Dermatology Rash Lecture
Dermatology Rash Lecture
Dermatology Rash Lecture
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DIAGNOSIS BY LESION<br />
AND REGION<br />
WARREN W. PIETTE, MD<br />
COOK COUNTY HOSPITAL
FOCAL HYPOPIGMENTATION<br />
• POST-INFLAMMATORY<br />
HYPOPIGMENTATION<br />
• TINEA VERSICOLOR<br />
• VITILIGO
POST-INFLAMMATORY HYPO-<br />
& HYPERPIGMENTATION (DLE)
TINEA VERSICOLOR<br />
• TINEA<br />
VERSICOLOR<br />
– TRUNCAL<br />
– MAY DARKEN IN<br />
WINTER<br />
– KOH PREP +<br />
• VITILIGO<br />
– ACRAL, ORIFICIAL<br />
– ALWAYS WHITE<br />
– KOH PREP –<br />
VS VITILIGO
RECURRENT FACIAL<br />
PAPULES AND PUSTULES<br />
• ACNE<br />
• ROSACEA<br />
• PERIORAL DERMATITIS<br />
• FURUNCULOSIS<br />
• PSEUDOFOLLICULITIS BARBAE
• Age helpful, but late<br />
onset or recurrence<br />
common<br />
• Comedone is<br />
diagnostic key<br />
• Cheeks, forehead,<br />
jawline<br />
ACNE
• Typically involves<br />
central third of face<br />
• Begins in 20’s or later<br />
• Flushing prominent<br />
and sometimes only<br />
component<br />
ROSACEA
PERIORAL DERMATITIS<br />
• Small red papules,<br />
pustules, plaques<br />
• Perioral<br />
• Usually women
• Fewer lesions than<br />
others<br />
• Lesions larger, more<br />
tender<br />
• Staph aureus<br />
FURUNCULOSIS
PSEUDOFOLLICULITIS BARBAE
PSEUDOFOLLICULITIS<br />
BARBAE<br />
• Usually in men with darker, coarser beard<br />
• Most commonly along and below jaw line<br />
• Traction on skin, repeated passes with razor<br />
result in cut hair tip below skin level when<br />
traction released<br />
• Slight twist in hair with growth results in<br />
sharp hair tip penetrating follicular wall
RECURRENT FACIAL RASH<br />
WITHOUT PUSTULES<br />
• SEBORRHEIC DERMATITIS<br />
• ECZEMA<br />
• PSORIASIS<br />
• CONTACT DERMATITIS<br />
• TINEA FACEI
SEBORRHEIC DERMATITIS<br />
• Scalp, eyebrows, ears,<br />
nasolabial fold, chin<br />
• Need to treat scalp to<br />
minimize facial flares
SEBORRHEIC DERMATITIS<br />
MIMICKING TINEA
• Cheeks, lids<br />
• Rough, red patches or<br />
dyspigmentation<br />
• Usually worse in<br />
winter due to dryness<br />
• Emollients essential<br />
ECZEMA
• Can appear anywhere<br />
on face, but often has<br />
a seb derm distribution<br />
(sebopsoriasis)<br />
• Compared to eczema,<br />
usually thicker plaque,<br />
more prominent scale<br />
PSORIASIS
• Can mimic seb derm,<br />
and vice versa<br />
• Pustules favor<br />
diagnosis<br />
• KOH prep essential<br />
for diagnosis<br />
TINEA FACEI
CONTACT DERMATITIS<br />
• Face and especially<br />
lids very susceptible<br />
• Linear or geometric is<br />
clue, but may be<br />
diffuse<br />
• Usually pruritic; if<br />
irritant may burn
PERSISTENT RED PAPULES<br />
OR PLAQUES ON TRUNK<br />
• ECZEMA<br />
• PSORIASIS<br />
• PITYRIASIS ROSEA<br />
• CONTACT DERMATITIS<br />
• DRUG OR VIRAL ERUPTION<br />
• LESS COMMON<br />
– LICHEN PLANUS, 2 LUES, TINEA
• Usually pruritic<br />
• Worse in winter,<br />
frequent bathing<br />
• Favors flexural areas<br />
• Hx of atopy, wool<br />
intolerance<br />
• Emollients essential<br />
ECZEMA
• Sometimes pruritic<br />
• Worse in winter<br />
• Favors extensor areas,<br />
esp elbows and knees<br />
• Thick white scale<br />
characteristic, but not<br />
always present<br />
PSORIASIS
CONTACT DERMATITIS<br />
• Often asymmetric or<br />
geometric<br />
• Pruritic<br />
• Minimal scale<br />
• Often due to reaction<br />
to topical medication
• Wickham’s striae<br />
• Flat, polygonal<br />
violaceous papules<br />
• Pruritic<br />
LICHEN PLANUS<br />
• May be associated<br />
with hepatitis C, rare
SECONDARY SYPHILIS<br />
• Can mimic pityriasis<br />
rosea, but hand<br />
involvement rare in<br />
PR.
