when symptoms cleared) |
| Psoriasis | Clearly defined red and scaly plaques, symmetrically distributed Most common locations are scalp, elbows, knees Sx: Pruritus is common but mostly mild, treating can lead to hyper/hypopigmented plaques that fade over time |
Limited disease ➔topical corticosteroids and emollients - Scalp/external ear canal: potent corticosteroids - clobetasol propionate 0.05% BID until lesions clear Face/intertriginous: low-potency OTC hydrocortisone 1% or prescription-strength 2.5% BID until lesions clear Thick plaques on extensor surfaces: clobetasol propionate 0.05% BID until lesions clear Moderate to Severe ➔ Phototherapy + topical steroids/emollients, before systemic agents (e.g. MTX) |
| Acne | Open and closed comedones, noninflammatory versus inflamed papules/pustules Severe cases involve nodules, pseudocysts with scarring |
sunscreen SPF >=30 daily with broad spectrum coverage Mild acne: daily topical retinoid (tretinoin) + benzoyl peroxide (if papulopustular lesions present) Moderate/severe: Isotretinoin (cumulative dose of 120-150 mg/kg) If isotretinoin is contraindicated, consider oral doxy (100 mg daily for 3-4 m) OR OCP OR spironolactone (25 to 50 mg/day in 1 to 2 divided doses, titrate based on response/tolerability) |
| Allergic Contact Dermatitis | Type of eczema caused by allergic reaction to allergen (type IV hypersensitivity), usually 48-72 hours after exposure Symptoms include erythematous, indurated pruritic plaques, +/- edema, +/- blistering, +/- scale Consider triggers such as nickel, fragrances/perfumes, work exposures, poison ivy |
Determine allergen, if not identified easily, can have comprehensive patch testing Acute/localized rash on hands/feet or nonflexural areas ➔ high potency topical corticosteroids BID until resolution (up to 4 weeks) then taper over 2 weeks Acute/localized rash on face/flexural areas ➔ medium/low potency topical steroids BID for 1-2 weeks then taper over 2 weeks OR topical tacrolimus 0.1% until resolution then taper |
| Stasis Dermatitis | Caused by venous hypertension resulting from dysfunction of venous valves, obstruction to venous flow Sx: include edema, inflammatory skin changes, pruritus, tenderness, ulceration, varicosity and hyperpigmentation (hemosiderin deposition) |
Compression therapy with bandaging systems or stockings, elevation of legs, regular exercise other than standing Emollient (petroleum jelly) application for dryness/pruritus Acute disease w/ erythema, pruritus, vesiculation, and oozing ➔ consider high/mid-potency topical corticosteroids BID for 1-2 weeks Referral to vascular if persistent symptoms |
| Rosacea | Chronic inflammatory condition affecting central face, usually appears between 30-60 yo Persistent facial redness, telangiectasia, thickening of skin and possible development of inflammatory papules/pustules. Pathophysiology multifactorial, includes genetic susceptibility, immune dysregulation, neurocutaneous triggers (sunlight, temperature, exercise, spicy foods, alcohol, stress, tobacco) |
Learn/avoid triggers (alcohol, tobacco), use gentle skin care products, and sun protection Consider pharmacological intervention with topical brimonidine, laser or intense pulsed light therapy If complicated by papular/pustular disease, consider topical metronidazole 0.75% gel for mild disease, and oral tetracycline/doxycycline for moderate to severe disease |