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How to Approach a Patient with

Rash

1. Learning Objective

By the end of this lecture students will know

Basic dermatological terms

Important points in history and clinical examination

Important Infectious causes of rash

2. Important Dermatological Terms

3. History

The most important initial questions to ask patients with new rashes includethe following:

How long has the rash/lesion been present?

How did it look when it first appeared, and how is it now different?

Where did it first appear, and where is it now?

What treatments have been used, and what was the response, this time andpreviously?

4. History

What associated symptoms, such as itching or pain, are associated with thelesion?

Are any other family members affected or have a similar complaint?

Has the patient ever had this rash before? If so, what treatment wasused/response?

5.

What does the patient think caused the rash?

Is anything new or different, ie, medications, personal care products,occupational or recreational exposures?

6. Physical Examination

Type of lesion

Shape of individual lesions

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Arrangement of multiple lesions (eg, scattered, grouped, linear, etc.)

Distribution of lesions

Color

Consistency and feel7. Etiologies

The Infectious causes of Rash are

Bacterial

Viral

Fungal

Parasitic

8. Bacterial

Scarlet fever

a. Group A streptococcus (GAS) infection

b. Exotoxin (erythrogenic toxin)-mediated diffuse erythematous rash

c. coarse, sandpaper-like, erythematous, blanching rash, whichultimately desquamates

9. Rash of Scarlet fever

Accompanied by Strawberry tongue

10. Bacterial

Acute Rheumatic Fever

a. Another Complication of group A streptococcal pharyngeal infection

b. Erythema marginatum

i. Transient macular lesions with central clearing found onextensor surfaces

c. Subcutaneous nodules often located over bony prominences

11. Bacterial

Mycoplasma Pneumonia

a. It can present in following forms

b. Mild erythematous maculopapular

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c. Vesicular rash

d. Erythema multiforme, or the Stevens-Johnson syndrome

12. Target lesion of Erythema Multiforme

13. Bacteria

Rocky Mountain spotted fever

a. Tick-borne lethal disease

b. Rickettsia rickettsii

c. Vector Dermacentor andersoni (Tick)

d. Rash between the third and fifth days of illness

e. Begins on the ankles and wrists and spreads both centrally and

to the palms and soles

14.

15. Bacteria

Lyme disease

a. Tick-borne illness

b. Spirochete Borrelia burgdorferi

c. Erythema Migrans in Early localized and Early disseminated stages of

diease

16. Bacterial

Miscellaneous Causes

a. Bacillus Anthracis

b. Staph AureusScalded Skin Syndrome

c. Pseudomonas Ecthyma Gangrenosum

d. Acne Propionobacterium Acnes

e. Mycobacterium species Skin abscess

17. Viral

Measles

a. Paramyxovirus single stranded RNA virus

http://en.wikipedia.org/wiki/Paramyxovirushttp://en.wikipedia.org/wiki/Paramyxovirus

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b. Blanching erythematous "brick-red" maculopapular rash

c. Beginning in the head and neck area and spreading centrifugally to thetrunk and extremities

d. Fever, cough, coryza, and conjunctivitis

18.

19. Viral

Chickenpox (Varicella)

a. Varicella-zoster virus (VZV)

b. Classic vesicular lesions on an erythematous base

c. Present in different stages from papules through vesicles to crusting

20. Rash of Varicella in different stages

21. Viral

Rubella (Post-natal)

a. Morbilliform Rash that resembles measles

b. Low constitutional symptoms

c. Prominent postauricular, posterior cervical, and/or suboccipital

adenopathy

d. Punctate soft palate macules, can be a helpful clue

22. Morbilliform Rash of Rubella

23. Parvovirus

a. Parvovirus B-19 causes Erythema Infectiosum (Fifth Disease)

b. In children Slapped Cheek Pattern

c. Joint involvement in Adults

d. Rash is erythmatous on face and lace like pattern on limbs and trunks

24. Slapped Cheek appearance of Parvovirus rash

25. Viral

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Miscellaneous

a. Non polio enterovirus

b. HHV 8 Immunocompomised

c. HIV Occasional Rash in Initial Stages

26. Fungal

Pityriasis Versicolor

a. Malessezia Furfur, M globosa, M restricta

b. Discrete serpentine hyper or hypo pigmented macules

c. Chest, upper Back, Arms or and Abdomen

d. Parasitic

27.

28. Cutaneous Leishmaniasis

a. L.Tropica, L.Major, L. braziliensis etc

b. Papular, nodular, or ulcerative lesions

c. Parasitic

29. Cutaneous Larva Migrans

a. Causes Include Nematodes importantly Ancylostoma etc

b. Accidental penetration of Skin by larvae

c. Erythematous, serpiginous, pruritic, cutaneous eruption

30. Parasitic

Scabies

a. Sarcoptes Scabiei (Mite)

b. Highly contagious

c. Intense itching especially at Night

d. Superficial burrows of scabies usually occur in the area of the hands,feet, wrists, elbows, back, buttocks, and external genitals

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31. Burrows of scabies on hand

32. Summary

There are thousands of other causes of Infectious Skin conditions

Most of them can be diagnosed and differentiated on History and PhysicalExamination only.