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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2866_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 20. Rash
409
F . Chronic eczema. Lichenification and hyperpigmented
papulonodules in the antecubital fossa of a child with atopic dermatitis
410
A. Howell and K. Krishnamurthy
Dermal
1. Subcutaneous.
(a) Panniculitis. Erythematous deep nodules:
• Septal: superficial thrombophlebitis, erythema
nodosum, or cutaneous polyarteritis nodosa.
• Lobular: erythema induratum, Crohn’s disease, calciphylaxis, lupus panniculitis, or pancreatic panniculitis (Fig.20.5).
(b) Cellulitis. Erythema, edema, warmth and pain with/
without fever, and lymphadenopathy.
(c) Necrotizing fasciitis. Erythema, edema, warmth and
pain out of proportion to skin ndings initially. Rapid
progression to a gray-blue color in ill-dened patches
with “woody” induration. Hemorrhagic bullae may
develop. Treatment is emergent extensive surgical
debridement. Termed fournier gangrene if perineum
and genetalia are involved.
F . Erythema nodosum. Tender, erythematous nodules
over the shins in a young female taking oral contraceptive pills
Chapter 20. Rash
411
2. Inammatory
(a) Lupus erythematosus. Malar erythema (spares nasola-
bial fold) with conuent erythema and edema or maculopapular lesions in sun-exposed areas. Oral ulcers
may be present.
(b) Granuloma annulare. Groups of 1–2-mm papules in an
annular arrangement often found on distal extremities,
hands, feet, ngers, and extensor aspects of the arms
and legs.
(c) Sarcoidosis. Purple-red or brown indurated circular
plaques. Erythema nodosum may be present.
3. Infectious
(a) Erysipelas. Well-demarcated ery-red indurated, tense,
often shiny, plaque that is most often on the lower
extremities or face. Abrupt demarcation from healthy
skin is a classic clinical sign.
(b) Deep fungal infections. Often rapidly spreading patch,
plaque, nodule, or abscess often with necrotic center,
ulcers, or sinuses. Causes include histoplasmosis, blastomycoses, coccidioidomycoses, and cryptococcus.
(c) Atypical mycobacterium, sporotrichosis, and cat-
scratch disease. Linear subcutaneous nodules with unilateral lymphadenitis.
4. Proliferative
This category includes various benign and malignant
dermal neoplasms or proliferations. The list of dermal proliferations is long and includes various cysts, adnexal
tumors (eccrine gland, apocrine gland, hair tumors), tumors
derived from collagen/elastin, muscle cells, nerve cells,
blood vessels, and melanocytic lesions. Finally, what is
referred to as the “purple plum” differential is considered,
which includes amelanotic melanomas, cutaneous
metastases, sarcomas, vascular tumors (Kaposi sarcoma
and angiosarcoma), lymphomas, and leukemia cutis.
412
A. Howell and K. Krishnamurthy
5. Depositional
A group of unrelated disorders characterized by deposi-
tion of substances within the dermis. This is broken down
into the type of substance deposited: lipid (xanthomas),
mucin (myxedema, granuloma annulare, necrobiosis
lipoidica diabeticorum), amyloid (primary, secondary, macular, or nodular), calcium (calciphylaxis, dystrophic, metabolic), or urate (gout).
Vascular
Vascular rashes are red in color and are distinguished first by
whether or not they are blanching due to vasodilation.
Purpuric rashes are non-blanching due to red blood cell
extravasation. Palpable purpura indicates vasculitis.
1. Urticaria. Classic hive or wheal appearance: edematous,
blanching erythematous plaques due to a type I
hypersensitivity.
2. Toxic erythema. Diffuse and conuent blanching erythem-
atous macules and papules. These can be deadly. Etiologies
include viral exanthems, drug eruptions, and the following:
(a) Scarlet fever. Features multiple 1–2-mm punctate pap-
ules with sandpapery feel. Treat with penicillin or
erythromycin.
(b) SSSS. Diffuse yellow-red tender erythema that pro-
gresses to large, accid bullae with desquamation.
Treat with penicillins, cephalexin, cefazolin, or
TMP-SMX.
(c) TSS. Fever >102 °F, rash, late desquamation, straw-
berry tongue, pharyngeal redness, and conjunctivitis.
Treat with clindamycin, vancomycin, or nafcillin.
(d) Kawasaki disease. Polymorphous rash, strawberry
tongue, conjunctivitis, redness and scaling of palms and
soles, and cervical adenopathy. Treat with aspirin and
IVIG [5].
Chapter 20. Rash
413
(e) Stevens-Johnson syndrome/toxic epidermal necrolysis
(SJS/TEN). Diffuse erythema, bullae that become
necrotic followed by diffuse desquamation of the skin.
Commonly implicated drugs include NSAIDs, penicillins, sulfa drugs, anticonvulsants, barbiturates, and
allopurinol.
3. Erythema multiforme. Targetoid red papules with dusky
center that can be bullous. Involves palms and soles, unlike
many other rashes.
4. Vasculitis. Palpable purpura. Can be vesicular or bullous
[6] (Fig.20.6).
(a) Hypersensitivity. Symmetric. Infection (HCV, group A
Streptococcus [GAS], autoimmune disease, drug,
malignancy, and Henoch-Schonlein purpura.
(b) Septic: Asymmetric, often involving acral surfaces.
Meningococcemia, pseudomonas, gonococcemia, and
GAS.
F . Palpable purpura on the lower extremity indicating
leukocytoclastic vasculitis
414
A. Howell and K. Krishnamurthy
5. Vasculopathy. Ranges from petechiae to purpura with
ulceration and atrophy. Etiologies include idiopathic
thrombocytopenic purpura, thrombotic thrombocytopenic
purpura, hypercoagulable states, renal failure, hereditary
platelet disorders, scurvy, DIC, and lymphoproliferative
states (Waldenstrom macroglobulinemia, leukemias,
myeloma) [6].
