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Teen with a Diffuse Erythematous, Pruritic Eruption

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Teen with a Diffuse Erythematous, Pruritic Eruption Christopher R. Worley, DO; Larissa S. Buccolo, Teen with a diff use MD; David A. Boyd, MD Family Medicine Department (Drs. Worley erythematous, pruritic eruption and Buccolo), Department of Dermatology (Dr. Boyd), Naval Hospital, Was there a connection between the papules and plaques Jacksonville, Fla on the patient’s face, trunk, and legs and the sore throat christopher.r.worley she’d had 2 weeks earlier? @med.navy.mil DEPARTMENT EDITOR Richard P. Usatine, MD University of Texas Health Science Center at An 18-year-old caucasian female sought On physical exam, the patient had multi- San Antonio care at our dermatology clinic for a progres- ple erythematous papules and plaques with a The authors reported no sive, erythematous eruption on her face, neck, fi ne scale over her face, neck, trunk, and low- potential confl ict of interest trunk, and extremities (FIGURES 1A AND 1B). er legs (FIGURE 2). Th ere were areas of confl u- relevant to this article. Any opinions expressed in this She noted that the eruption had developed ence on her face and neck. Her palms, soles, article are those of the authors suddenly and that it was itchy. nails, and intertriginous areas were spared. and do not refl ect upon the offi cial policy of the Bureau Th e patient had no signifi cant past medi- Th e patient’s mucous membranes were of Medicine and Surgery, Department of Navy, and/or cal history and denied being sexually active. moist and there was no erythema or tonsil- the Department of Defense. Th e only medication she was taking was mes- lar exudate in her pharynx. A complete blood tranol/norethisterone. count, basic metabolic panel, and urinalysis Th e patient denied any new exposures were all within normal limits; a rapid plasma to medications, detergents, or foods. Upon reagin (RPR) was nonreactive. questioning, she did note that about 1 to 2 weeks prior to the skin eruption, she had a ● WHAT IS YOUR DIAGNOSIS? mild sore throat and cough. However, her up- per respiratory symptoms had resolved by the ● HOW WOULD YOU TREAT THIS time she arrived at the clinic. PATIENT? FIGURE 1 Papules and plaques with fi ne scale A B PHOTOS COURTESY OF: DAVID A. BOYD, MD OF: DAVID PHOTOS COURTESY This 18-year-old patient had multiple, erythematous papules and plaques with a fi ne scale over her face, neck, trunk, and lower legs. We performed a punch biopsy on her left posterior shoulder. JFPONLINE.COM VOL 60, NO 1 | JANUARY 2011 | THE JOURNAL OF FAMILY PRACTICE 37 Diagnosis: Guttate psoriasis susceptible hosts is at work. It’s thought We diagnosed guttate psoriasis in this patient that T-cell stimulation from a streptococcal based on her history and physical exam, a superantigen is responsible for the acute cu- throat culture that was positive for group A taneous eruption. Various human leukocyte beta-hemolytic streptococci, and blood work antigens, including HLA-Bw17, HLA-B13, that showed an elevated antistreptolysin O and HLA-Cw6, have been identifi ed and ap- titer. Further confi rmation was obtained via pear to confer a genetic predisposition to the punch biopsy. development of guttate psoriasis.3 Guttate psoriasis is a fairly uncommon form of psoriasis, aff ecting approximately 2% of patients with psoriasis.1 It is characterized Differential includes by the abrupt onset of pruritic, salmon-pink secondary syphilis 1- to 10-mm drop-like lesions with fi ne scale Th e diff erential diagnosis of guttate psoriasis that may spread to the face, but spare the includes lichen planus, pityriasis rosea, and palms and soles. It’s uncommon for this sub- secondary syphilis. type of psoriasis to involve the nails. ❚ Lichen planus is characterized by pru- Guttate psoriasis aff ects individuals ritic, planar, polyangular purple papules younger than 30 years of age; there appears to with a reticular pattern of criss-crossed whit- be no gender predilection.2 Th e rash usually ish lines called “Wickham’s striae,” which are appears 2 to 3 weeks after an upper respirato- areas of epidermal thickening.1 ry group A beta-hemolytic streptococci infec- ❚ Pityriasis rosea typically presents in a tion. Although less common, there have also “Christmas-tree” distribution in which the been reports of guttate psoriasis associated long axis of these oval plaques are oriented with perianal streptococcal disease.2 along skin lines. Also, the lesions have a dis- ❚ While the pathophysiology is un- tinctive collarette scale, appearing as a fi ne, clear, recent evidence suggests that a genetic wrinkled tissue-like scale surrounding the autoimmune-mediated reaction to a recent plaque borders. streptococcal infection in immunologically ❚ Secondary syphilis has numerous signs FIGURE 2 and symptoms, including rash. In this case, Papules