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Skin Rashes That Involve Palms and Soles: an Internist’S View

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Skin Rashes That Involve Palms and Soles: an Internist’S View Review Article Annals of Nursing and Primary Care Published: 29 Dec, 2018 Skin Rashes that Involve Palms and Soles: An Internist’s View Shahriar Tavakoli Tabasi1,2* 1Michael E DeBakey Veterans Affairs Medical Center (MEDVAMC), USA 2Baylor College of Medicine (BCM), USA Abstract Skin rash involving palms and soles can be a manifestation of serious underlying medical condition. Some of these conditions are acute conditions, requiring immediate recognition and treatment. Others, while not life-threatening, need recognition to avoid transmission to others. Finally, some are associated with serious inflammatory, hematologic, and oncologic conditions that need to be suspected and diagnosed in a timely manner, but are not immediately life-threatening. In this paper we have provided a review of medical conditions that are associated with rash involving palms and soles. Introduction Primary care providers often are in the position to evaluate and manage patients who present with rash. In fact, rash is one of the common conditions encountered in clinical practice [1-3]. Differential diagnosis of diseases presenting with rash can be broad, and at times challenging [4]. However, description of the lesions, as well as distribution of rash allow for narrowing the differential diagnosis. One such case is when rash involves palms and soles, which significantly narrows the diagnostic possibilities. In this review, we aim to discuss differential diagnosis of rashes involving palms and soles, with the aim of providing a practical guide for primary care clinician to diagnose the etiology in a timely manner. We will divide the medical conditions presenting with palms and soles rash based on acuity and presence or absence of fever. We will attempt to provide a simple diagnostic approach to clinicians to evaluate and treat patients in a timely manner, and OPEN ACCESS recognize urgent conditions easily. *Correspondence: Conditions Associated with Palms and Soles Rash Shahriar Tavakoli Tabasi, Michael E Acute febrile illnesses caused by a bacterial agent, with generalized rash involving DeBakey VA Medical Center, 2002 palms and soles Holcombe Blvd, 111ID, Houston, Texas In this category several life-threatening conditions are discussed, for which a delay in diagnosis , 77030, USA, Tel: 713-794-7384; could result in increased mortality and timely diagnosis is of outmost importance. Neisseria E-mail: Shahriar.Tavakoli-Tabasi@ meningitidis infection, Toxic shock syndrome, and Rocky Mountain spotted fever have the highest va.gov mortality if not treated in a timely manner. Other potentially life-threatening conditions include Received Date: 14 Nov 2018 rat-bite fever, caused by Streptobacillus moniliformis, human monocytic ehrlichiosis, and subacute Accepted Date: 26 Dec 2018 infective endocarditis. Murine typhus has lower mortality among these conditions. Secondary Published Date: 29 Dec 2018 syphilis, while mostly afebrile and subacute, can at times present more acutely and with low- Citation: grade fever. While mortality from secondary syphilis is low, timely recognition has public health Tabasi ST. Skin Rashes that Involve implications and delay in diagnosis is not warranted. Palms and Soles: An Internist’s View. Meningococcal infection, although more common in early life, can occur at any age. Presentation Ann Nurs Primary Care. 2018; 1(2): is usually acute with fever, with or without meningeal signs, and can rapidly progress to sepsis and 1012. shock. Rash is present in up to 2/3 of the cases and can involve palms and soles. Rash is typically Copyright © 2018 Shahriar Tavakoli petechial/purpuric, although a maculopapular blanching eruption has also been reported. The Tabasi. This is an open access appearance of rash usually heralds poor prognosis. Both meningococcemia and meningococcal article distributed under the Creative meningitis can rapidly progress to shock and death. Currently mortality is about 9% to 16% in Commons Attribution License, which meningitis and meningococcemia [5]. High degree of suspicion, early institution of antibiotic permits unrestricted use, distribution, therapy, and early referral to intensive care is warranted. and reproduction in any medium, Rocky Mountain spotted fever is caused by Rickettsia rickettsii. It is endemic in south-Atlantic, provided the original work is properly the Pacific, and west south-central United States. The states with the highest incidences of Rocky cited. Mountain spotted fever are North Carolina and Oklahoma. The incubation period of RMSF ranges Remedy Publications LLC. 1 2018 | Volume 1 | Issue 2 | Article 1012 Shahriar Tavakoli Tabasi Annals of Nursing and Primary Care from 2 to 14 days, with