6. Annular erythema. Erythema chronicum migrans (ECM).
Associated with Lyme disease. An erythematous ring
around a central punctate erythematous papule (indicates
tick site) spreading outwardly with annular appearance.
Vesiculobullous
Blistering rashes with either intraepidermal or subepidermal
bullae and a background of inflammatory or noninflammatory skin. Various conditions already mentioned can also
blister, including meningococcemia, contact dermatitis, vasculitis, erythema multiforme, and SJS/TEN [7].
Infectious
Herpes simplex virus. Grouped vesicles on an erythematous
base. Vesicles crust over as they heal.
Herpes zoster. Grouped painful/burning herpetic vesicles on
an erythematous base in a dermatomal distribution. Pain
often precedes rash (Fig.20.7).
Coxsackie. Vesicles on the tongue or buccal mucosa, hands,
and feet, including the palms and soles. Uncommonly, the
buttocks and genitalia are involved. Vesicles are tender
and may ulcerate, but are usually not pruritic.
Chapter 20. Rash
415
F . Herpes zoster. Vesicles and crusting involving the trigeminal nerve (V1 and V2) distribution
416
A. Howell and K. Krishnamurthy
Autoimmune, Intraepidermal
Pemphigus vulgaris (PV). Flaccid blisters with crust and ero-
sions present. Oral involvement is common. Positive
Nikolsky sign.
Autoimmune, Subepidermal
Bullous pemphigoid. Common condition seen in the elderly.
Tense bullae that do not rupture easily. Common locations
include trunk and flexural areas (Fig.20.8).
Noninflammatory
Porphyria cutanea tarda. Acral blisters that worsen with sun
exposure, alcohol use, and estrogen [8].
Miliaria crystallina. Numerous small superficial vesicles in
intertriginous areas or head/neck in infants caused by
obstruction of the sweat glands. Can also be seen in febrile
adults.
F . Bullous pemphigoid. Tense bullae on the lower extremities. (Previously published in Buka B, Uliasz A, Krishnamurthy
K.Buka’s Emergencies in Dermatology. NewYork: Springer; 2013)
Chapter 20. Rash
417
History andPhysical Examination
History
• Duration and history of rash: acute vs. chronic, symptoms
(itchy, painful, progression of lesion color/texture and distribution, drainage, fever), aggravating and alleviating factors, previous treatments attempted including topical and
over-the-counter formulations.
• Description: location of rash, color, texture.
• Medical history: recent changes in health problems, recent
illnesses or hospitalizations, new medications.
• Social history: recent travel, contact with plants or bodies
of water, sick contacts, pets, arthropod bites, occupation
(chemical exposures), sexual history.
• Environmental changes: new products including but not
limited to perfumes, cosmetics, soaps, shampoos, detergents, hair dye, nail polish, clothing components (nickel in
buttons, leather shoes, etc.)
Physical Examination
• Vital signs: presence of fever, signs of hemodynamic
instability.
• Gross inspection [4, 9]:
– Primary morphology represents the native initial
appearance of the rash and the morphologic terms are
described as follows:
Macule: nonpalpable (flat) lesion less than 1cm.
Patch: nonpalpable (flat) lesion greater than 1cm.
Papule: palpable (commonly elevated, rarely
depressed) lesion less than 1cm.
Plaque: palpable (commonly elevated, rarely
depressed) lesion greater than 1cm.
Nodule: palpable (elevated) lesion often greater than
1cm involving the dermis and subcutaneous tissues.
Wheal: transient elevation of the skin due to dermal
edema.
Vesicle: fluid-filled lesion less than 1cm.
Bulla: fluid-filled lesion greater than 1cm.
418
A. Howell and K. Krishnamurthy
Pustule: lesion filled with purulent fluid from onset.
Furuncle: abscess involving a single follicular unit.
Carbuncle: abscess involving multiple follicular units.
– Secondary change represents the effects of exogenous
forces or temporal change to the primary lesion and
they are described as follows:
Excoriation: exogenous injury to the epidermis
(common following scratching).
Scale: accumulation of the stratum corneum
(hyperkeratosis).
Crust: dried serum, blood, or purulence overlying the
lesion.
Erosion: partial loss of the epidermis.
Ulceration: loss of the full epidermis and occasionally the dermis or subcutis.
Fissure: linear cleft in the skin.
Lichenification: accentuation of the skin lines as a
result of epidermal thickening (often due to chronic
rubbing or scratching).
– Color: erythematous, hyperpigmented/hypopigmented,
flesh-colored, red-brown, violaceous, purpuric, dusky
(dark purple/gray that suggests necrosis).
– Shape: annular (circular with central clearing), nummu-
lar (circular with central involvement), ovoid, linear,
serpiginous, targetoid, polycyclic (coalescing annular),
arcuate (incomplete annular), polymorphous (many
shapes).
– Distribution: generalized, central, peripheral, palms/
soles (“acral”), flexural vs. extensor surfaces, unilateral
vs. symmetric, photo-distributed (sun-exposed skin) vs.
photoprotected skin (buttocks, hips, etc.), intertriginous,
mucosal involvement.
– Configuration: linear/geometric (suggests outside influ-
ence), dermatomal, grouped/coalescing.
– Texture: soft, firm, fleshy, indurated, fluctuant.
– Patterns: follicular, morbilliform (“measles-like” aka
maculopapular), reticular (“net-like”), monomorphic,
guttate (drop-like).