and plaques on lower legs we ruled it out because our patient had no history of sexual contacts and a negative RPR. Testing confi rms suspicions, identifi es organism Th e diagnosis of guttate psoriasis is estab- lished from clinical presentation. While there is no laboratory test specifi c for diagnosis, as many as 80% of patients will have clinical or laboratory evidence suggestive of a strepto- coccal infection—specifi cally tonsillopharyn- gitis.4 Utilize bacteriologic throat or perianal cultures to isolate the organism. Levels of an- tibodies to streptolysin O, hyaluronidase, and deoxyribonuclease B may be elevated.4 Urinalysis can be used to rule out asso- ciated streptococcal complications, such as poststreptococcal glomerulonephritis. Fur- ther serologic evaluation may also include RPR testing to exclude secondary syphilis. Biopsy is rarely needed to establish the diagnosis, but may be used for confi rmation of complicated presentations or to rule out 38 THE JOURNAL OF FAMILY PRACTICE | JANUARY 2011 | VOL 60, NO 1 ERYTHEMATOUS, PRURITIC ERUPTION other concerning diagnoses. Histologic fi nd- Due to the clear association between ings demonstrate epidermal hyperplasia with guttate psoriasis and streptococcal disease, small foci of parakeratosis and dermal layer appropriate testing should be done and capillary dilation and edema. Infi ltrating lym- antistreptococcal antibiotics initiated. While phocytes, macrophages, and polymorpho- erythromycin and penicillin VK have been nuclear leukocytes may be found at all der- used in the past as fi rst-line agents (with mal levels.5 the addition of rifampin usually reserved for more resistant cases or chronic carrier states), a small case-controlled study failed Symptoms dictate to fi nd statistically signifi cant improvement treatment strategies with a course of penicillin or erythromycin.8 Guttate psoriasis is usually self-limiting and For patients with recurrent or chronic guttate resolves within a few weeks to months. One psoriasis, tonsillectomy for poststreptococcal small study, however, suggests that 33% of pa- tonsillitis may be off ered, although a system- tients will eventually develop chronic plaque atic review failed to show a benefi t.9 disease.6 A systematic review of treatments for guttate psoriasis failed to show fi rm evidence A chronic problem for our patient in favor of any specifi c treatment.7 Treatment We initially treated our patient with a 10-day strategies are thus based on symptomatology course of penicillin VK and UV-B photothera- and may include emollients or, less common- py. Eight weeks later, she had 90% resolution We ruled out ly, low-potency topical corticosteroids. of her lesions. However, our patient subse- secondary Phototherapy, via direct sunlight expo- quently experienced a fl are, suggesting that syphilis because sure or by a short course of UV-B photother- she might go on to develop chronic plaque our patient had apy, has been used to help clear lesions, but psoriasis. JFP no history of care must be taken to avoid burns, which can sexual contacts exacerbate the eruption. More resistant cases CORRESPONDENCE and a negative may benefi t from oral psoralen plus exposure Christopher R. Worley, DO, LT, MC, USN, Naval Hospital Jacksonville, 2080 Child Street, Jacksonville, RPR. to ultraviolet A radiation. 7 FL 32214; [email protected] References 1. Habif TP. Clinical Dermatology. 4th ed. St. Louis, Mo: Mosby; tol. 1984;82:465-470. 2004:209-239. 6. Martin BA, Chalmers RJ, Telfer NR. How great is the risk of fur- 2. Honig PJ. Guttate psoriasis associated with perianal strepto- ther psoriasis following a single episode of acute guttate pso- coccal disease. J Pediatr. 1988;113:1037-1039. riasis? Arch Dermatol. 1996;132:717–718. 3. Holm SJ, Sakuraba K, Mallbris L, et al. Distinct HLA-C/KIR 7. Chalmers RJ, O’Sullivan T, Owen CM, et al. A systematic review of genotype profi le associates with guttate psoriasis. J Invest Der- treatments for guttate psoriasis. Br J Dermatol. 2001;145:891-894. matol. 2005;125:721-730. 8. Dogan B, Karabudak O, Harmanyeri Y. Antistreptococcal 4. Telfer NR, Chalmers RJ, Whale K, et al. Th e role of streptococ- treatment of guttate psoriasis: a controlled study. Int J Derma- cal infection in the initiation of guttate psoriasis. Arch Derma- tol. 2008;47:950-952. tol. 1992;128:39-42. 9. Owen CM, Chalmers RJ, O’Sullivan T, et al. A systematic review 5. Brody I. Dermal and epidermal involvement in the evolution of antistreptococcal interventions for guttate and chronic of acute eruptive guttate psoriasis vulgaris. J Invest Derma- plaque psoriasis. Br J Dermatol. 2001;145:886-890. The recruitment hub created exclusively for physicians and advanced practice clinicians. MedOpportunities.com A VITAL WEBSITE BROUGHT TO YOU BY THE JOURNAL YOU TRUST. JFPONLINE.COM VOL 60, NO 1 | JANUARY 2011 | THE JOURNAL OF FAMILY PRACTICE 39.
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