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3.5 Pityriasis Versicolor (Tinea Versicolor) 33
– It is caused mainly by yeast. Malasazzia furfur and Malasazzia globosa are the
common species (Saizan and Elbuluk
2022).
– Manifests as well demarcated macules or patches that are either pink or
hyperpigmented (Fig.
3.10) or hypo pigmented (on dark skin).
– There is a fine scaling.
– Besides the trunk, neck and upper extremities can also be involved (Brandi et al.
2019
).
– Asymptomatic.
Fig. 3.10 Pityriasis
versicolor
34 3 Papulosquamous Disorders (Skin Disorders with Scales)
3.5.1 Diagnosis
– Clinical findings confirmed with positive potassium hydroxide (KOH) preparation
findings.
– Microscopic examination of scales prepared with KOH shows filamentous hyphae
and globose forms of yeast, a ‘spaghetti and meatballs’ appearance (Saizan and
Elbuluk
Wood’s lamp and skin biopsy also help, with the former showing copper-orange
–
or yellowish-white fluorescence of scales (Ponka and Baddar
2022).
2012).
3.5.2 Management
– Topical selenium sulfide (2.5%) lotion or shampoo, or ketoconazole shampoo
or azole creams (ketoconazole, econazole, micronazole, or clotrimazole) or
terbinafine 1% solution.
– Systemic therapy in adults: Fluconazole and itraconazole are options (Karray et al.
).
2022
– Please note the dyspigmentation can persist for months even after infection is
cleared.
3.6 Seborrheic Dermatitis
–
Seborrheic dermatitis (Fig. 3.11) is a type of endogenous eczema that is manifested
with greasy looking scales involving seborrheic areas such as scalp, eyebrows,
glabella, nasolabial folds, tip of the chin, front of the chest and pubic area.
Please see Chap.
of Seborrheic dermatitis.
5 ‘Eczema’ for clinical features, diagnosis and management
3.7 Tinea Corporis 35
Fig. 3.11 Seborrheic
Dermatitis
3.7 Tinea Corporis
– It is a superficial fungal infection that is caused by dermatophytes. The lesions
of tinea corporis show central clearing with raised borders. It can have some fine
scaling and thus sometimes comes in the differential diagnosis of papulosqumous disorders such as pityriasis rosea. Please see Chap.
Infections’ for clinical features, diagnosis and management of tinea corporis.
As a summary, Table 3.1 shows salient features of the scaly disorders discussed
above.
6 ‘Common Cutaneous
36 3 Papulosquamous Disorders (Skin Disorders with Scales)
Table 3.1 A summary of salient features of the papulosquamous disorders & other conditions that
can mimic them
Skin
disorder
Psoriasis Minimal or no itching, distribution: extensors, silvery adherent scales
Lichen
planus
Pityriais
rosea
Tinea
corporis
Seborrheic
dermatitis
Subacute LE Minimal or no itching. Distribution: sun exposed parts like outer aspects of upper
Pityriasis
versicolor
Salient clinical features
Nail changes (please see the text)
Intense itching
Distribution: flexors, violate, flat topped, polygonal papules/plaques
Oral mucosa can be involved
Nail changes (please see the text)
Minimal or no itching
H/O Herald patch with daughter patches is usually present
Distribution: commonly involves trunk
Peripheral colarette of scaling noted
Itching present. Central clearing and borders are raised. Fine scaling present
Greasy looking scales present in seborrheic areas such as scalp, eyebrows,
glabella, nasolabial folds, tip of the chin, front of chest and pubic area
extremities, V area of the chest and upper back
Well-demarcated macules or patches that are either pink or hyperpigmented or
hypopigmented (on dark skin). Fine scaling. Asymptomatic. Trunk and upper
extremities are commonly involved
Bibliography
Asarch A, Gottlieb AB, Lee J, Masterpol KS, Scheinman PL, Stadecker MJ, et al. Lichen planus–like
eruptions: an emerging side effect of tumor necrosis factor-α antagonists. J Am Acad Dermatol.
2009;61(1):104–11.
Attwa EM, Elkot RA, Abdelshafey AS, Hafez AR. Subcutaneous methotrexate versus oral form
for the treatment and prophylaxis of chronic plaque psoriasis. Dermatol Therapy. 2019;32(5).
Brandi N, Starace M, Alessandrini A, Piraccini BM. Tinea versicolor of the neck as side effect of
topical steroids for alopecia areata. J Dermatol Treat. 2019;30(8):757–9.
Breathnach S. Drug reactions. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook’s
textbook of dermatology, vol 4. 8th ed. Oxford: Blackwell Science; 2010. p. 73.1, 177.
