The Generalized Rash: Diagnostic and Treatment Considerations

The Generalized Rash:
Diagnostic and Treatment Considerations
Lorraine L. Rosamilia, MD
Staff Dermatologist – Scenery Park
Geisinger Health System
State College, PA
Objectives
Upon completion of this presentation,
participants should be able to:
• Identify common/uncommon, acute/chronic,
indolent/emergency etiologies of generalized skin
eruptions
• Determine utility of diagnostic testing for
generalized skin eruptions
• Initiate management for generalized skin
eruptions and further identify cases in which
additional consultation is prudent
Generalized skin eruptions
• Common
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Dermatitis (atopic, contact, essential, seborrheic)
Exanthems (viral, drug)
Psoriasis
Id reaction
Arthropod assault
Urticaria
Tinea corporis/Majocchi granuloma
Lichenoid reactions
Pityriasis rosea
Erythema multiforme
Other infectious (VZV, Lyme, Staph, molluscum)
Other (Grovers, folliculitis, miliaria, tinea versicolor)
Generalized skin eruptions
• Uncommon
– Autoimmune blistering diseases (BP, PV, DH)
– Connective tissue disease
– Cutaneous T-cell lymphoma
– Septicemia (gono/meningococcemia)
– Other rare infections (syphilis, HIV, RMSF, SSSS,
TSS, disseminated viral)
– Rare drug eruptions (SJS, TEN, DRESS, AGEP,
EGFRi, other chemo)
– Other (GA, paraneoplastic, Sweets, idiopathic)
Generalized skin eruptions
• Most are acute on chronic
– Dermatitis, psoriasis, lichenoid, chronic
urticaria, tinea versicolor, Grovers, CTCL, GA,
blistering diseases, tinea corporis, folliculitis
• Acute
– Acute urticaria, exanthems, drug, EM, id,
arthropod, pityriasis rosea, infection, Sweets
Emergencies
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Urticaria with airway dysfunction
SJS/TEN, DRESS
Disseminated viral, septicemia
TSS, SSSS
RMSF, Lyme
Any generalized eruption with unstable
volume loss or severe mucosal involvement
Clinical clues
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Distribution, distribution, distribution
Morphology, morphology, morphology
Symptoms, symptoms, symptoms, symptoms
Medication, dietary, and topical history
Travel history, sick contacts
Occupation
Immune status, comorbidities
Gestalt
Diagnostics
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Infectious parameters (CBC, titers, cultures)
Skin scraping (scabies prep, KOH, Tzanck)
Skin biopsy (+/- DIF, tissue culture)
R/O DRESS (CBC/diff, CMP, TSH)
Hypovolemia parameters (BP, BMP, UA)
Management
• ‘Do-nothing’ rashes, symptom control
– Pityriasis rosea, mild exanthems, mild urticaria,
miliaria, Grovers, molluscum, GA,
• Topical control
– Localized psoriasis or dermatitis (steroids,
emollients)
– Localized tinea (antifungals)
– Localized lichenoid (steroids)
– Mild folliculitis (antimicrobial, barrier topicals)
– Scabies (permethrin)
Management
• Systemic therapy
– Diffuse dermatitis, drug esp DRESS, blistering
diseases, lichenoid (oral steroids, inpatient?)
– Diffuse tinea/Majocchi (oral antifungals)
– Diffuse urticaria, symptomatic control of pruritus
(systemic antihistamines)
– Infection (systemic antimicrobials)
– Neoplasia/paraneoplasia, CTD (complex)
Cheat sheets
• Clinical features of dermatitis, psoriasis, and
tinea can distinguish them from each other
– Dermatitis – background xerosis, classic atopic
distribution for age, eyelid involvement
– Psoriasis – flexors, scalp, gluteal cleft distribution,
silvery scale
– Tinea – annular scaly plaques with central
clearing, sometimes follicular prominence
Cheat sheets
• Scabies prep and KOH clearly diagnose scabies
infestation and tinea variants respectively
• Skin biopsy is helpful for blistering diseases, CTD,
lichenoid eruptions, and some infections
• Skin biopsy is often not helpful for urticaria,
exanthema, some drug reactions, and some
phases of cutaneous lymphoma
• Psoriasis, dermatitis, erythema multiforme,
Grovers, folliculitis, GA, PR, and id are typically
clinical diagnoses
Cheat sheets
• Systemic steroids ameliorate psoriasis only
while taking them, with resultant rebound
• Systemic steroids will lead to muted
inflammation/diagnostic clues on skin biopsy
• Topical and systemic steroids will cause tinea
to persist and worsen
• Extensive scabies is better managed with
combination of oral and topical antiparasitic
agents, herd decontamination
Conclusions
• Common disorders like psoriasis, dermatitis,
and tinea are often clinical and/or point-ofcare diagnoses
• Skin biopsy can be unhelpful for certain
conditions, particularly exanthema
• It is important to distinguish between indolent
and emergency presentations of generalized
eruptions, as mortality rates hinge upon time
to diagnosis, treatment, and supportive care
Thank you!
Lorraine L. Rosamilia, MD
llrosamilia@geisinger.edu