MORBILLIFORM ERUPTION
MORBILLIFORM ERUPTION<br />
• Measles-like<br />
• Usually virus or drug<br />
• Not necessarily<br />
allergic (ampicillin &<br />
EBV)
RECURRENT BODY FOLD<br />
• INTERTRIGO<br />
• CANDIDIASIS<br />
• TINEA<br />
• PSORIASIS<br />
ERYTHEMA
• Usually burns more<br />
than itches<br />
• Pustules key feature<br />
• KOH pustule roof<br />
• Complicates intertrigo<br />
CANDIDIASIS
• TINEA CRURIS<br />
TINEA CRURIS vs<br />
• Usually itches more<br />
than burns, less red<br />
• Usually spares<br />
scrotum<br />
• Pustules rare<br />
• Complicates intertrigo<br />
occasionally<br />
CANDIDIASIS<br />
CANDIDIASIS<br />
• Usually burns more<br />
than itches, raw red<br />
• Usually involves<br />
scrotum<br />
• Pustules key feature<br />
• Complicates intertrigo<br />
frequently
• Genital area frequent<br />
site, may be localized<br />
• Mimics tinea more<br />
than candidiasis<br />
• Plaques thicker, more<br />
scale than tinea,<br />
intertrigo<br />
PSORIASIS
INTERTRIGO<br />
• Most common cause of intertriginous<br />
erythema and discomfort<br />
• Caused by warmth and moisture<br />
• Chronic redness and discomfort, waxes and<br />
wanes<br />
• KOH negative<br />
• Keep cool & dry, Zn oxide ointment, 1%<br />
hydrocortisone
CRUSTING AND VESICLES<br />
• IMPETIGO<br />
• CONTACT ALLERGIC DERMATITIS<br />
– RHUS (POISON IVY) OR NEOSPORIN<br />
• HERPES SIMPLEX<br />
• HERPES ZOSTER
IMPETIGO
BULLOUS IMPETIGO<br />
• Caused by Staph<br />
aureus exotoxin<br />
• Subepidermal split<br />
• Staph Scalded Skin<br />
Syndrome: same toxin<br />
in blood<br />
– Infants<br />
– Immunocompromised<br />
– Renal failure
• Itches<br />
CONTACT DERMATITIS<br />
• Usually linear or<br />
geometric
HERPES SIMPLEX<br />
• Clustered vesicles on<br />
red base<br />
• May disseminate, as<br />
shown, in patients<br />
with certain skin<br />
diseases, including<br />
eczema
• Pain important clue<br />
HERPES ZOSTER<br />
• Some lesions outside<br />
dermatome expected<br />
• Tzanck prep useful for<br />
simplex and zoster
HAND/FOOT SCALING,<br />
PUSTULES, VESICLES<br />
• ECZEMA<br />
• PSORIASIS<br />
• CONTACT DERMATITIS<br />
• TINEA
• Pruritus, often intense<br />
• Sides of fingers clue<br />
• Atopic hx, wool<br />
intolerance<br />
HAND ECZEMA<br />
• Hand/foot<br />
hyperhidrosis common
CONTACT DERMATITIS<br />
• Rare on hands & feet<br />
because of epidermal<br />
thickness<br />
• Dorsum of hands &<br />
feet more common
CHRONIC CONTACT<br />
• May not show vesicles<br />
• Sore or itching<br />
• May be irritant, as<br />
with chronic workers<br />
DERMATITIS
• Can be difficult to<br />
separate<br />
FOOT VESICLES<br />
• KOH essential to rule out<br />
tinea (roof)<br />
• Itch favors eczema,<br />
soreness—psoriasis<br />
• Pustules psoriasis, but<br />
vesicles can appear yellow<br />
due to thick skin
TINEA CORPORIS, PEDIS
THE RED LEG<br />
• STASIS DERMATITIS<br />
• STASIS DERMATITIS<br />
• STASIS DERMATITIS<br />
• CELLULITIS<br />
• ERYSIPELAS
STASIS DERMATITIS<br />
• Can mimic infection with erythema and<br />
tenderness<br />
• Can be unilateral or bilateral, but infection<br />
is not usually bilateral<br />
• Patient usually afebrile<br />
• Rapid response in erythema, pain, and<br />
swelling with overnight leg elevation
CELLULITIS/ERYSIPELAS
ERYSIPELAS
NAIL DYSTROPHY
NAIL DYSTROPHY
NAIL DYSTROPHY<br />
• Can be difficult or<br />
impossible to tell<br />
clinically if<br />
onychomycosis<br />
• KOH, culture, or nail<br />
clipping should be<br />
used to confirm<br />
presence of fungus<br />
before treatment
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