Download A rash starting on the palms and soles

BMJ 2015;351:h5452 doi: 10.1136/bmj.h5452 (Published 19 October 2015)
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Endgames
ENDGAMES
CASE REVIEW
A rash starting on the palms and soles
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3
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Vinod E Nambudiri physician , Navya S Nambudiri physician , Rosalynn M Nazarian pathologist ,
2
Sandy S Tsao dermatologist
Department of Internal Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; 2Department of Dermatology, Massachusetts General
Hospital, Boston; 3Cooperative Medical College, Cochin, Kerala, India; 4Department of Pathology, Massachusetts General Hospital
1
A 23 year old man presented with a rash eight weeks after
emigrating to the United States. One week after immigration
he had a sore throat, dysphagia, and mild subjective fevers,
which resolved in 10 days. Two weeks later, he developed a
papular eruption starting on his hands and feet. He had no
arthralgia, myalgia, or systemic symptoms. He took no drugs,
had no allergies, no family history of skin eruptions, and no
close contacts with a similar rash.
He was evaluated at an urgent care clinic one week after the
eruption started. The rash was mainly on his palms and soles
but was spreading to the arms and legs. Blood was sent for
antibodies to Rocky Mountain spotted fever (RMSF) and
coxsackievirus. Given the life threatening nature of RMSF, he
was treated empirically with seven days of doxycycline without
improvement; both tests were negative.
Over the next two weeks the rash spread diffusely, becoming
mildly pruritic, and he presented to our institution for evaluation.
His vital signs were within normal limits and he had no erythema
of the oral mucosa or lymphadenopathy. Hundreds of pink
papules with silvery scale measuring 2-3 mm in diameter were
noted on his face, palms and dorsal hands, arms, trunk, legs,
and feet (fig 1). Linear lesions in areas of excoriation were seen
in the right antecubital fossa.
Anti-streptolysin O and anti-DNase-B titers were both raised
(695 IU/mL (reference value <530) and 706 IU/mL (<300),
respectively). Skin biopsy of a lesion showed hyperplasia of
the epidermis, neutrophilic microabscess formation, dilated
superficial dermal blood vessels, and overlying parakeratotic
hyperkeratotic scale.
Questions
1. What are the differential diagnoses for rashes on the palms
and soles?
2. What is the diagnosis and what phenomenon do the linear
lesions in areas of excoriation demonstrate?
3. How does the antecedent pharyngitis relate to the rash?
4. How can this condition be treated?
5. In patients who present to primary care, what are the
referral criteria to dermatology?
Answers
1. What are the differential diagnoses for
rashes on the palms and soles?
Short answer
Infections such as coxsackievirus, syphilis, Rocky Mountain
spotted fever, scabies, and tinea; inflammatory dermatoses such
as psoriasis, eczema, erythema multiforme, and mycosis
fungoides, and drug eruptions.
Discussion
Fig 1 Pink papules with scale on the palms (A) and chest
(B). Note the lesions overlying a linear excoriation on the
right distal upper arm just proximal to the antecubital fossa
First determine whether the process is consistent with a primary
infection or other cause. Viruses (coxsackievirus), bacteria
(rickettsia, treponema), fungi (dermatophytes), and parasites
(scabies) can all cause eruptions of the palms and soles.
Non-infectious causes include common inflammatory
dermatoses (eczema, psoriasis), reactive processes (erythema
multiforme, keratodermas), cutaneous adverse drug reactions,
Correspondence to: V E Nambudiri [email protected]
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BMJ 2015;351:h5452 doi: 10.1136/bmj.h5452 (Published 19 October 2015)
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ENDGAMES
and primary neoplastic processes (mycosis fungoides). History
and the physical examination provide important clues to the
diagnosis.
2. What is the diagnosis and what
phenomenon do the linear lesions in areas of
excoriation demonstrate?
Short answer
The history, clinical presentation, laboratory findings, and
histopathology are consistent with a diagnosis of guttate
psoriasis. The development of skin lesions in trauma sites is
known as the Koebner phenomenon.
Discussion
Guttate psoriasis is a benign inflammatory dermatosis
characterized by numerous eruptive papules and plaques on the
trunk and extremities. It is most common in children and young
adults. The lesions derive their name from the Latin guttae
(drops), which reflects their diffuse sprinkled distribution. The
initially thin pink plaques develop an increasingly silvery scale,
which reflects the epidermal hyperplasia and hyperkeratosis
seen on biopsy (fig 2). This helps distinguish guttate psoriasis
from other diagnoses including acute viral exanthemata, eczema,
morbilliform drug eruptions, and pityriasis rosea.