a median of 7 days. Early in the disease fever, characteristics of this rash. Other symptoms that can be present myalgia, and headaches are prominent, as well as gastrointestinal include fever, malaise, pharyngitis, anorexia, weight loss, arthralgias, symptoms. Rash appears on the 3rd to 5th day and will ultimately and myalgias. Involvement of other organs, including liver with be present in about 90% of patients overall. It typically will appear elevated serum alkaline phosphatase, uveitis, and CNS involvement first around the wrists and ankles and will involve palms and soles should be considered [12]. in 1/3 to 2/3 of the cases [6]. Mortality is low when treatment with Murine typhus is caused by Rickettsia typhi and transmitted to tetracyclines is started within 5 days of the onset of symptoms. human by rat and cat fleas. It is especially prevalent in tropical and However, when treatment is delayed, there is significant increase in subtropical seaboard regions. In the United States the majority of mortality up to 23% [7]. cases are seen in South Texas and Southern California. Following an Rat-bite fever, caused by Streptobacillus moniliformis, is another incubation period of 1 to 2 weeks, patients present with fever, headache, cause of febrile rash involving palms and soles. After the bite of a myalgia, and gastrointestinal symptoms. Rash is common but may be rat, which may be healed and forgotten by the time patient, develops missed in dark-skinned individuals. It is macular, maculopapular, or symptoms, there is an incubation period which is usually less than petechial and mostly distributed on the trunk. Involvement of palms 10 days. Sudden onset of fever, chills, headache heralds the onset of and soles by the rash of murine typhus is seen in about 3% of cases. the disease. Patients often have GI symptoms, arthralgias, and septic The disease is usually mild; however, involvement of central nervous arthritis. Significant leukocytosis and false positive nontreponemal system, lungs and kidneys may occur and require hospitalization. syphilis serologies are frequent laboratory abnormalities. Rash usually Among hospitalized adults with murine typhus morality up to 4% appears 2 to 4 days after onset of fever and commonly involves palms has been reported [13]. and soles and extremities. Rash maybe maculopapular, morbilliform, petechial, vesicular or pustular. Approximately 50% of patients Viral disease presenting with palm and sole rash develop asymmetrical polyarthritis or true septic arthritis. In many Chikungunya virus is an important cause of febrile illness in cases fever resolves on its own. However, in some cases fever may Africa and Asia. It is transmitted to humans by the bite of Aedes relapse in an irregular pattern for weeks or months. Untreated mosquitoes. Disease is characterized by fever, and prominent joint mortality can be up to 13%. Complications include endocarditis, pain that may persist for months. In late 2013, chikungunya virus was meningitis, as well as involvement of lung, liver, and other organs found for the first time in the Americas on islands in the Caribbean. with infection and/or abscess formation [8]. Beginning in 2014, chikungunya virus disease cases were reported among U.S. travelers returning from affected areas in the Americas. Two types of skin lesions, involving palms and soles, can be seen Several cases of local transmission have also been reported in Florida in infective endocarditis. Janeway lesions are non-tender maculae and Texas since then [14]. Skin rash is a common manifestation of the on the extremities, especially on toes and the soles of the feet, but disease, and can present early in the febrile period, or after a few days also on fingers and palms of the hands. They are purpuric lesions of delay. An erythematous maculopapular rash affecting the trunk caused by septic emboli, usually in acute infective endocarditis. Osler and extremities were the most common. However, a few patients will nodes, on the other hand, are tender and believed to be immune- have involvement of palms, and soles. The rash is mostly non-pruritic complex related in subacute infective endocarditis. They are small [15]. subcutaneous nodules, ranging from red to purple, and are primarily found on pulp spaces of the terminal phalanges of the fingers and Herpes simplex virus-associated erythema multiforme is another toes, soles of the feet, and the thenar and hypothenar eminences of condition that can present with rash involving palms and soles. It is a the hands [9]. complication of HSV reactivation. Patients present with fixed target or “bull’s eye” lesions distributed diffusely in the body, with predilection Tick-borne human monocytic ehrlichiosis is caused by Ehrlichia for palms and soles. This condition usually occurs within 10 days of chaffeensis. It is most commonly reported
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