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Diffuse, Bright-Red Rash with Desquamation and Scaling in an Adult JAIVIDHYA DASARATHY, MD; MAHDI AWWAD, MD; and CHRISTINE ALEXANDER, MD, Metro Health Medical Center, Case Western University School of Medicine, Cleveland, Ohio

The editors of AFP wel- A 59-year-old man presented with fever, come submissions for chills, and a pruritic rash that had general- Photo Quiz. Guidelines for preparing and sub- ized peeling and underlying redness. The mitting a Photo Quiz rash began one month prior as small pap- manuscript can be found ules on his arms and then spread across his in the Authors’ Guide at entire body, including his palms and soles. http://www.aafp.org/ afp/photoquizinfo. To be He also had pain in his hands. The rash did considered for publication, not improve after treatment with a topical submissions must meet medium-potency steroid, but subsequently these guidelines. E-mail responded to a course of oral prednisone. submissions to afpphoto@ aafp.org. His medical history was significant for hyper- tension and hyperlipidemia. He was taking This series is coordinated by John E. Delzell, Jr., MD, hydrochlorothiazide and rosuvastatin (Cre- stor). He did not have any sick contacts MSPH, Assistant Medical Figure 1. Editor. and was not using any new soap, lotion, or A collection of Photo Quiz detergent. published in AFP is avail- On physical examination, he was ill able at http://www.aafp. appearing and febrile. His heart rate was 120 org/afp/photoquiz. beats per minute, and his blood pressure was Previously published Photo 90/50 mm Hg. The skin rash (Figure 1) con- Quizzes are now featured sisted of diffuse pustules on an erythema- in a mobile app. Get more information at http:// tous background and involved more than www.aafp.org/afp/apps. 85% of his body surface area, including his head, trunk, and upper and lower extremi- ties. There was a thick scale, including on Figure 2. the palms and soles (Figure 2). Bacterial and viral culture results were negative.

Question Based on the patient’s history and physical examination findings, which one of the fol- lowing is the most likely diagnosis? ❑ A. Acute generalized exanthematous pustulosis. ❑ B. Allergic contact dermatitis. ❑ C. Erythrodermic psoriasis. ❑ D. Pityriasis rubra pilaris. See the following page for discussion.

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Discussion is characterized by the sudden appearance The answer is C: erythrodermic psoria- of dozens of sterile, nonfollicular, small sis. Characteristic features include a dif- pustules on erythematous and edematous fuse, bright-red rash and desquamation with skin.4 It most commonly occurs with the use superficial scaling and often exudation. This of antibiotics (penicillins and macrolides), is unlike plaque psoriasis, a common variant calcium channel blockers, and antimalari- of psoriasis, which has thick, adherent white als. Fever and neutrophilia are present, and scales. The average age of onset is 50 years.1 sometimes there is mild nonerosive muco- The erythrodermic form is considered the sal involvement. One-third of patients have most active psoriatic process with increased peripheral eosinophilia.4 Within a few days proliferation. This results in a loss of kerati- of stopping the causative drug, pustules nocyte maturation and abnormal keratino- spontaneously disappear. The desquamation cytes that are loosely bound and more easily and reaction fully resolve within 15 days.4 shed. In this patient, a skin biopsy showed Allergic contact dermatitis manifests as dermal lymphohistiocytic inflammation with erythematous vesicles and bullae with scaling occasional eosinophils. and relatively well-demarcated borders on Patients with erythrodermic psoriasis can exposed skin, typically along the hands, face, have excessive heat loss from generalized and neck, although any area can be affected. vasodilation of cutaneous vessels, leading to Pruritus is the most common symptom.5 shivering and hypothermia. Vasodilation can Pityriasis rubra pilaris is an inflammatory lead to loss of protein and extremity edema.2 condition of uncertain etiology. The rash is Patients with this condition also have signs of typically erythematous with salmon-colored systemic illness, including generalized pruri- plaques. It is clinically distinguished from tus, fever, chills, dehydration, and lymphade- plaque psoriasis by the presence of red-orange, nopathy.1 Erythrodermic psoriasis usually palmoplantar, keratotic follicular papules and arises from pustular psoriasis but can be islands of well-demarcated sparing on the triggered by sunburn, human immunodefi- trunk.6 Autoimmune diseases, infections, or ciency virus infection, systemic infections, malignancies are possible triggers. malignancies (mainly lymphomas), and even Address correspondence to Jaividhya Dasarathy, MD, at chronic plaque psoriasis.3 It can also arise [email protected]. Reprints are not available after the withdrawal of systemic steroids.1,3 from the authors. Treatment occurs in the intensive care unit Author disclosure: No relevant financial affiliations. and includes fluid and electrolyte manage- ment, and treatment for sepsis.2 REFERENCES

Acute generalized exanthematous pustu- 1. Hulmani M, Nandakishore B, Bhat MR, et al. Clinico- losis is a rare, drug-induced eruption that etiological study of 30 erythroderma cases from ter- tiary center in South India. Indian Dermatol Online J. 2014;5(1):25-29. 2. Varman KM, Namias N, Schulman CI, Pizano LR. Acute Summary Table generalized pustular psoriasis, von Zumbusch type, treated in the burn unit. A review of clinical features and new therapeutics. Burns. 2014;40(4):e35-e39. Condition Characteristics 3. Borges-Costa J, Silva R, Gonçalves L, Filipe P, Soares de Almeida L, Marques Gomes M. Clinical and labora- Acute generalized Sterile, nonfollicular, small pustules on erythematous tory features in acute generalized pustular psoriasis: a exanthematous and edematous skin; associated with a medication retrospective study of 34 patients. Am J Clin Dermatol. pustulosis exposure 2011;12(4):271-276. Allergic contact Erythematous, pruritic vesicles and bullae with scaling 4. Vassallo C, Derlino F, Brazzelli V, D’Ospina RD, Borroni G. Acute generalized exanthematous pustulosis: report dermatitis and relatively well-demarcated borders on exposed of five cases and systematic review of clinical and skin, typically along the hands, face, and neck histopathological findings. G Ital Dermatol Venereol. Erythrodermic Diffuse, bright-red rash, and desquamation with 2014;149(3):281-290. psoriasis superficial scaling and often exudation 5. Usatine RP, Riojas M. Diagnosis and manage- Pityriasis rubra Erythematous with salmon-colored plaques; red- ment of contact dermatitis. Am Fam Physician. pilaris orange, palmoplantar, keratotic follicular papules 2010;82(3):249-255. 6. Klein A, Landthaler M, Karrer S. Pityriasis rubra pilaris: a and islands of well-demarcated sparing on the trunk review of diagnosis and treatment. Am J Clin Dermatol. 2010 ;11(3):157-170. ■

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