Canpolat Kirac B, Adisen E, Bozdayi G, Yucel A, Fidan I, Aksakal N, et al. The role of human
herpesvirus 6, human herpesvirus 7, Epstein-Barr virus and cytomegalovirus in the aetiology
of pityriasis rosea. J Euro Acad Dermatol Venereol JEADV. 2009;23(1):16–21. Available from
https://pubmed.ncbi.nlm.nih.gov/18713231/.
Chong BF, Song J, Olsen NJ. Determining risk factors for developing systemic lupus erythematosus
in patients with discoid lupus erythematosus. Br J Dermatol. 2011;166(1):29–35.
Cohen MR, Crosby D. Systemic disease in subacute cutaneous lupus erythematosus: a controlled
comparison with systemic lupus erythematosus. PubMed. 1994;21(9):1665–9.
Crowson AN, Magro C. The cutaneous pathology of lupus erythematosus: a review. J Cutan Pathol.
2001;28(1):1–23.
do Vale ECS, Garcia LC. Cutaneous lupus erythematosus: a review of etiopathogenic, clinical,
diagnostic and therapeutic aspects. Anais Brasileiros de Dermatologia. 2023.
Bibliography 37
Dupire G, Droitcourt C, Hughes C, Le Cleach L. Antistreptococcal interventions for guttate and
chronic plaque psoriasis. Cochrane Database Syst Rev. 2019.
Ellis CN, Fradin MS, Messana JM, Brown MD, Siegel MT, Hartley AH, et al. Cyclosporine for
plaque-type psoriasis. N Engl J Med. 1991;324(5):277–84.
Fabbri P, Cardinali C, Giomi B, Caproni M. Cutaneous lupus erythematosus: diagnosis and
management. Am J Clin Dermat. 2003;4(7):449–65.
Griffiths CEM, Armstrong AW, Gudjonsson JE, Barker JNWN. Psoriasis. Lancet.
2021;397(10281):1301–15.
Gudjonsson JE, Karason A, Hjaltey Runarsdottir E, Antonsdottir AA, Hauksson VB, Jónsson
HH, et al. Distinct clinical differences between HLA-Cw*0602 positive and negative psoriasis patients—an analysis of 1019 HLA-C- and HLA-B-typed patients. J Investig Dermatol.
2006;126(4):740–5.
Gudjonsson JE, Elder JT. Psoriasis. In: Kang S, Amagai M, Bruckner AL, Enk AH, Margolis DJ,
McMichael AJ, Orringer JS, editors. Fitzpatrick’s Dermatology, 9e. McGraw-Hill Education;
2019.
Gupta M, Gupta H, Gupta A. Tenofovir induced lichenoid drug eruption. Avicenna J Med.
2015;5(3):95.
Jorge AM, Melles RB, Zhang Y, Lu N, Rai SK, Young LH, et al. Hydroxychloroquine prescription
trends and predictors for excess dosing per recent ophthalmology guidelines. Arthritis Res Ther.
2018;20(1).
Karray M, McKinney WP. Tinea versicolor. 2022 Aug 8. In: StatPearls. Treasure Island: StatPearls
Publishing; 2024. PMID: 29494106.
Kuhn A, Gensch K, Haust M, Schneider SW, Bonsmann G, Gaebelein-Wissing N, et al. Efficacy
of tacrolimus 0.1% ointment in cutaneous lupus erythematosus: a multicenter, randomized,
double-blind, vehicle-controlled trial. J Am Acad Dermatol. 2011;65(1):54–64.e2.
Lajevardi V, Ghodsi SZ, Hallaji Z, Shafiei Z, Aghazadeh N, Akbari Z. Treatment of erosive
oral lichen planus with methotrexate. JDDG J der Deutschen Dermatologischen Gesellschaft.
2016;14(3):286–93.
Le Cleach L, Chosidow O. Lichen planus. N Engl J Med. 2012;366(8):723–32.
Leung AKC, Lam JM, Leong KF, Hon KL. Pityriasis rosea: an updated review. Curr Pediatric Rev.
2020. Available from
Lin J, Dutz JP, Sontheimer RD, Werth VP. Pathophysiology of cutaneous lupus erythematosus.
2007;33(1–2):85–106.
Lu Q, Long H, Chow S, Hidayat S, Danarti R, Listiawan Y, et al. Guideline for the diagnosis,
treatment and long-term management of cutaneous lupus erythematosus. 2021;123:102707–7.
Mangold AR, Pittelkow MR. Lichen planus. In: Kang S, Amagai M, Bruckner AL, Enk AH,
Margolis DJ, McMichael AJ, Orringer JS, editors. Fitzpatrick’s Dermatology, 9e. McGraw-Hill
Education; 2019.
Martin BA. How great is the risk of further psoriasis following a single episode of acute guttate
psoriasis? Arch Dermatol. 1996;132(6):717.
Marzano AV, Lazzari R, Polloni I, Crosti C, Fabbri P, Cugno M. Drug-induced subacute cutaneous
lupus erythematosus: evidence for differences from its idiopathic counterpart. Br J Dermatol.
2011;165(2):335–41.
McCauliffe DP. Cutaneous lupus erythematosus. Semin Cutan Med Surg. 2001;20(1):14–26.
Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, et al. Guidelines of care
for the management of psoriasis and psoriatic arthritis. J Am Acad Dermatol. 2011;65(1):137–74.
Micali G, Verzì AE, Giuffrida G, Panebianco E, Musumeci ML, Lacarrubba F. Inverse psori-
asis: from diagnosis to current treatment options. Clin Cosmetic Investigational Dermatol.
2019;12(12):953–9. Available from
Okon LG, Werth VP. Cutaneous lupus erythematosus: diagnosis and treatment. Best Pract Res Clin
Rheumatol. 2013;27(3):391–404.
https://pubmed.ncbi.nlm.nih.gov/32964824/.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6997231/.
38 3 Papulosquamous Disorders (Skin Disorders with Scales)
Pearson DR. Skin signs of systemic disease. In: Soutor C, Hordinsky MK, editors. Clinical
dermatology: diagnosis and management of common disorders, 2e. McGraw-Hill Education;
2022.
Ponka D, Baddar F. Wood lamp examination. Canadian Family Physician. 2012;58(9):976. Available
from
Quimby S, Markowitz H, Winkelmann R. Antideoxyribonuclease B titers in psoriasis. Acta Derm
Rachakonda TD, Dhillon JS, Florek AG, Armstrong AW. Effect of tonsillectomy on psoriasis: a
Rasi A, Behzadi AH, Davoudi S, Rafizadeh P, Honarbakhsh Y, Mehran M et al. Efficacy of oral
Reich K, Nestle FO, Papp K, Ortonne JP, Evans R, Guzzo C, et al. Infliximab induction and
Roflumilast cream, for topical use. US Food and Drug Administration (FDA) approved product
Saber M, Naeini F, Asilian A, Hosseini S. Clinical efficacy and safety of methotrexate versus
Saizan AL, Elbuluk N. Pigmentary disorders. In: Soutor C, Hordinsky MK, editors. Clinical
Saleh D, Tanner LS. Guttate Psoriasis. 2023 Jul 31. In: StatPearls. Treasure Island: StatPearls
Silverman S, Gorsky M, Lozada-Nur F. A prospective follow-up study of 570 patients with oral
Solimani F, Forchhammer S, Schloegl A, Ghoreschi K, Meier K. Lichen planus—a clinical guide.
Vera-Recabarren MA, García-Carrasco M, Ramos-Casals M, Herrero C. Comparative analysis of
Villalon-Gomez JM. Pityriasis rosea: diagnosis and treatment. Am Fam Physician. 2018;97(1):38–
Walling HW, Sontheimer RD. Cutaneous lupus erythematosus. Am J Clin Dermatol.
Wenzel J. Cutaneous lupus erythematosus: new insights into pathogenesis and therapeutic strategies.
Wilson FC, Icen M, Crowson CS, McEvoy MT, Gabriel SE, Kremers HM. Incidence and clinical
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3440273/.
Venereol. 1980;60(6):485–90.
systematic review. J Am Acad Dermatol. 2015;72(2):261–75.
metronidazole in treatment of cutaneous and mucosal lichen planus. PubMed. 2010;9(10):1186–
90.
maintenance therapy for moderate-to-severe psoriasis: a phase III, multicentre, double-blind
trial. Lancet. 2005;366(9494):1367–74. Available from
16226614.
information. Revised July 2022. US Food and Drug Administration.
fda.gov/drugsatfda_docs/label/2022/215985s000lbl.pdf.
hydroxychloroquine in preventing lichen planopilaris progress: a randomized clinical trial. Int
J Prev Med. 2017;8(1):37.
dermatology: diagnosis and management of common disorders, 2e. McGraw-Hill Education;
2022.
Publishing; 2024. PMID: 29494104.
lichen planus: persistence, remission, and malignant association. Oral Surg Oral Med Oral
Pathol. 1985;60(1):30–4.
JDDG J der Deutschen Dermatologischen Gesellschaft. 2021;19(6):864–82.
subacute cutaneous lupus erythematosus and chronic cutaneous lupus erythematosus: clinical
and immunological study of 270 patients. Br J Dermatol. 2009;162(1):91–101.
44.
2009;10(6):365–81.
Nat. Rev. Rheumatol. 2019;15(9):519–32. Available from
584-019-0272-0.
predictors of psoriatic arthritis in patients with psoriasis: a population-based study. Arthritis
Rheumatism. 2009;61(2):233–9. Available from
https://www.ncbi.nlm.nih.gov/pubmed/
https://www.accessdata.
https://www.nature.com/articles/s41
https://doi.org/10.1002/art.24172.
Chapter 4
Vesiculo Bullous Lesions (Blistering Rashes)
Abstract Vesiculo bullous lesions are commonly encountered in primary care. The
notable conditions that present with blisters are the following. This chapter provides
clinical tips regarding the diagnosis and management of these conditions.
Contact dermatitis
Insect bites
Herpes simplex
Herpes zoster
Bullous impetigo
Hand foot mouth disease
Bullous pemphigoid
Pemphigus vulgaris.
Keywords Bullous pemphigoid · Pemphigus vulgaris · Blisters · Vesicular rash ·
Hand foot mouth disease · Insect bites · Herpes simplex · Herpes zoster
4.1 Contact Dermatitis
4.1.1 Diagnostic Tips
– History of exposure to an offending agent such as poison ivy is usually given but
not always.
– Also, patient can sometimes give you prior history of having similar presentation
upon exposure to an offending agent such as poison ivy.
Can be localized or generalized.
–
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
D. K. Yellumahanthi, Manual of Primary Care Dermatology,
https://doi.org/10.1007/978-3-031-68406-7_4
39
40 4 Vesiculo Bullous Lesions (Blistering Rashes)
Fig. 4.1 Contact dermatitis
to poison ivy
Blisters can be noticed in acute stages. Presence of blisters in a linear fashion
–
suggesting contact with an extraneous source along that path, is often present.
Please see a linear lesion near the ulnar border of Fig.
4.1.
4.1.2 Management
–
Identifying and eliminating the offending agent is the initial step.
–
Depending on the body area, appropriate topical steroids can be given: For
instance, on the face, desonide 0.05% cream, on the body other than face,
depending on the severity, either hydrocortisone valerate 0.2% ointment or
betamethasone dipropionate 0.05% ointment.
– Oral prednisone for a short duration can be given if the inflammation is extensive.
–
Please see Chap. 5 ‘Eczema’ for more details on the clinical manifestations,
diagnosis and management of contact dermatitis.
4.3 Herpes Simplex 41
4.2 Insect Bites
– Can be localized or generalized.
– History of exposure to insects may or may not always be elicited.
– The lesions are usually painful to some degree than mere itching.
4.2.1 Management
– In localized cases, topical antibiotics to prevent secondary infection and oral anti-
histamines are usually all that is needed. In more extensive cases, oral antibiotics to
prevent secondary infection and oral steroids may have to be added as appropriate.
4.3 Herpes Simplex
– Caused by Herpes Simplex Virus (HSV) 1 and 2. HSV 1, usually presents as
groups of blisters around the corners of the mouth and HSV 2 on the genitalia.
Primary HSV1 can sometimes be severe leading to Herpetic gingivostomatitis.
– Please keep in mind, inoculated herpes can occur at any site on the body. There-
fore, if grouped vesicles are present locally anywhere on the body, think of the
possibility of herpes.
– Usually associated with pain or tingling sensation.
4.3.1 Management
– There are various regimens that includes either acyclovir or famciclovir or valacy-
clovir. For primary herpetic gingivitis, acyclovir could be a better option. If there
are too frequent flare ups, suppressive therapy with antivirals can be initiated.
– Please see Chap. 6 ‘Common cutaneous infections’ for more details on clinical
manifestations, diagnosis and management of herpes simplex.
42 4 Vesiculo Bullous Lesions (Blistering Rashes)
4.4 Herpes Zoster
– Blistering lesions occur along the dermatome. Therefore, seen in a ribbon shape
or segmentally. The lesions are only on one side of the body and never cross the
midline.
– Pain often precedes the rash by 2–3 days. But, can be longer sometimes.
– Rarely, herpes zoster could manifest only as pain along a dermatome without any
skin lesions.
–
Post herpetic neuralgia (PHN) is the dreaded complication. If significant pain
persists beyond 90 days after the onset of the rash, it is termed as PHN.
4.4.1 Management
Starting antivirals within 72 hours after the onset of rash, helps in reducing the
–
intensity of acute symptoms of zoster. It is not clear exactly if antivirals also will
benefit in reducing the chances of developing PHN. The following are the various
regimens of antivirals used in adults:
Valacylovir 1000 mg orally three times daily for 7 days.
Famciclovir 500 mg orally three times daily for 7 days and
Acyclovir 800 mg orally five times daily for seven days (Preferred regimen
among pregnant women).
– The acute pain of zoster if not better with oral antivirals, Non Steroid Anti Inflam-
matory Drugs (NSAIDs) and opioids can help. If still not better gabapentin or
pregabalin or a low dose of amitriptyline at bedtime can be tried.
If PHN ensues, it is better to refer the patient to a dermatologist.
–
– Please see Chap. 6 ‘Common cutaneous infections’ for more details on clinical
manifestations, diagnosis and management of herpes zoster.