Psoriasis is one of several inflammatory skin diseases that show
exacerbation or development of new lesions in areas of skin
trauma. Termed the Koebner phenomenon after the German
dermatologist Heinrich Koebner who first described it,
koebnerization is also be seen in lichen planus, vitiligo, pityriasis
rubra pilaris, and lichen sclerosus among other dermatoses.
Fig 2 Skin biopsy from the upper arm showed psoriasiform
hyperplasia of the epidermis, parakeratotic scale, and
dilated superficial dermal blood vessels, consistent with
psoriasis (A). Dense neutrophilic collections in the upper
epidermis—termed Munro’s microabscesses and
spongiform pustules of Kogoj—were also noted (B).
Hematoxylin and eosin stain; original magnification ×10
3. How does the antecedent pharyngitis relate
to the rash?
Short answer
Acute guttate psoriasis has been associated with preceding
streptococcal pharyngitis.
Discussion
A preceding streptococcal infection is seen in more than half
of patients who develop acute guttate psoriasis.1 Our patient’s
raised anti-streptolysin-O and anti-DNase-B titers confirmed
recent streptococcal infection. It has been proposed that the
unmasking of antigens by the streptococcal infection triggers
an inflammatory response that ultimately results in guttate
psoriasis. Flares of psoriasis have also been associated with
episodes of stress,2 and our patient’s recent immigration may
have contributed to the eruption.
4. How can this condition be treated?
Short answer
Treatments include topical corticosteroids, topical vitamin D
analogs, topical coal tar, and ultraviolet B phototherapy.
Prognosis is good—the disease course is limited in most patients,
with a minority developing chronic disease or plaque psoriasis.
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BMJ 2015;351:h5452 doi: 10.1136/bmj.h5452 (Published 19 October 2015)
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ENDGAMES
Discussion
The first line treatment for guttate psoriasis is usually mid to
high potency topical corticosteroids.3 The addition of a topical
vitamin D analog such as calcipotriol may also be helpful as a
steroid sparing agent, particularly when a large body surface
area is affected. Coal tar is another topical treatment option. For
topical resistant disease, phototherapy using narrow band or
broad band ultraviolet B radiation is often effective. Severe or
refractory cases may require oral retinoids or anti-inflammatory
agents such as methotrexate. Treatment with oral antibiotics
targeted at streptococci has not helped clear guttate psoriasis,
even with evidence of recent streptococcal infection.4 Clinicians
should suspect guttate psoriasis when evaluating an eruptive
scaly rash after recent pharyngitis.
5. In patients who present to primary care,
what are the referral criteria to dermatology?
Short answer
Consider referral to dermatology if the diagnosis of an acute
eruption is uncertain, there has been no response to initial
treatment, or specific treatments administered by dermatologists
are being considered.
Discussion
Many acute eruptions and skin lesions are first encountered in
primary care. Atopic dermatitis, plaque psoriasis, and seborrheic
dermatitis are common skin conditions that are often diagnosed
and managed exclusively in primary care. Dermatologists offer
additional expertise in the diagnosis and management of both
routine and less common cutaneous conditions. Patients should
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be referred if there is diagnostic uncertainty or if an acute
eruption presents with an unusual morphology or with widely
rapid dissemination. If an eruption does not respond to initial
treatment, consider consultation with a dermatologist for
diagnostic or therapeutic guidance. If the diagnosis is clear but
a treatment administered by dermatologists is being considered
(such as ultraviolet phototherapy), timely referral to a
dermatologist can help patients access effective treatment most
efficiently.
Patient outcome
The eruption cleared after a course of topical mid-potency
steroids (triamcinolone acetonide 0.1% ointment) and topical
calcipotriol. The disease has not relapsed after one year.
Competing interests: We have read and understood BMJ policy on
declaration of interests and declare the following interests: None.
Provenance and peer review: Not commissioned; externally peer
reviewed.
Patient consent obtained.
1
2
3
4
Naldi L, Peli L, Parazzini F, et al. Family history of psoriasis, stressful life events, and
recent infectious disease are risk factors for a first episode of acute guttate psoriasis:
results of a case-control study. J Am Acad Dermatol 2001;44:433-8.
Al’Abadie MS, Kent GG, Gawkrodger DJ. The relationship between stress and the onset
and exacerbation of psoriasis and other skin conditions. Br J Dermatol 1994;130:199-203.
Chalmers RJ, O’Sullivan T, Owen CM, et al. A systematic review of treatments for guttate
psoriasis. Br J Dermatol 2001;145:891-4.
Dogan B, Karabudak O, Harmanyeri Y. Antistreptococcal treatment of guttate psoriasis:
a controlled study. Int J Dermatol 2008;47:950-2.
Cite this as: BMJ 2015;351:h5452
© BMJ Publishing Group Ltd 2015
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