BMJ 2015;351:h5452 doi: 10.1136/bmj.h5452 (Published 19 October 2015) Page 1 of 3 Endgames ENDGAMES CASE REVIEW A rash starting on the palms and soles 1 2 3 4 Vinod E Nambudiri physician , Navya S Nambudiri physician , Rosalynn M Nazarian pathologist , 2 Sandy S Tsao dermatologist 1Department 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 A 23 year old man presented with a rash eight weeks after Anti-streptolysin O and anti-DNase-B titers were both raised emigrating to the United States. One week after immigration (695 IU/mL (reference value <530) and 706 IU/mL (<300), he had a sore throat, dysphagia, and mild subjective fevers, respectively). Skin biopsy of a lesion showed hyperplasia of which resolved in 10 days. Two weeks later, he developed a the epidermis, neutrophilic microabscess formation, dilated papular eruption starting on his hands and feet. He had no superficial dermal blood vessels, and overlying parakeratotic arthralgia, myalgia, or systemic symptoms. He took no drugs, hyperkeratotic scale. had no allergies, no family history of skin eruptions, and no Questions close contacts with a similar rash. He was evaluated at an urgent care clinic one week after the 1. What are the differential diagnoses for rashes on the palms eruption started. The rash was mainly on his palms and soles and soles? but was spreading to the arms and legs. Blood was sent for 2. What is the diagnosis and what phenomenon do the linear antibodies to Rocky Mountain spotted fever (RMSF) and lesions in areas of excoriation demonstrate? coxsackievirus. Given the life threatening nature of RMSF, he 3. How does the antecedent pharyngitis relate to the rash? was treated empirically with seven days of doxycycline without improvement; both tests were negative. 4. How can this condition be treated? Over the next two weeks the rash spread diffusely, becoming 5. In patients who present to primary care, what are the mildly pruritic, and he presented to our institution for evaluation. referral criteria to dermatology? His vital signs were within normal limits and he had no erythema of the oral mucosa or lymphadenopathy. Hundreds of pink Answers papules with silvery scale measuring 2-3 mm in diameter were noted on his face, palms and dorsal hands, arms, trunk, legs, 1. What are the differential diagnoses for and feet (fig 1). Linear lesions in areas of excoriation were seen rashes on the palms and soles? in the right antecubital fossa. 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 First determine whether the process is consistent with a primary infection or other cause. Viruses (coxsackievirus), bacteria Fig 1 Pink papules with scale on the palms (A) and chest (rickettsia, treponema), fungi (dermatophytes), and parasites (B). Note the lesions overlying a linear excoriation on the (scabies) can all cause eruptions of the palms and soles. right distal upper arm just proximal to the antecubital fossa 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] For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2015;351:h5452 doi: 10.1136/bmj.h5452 (Published 19 October 2015) Page 2 of 3 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. For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2015;351:h5452 doi: 10.1136/bmj.h5452 (Published 19 October 2015) Page 3 of 3 ENDGAMES Discussion be referred if there is diagnostic uncertainty or if an acute The first line treatment for guttate psoriasis is usually mid to eruption presents with an unusual morphology or with widely high potency topical corticosteroids.3 The addition of a topical rapid dissemination. If an eruption does not respond to initial vitamin D analog such as calcipotriol may also be helpful as a treatment, consider consultation with a dermatologist for steroid sparing agent, particularly when a large body surface diagnostic or therapeutic guidance. If the diagnosis is clear but area is affected. Coal tar is another topical treatment option. For a treatment administered by dermatologists is being considered topical resistant disease, phototherapy using narrow band or (such as ultraviolet phototherapy), timely referral to a broad band ultraviolet B radiation is often effective. Severe or dermatologist can help patients access effective treatment most refractory cases may require oral retinoids or anti-inflammatory efficiently. agents such as methotrexate. Treatment with oral antibiotics targeted at streptococci has not helped clear guttate psoriasis, Patient outcome even with evidence of recent streptococcal infection.4 Clinicians The eruption cleared after a course of topical mid-potency should suspect guttate psoriasis when evaluating an eruptive steroids (triamcinolone acetonide 0.1% ointment) and topical scaly rash after recent pharyngitis. calcipotriol. The disease has not relapsed after one year. 5. In patients who present to primary care, what are the referral criteria to dermatology? Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: None. Short answer Provenance and peer review: Not commissioned; externally peer Consider referral to dermatology if the diagnosis of an acute reviewed. eruption is uncertain, there has been no response to initial Patient consent obtained. treatment, or specific treatments administered by dermatologists are being considered. 1 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. Discussion 2 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. Many acute eruptions and skin lesions are first encountered in 3 Chalmers RJ, O’Sullivan T, Owen CM, et al. A systematic review of treatments for guttate psoriasis. Br J Dermatol 2001;145:891-4. primary care. Atopic dermatitis, plaque psoriasis, and seborrheic 4 Dogan B, Karabudak O, Harmanyeri Y. Antistreptococcal treatment of guttate psoriasis: dermatitis are common skin conditions that are often diagnosed a controlled study. Int J Dermatol 2008;47:950-2. and managed exclusively in primary care. Dermatologists offer additional expertise in the diagnosis and management of both Cite this as: BMJ 2015;351:h5452 routine and less common cutaneous conditions. Patients should © BMJ Publishing Group Ltd 2015 For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe.