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Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023
| Contributor Information
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Image from Wikimedia Commons | Camiloaranzales.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
Infectious skin rashes—bacterial, viral, or fungal—have many overlapping manifestations. Nevertheless, discrete, identifiable factors for each disease can aid in diagnosis and treatment.
Chickenpox (varicella), a highly contagious disease caused by varicella-zoster virus (VZV) and acquired via inhalation of airborne respiratory droplets or direct vesicle contact,[1,2] is shown in a 9-year-old boy who presented with a skin rash, low-grade fever, and intense pruritus. Since the initiation of vaccination in 1995, the incidence of chickenpox has fallen from more than 4 million to less than 150,000 cases annually. Breakthrough varicella—infection with wild-type VZV occurring in a vaccinated person more than 42 days after varicella vaccination—may occur but is usually mild. [1] Chickenpox usually resolves spontaneously over 5-10 days. Treatment is generally supportive.[2]
Image from Wikimedia Commons | Mariegriffiths.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
Herpes zoster (shingles) is a cutaneous and neurologic disorder caused by reactivation of VZV.[3] Proposed triggers include immunodeficiency/immunosuppression, radiation, trauma, medications, stress, and other infections.[3] Pain, itching, or tingling may occur with or precede the development of an erythematous rash, followed by the appearance of grouped herpetiform vesicles (shown). The cutaneous findings typically involve one or two adjacent dermatomes, and most commonly are unilateral and do not cross the midline.[3]
The vesicles are initially clear, but may become cloudy and may rupture, crust, and involute.[3] Pain may persist, in some cases for years, a condition referred to as post-herpetic neuralgia (PHN).[3] Antiviral agents given early in the disease course may shorten the recovery period and decrease the chance of PHN.[4] A vaccine is available and is recommended by the Centers for Disease Control and Prevention (CDC) for individuals 50 years of age or older, and for immunocompromised adults age 19 and older. Vaccination reduces the risk of developing shingles and PHN by over 90% in most age groups.[5]
Image from Wikimedia Commons | KlatschmohnAcker.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
This patient presented with cutaneous lesions on the hands, feet, and buttocks. These 2- to 10-mm erythematous macules may develop into a central, gray, oval vesicle. The lesions are elliptical, with the long axis parallel to the skin lines. What is this condition?
Image from Wikimedia Commons | Ngufra.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
Answer: Hand-foot-and-mouth disease
Hand-foot-and-mouth disease (HFMD) is a viral illness with oral and distal-extremity lesions. The oral lesions are normally 2- to 3-mm vesicles on an erythematous base. HFMD is most commonly caused by coxsackievirus A16 and typically affects children and infants.[6,7] The disease is highly contagious during the first week of infection and may lead to epidemics from direct contact with nasal and oral secretions or fecal material. The incubation period typically averages 3-7 days. Symptoms include fever, rash, headache, sore throat, oropharyngeal ulcers, and loss of appetite.[7] Care is typically supportive, with antipyretics and anesthetics used for symptomatic relief on a case-by-case basis.
Image from Medscape.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
This child presented with an illness that has three distinct phases with a mild prodrome. In the first phase (2-4 days), bright-red erythema appears over the cheeks in a classic slapped-cheek appearance (shown) that spares the nasal, periorbital, and perioral regions. In the second phase (1-4 days), an erythematous macular-to-morbilliform eruption occurs, predominantly on the extensor surfaces of the extremities. In the final stage (several days to weeks), the eruption fades, leaving behind a reticulated, lacy pattern. What is this illness?
Image courtesy of Justin Finch, MD.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
Answer: Erythema infectiosum
Erythema infectiosum, or fifth disease, is a common childhood exanthem caused by human parvovirus B19.[8,9] Transmission occurs via aerosolized respiratory droplets or through blood or blood products (eg, maternal-fetal transmission).[8,9] The condition has an incubation period of 4-14 days (up to 20 days).[9] Symptoms include fever, headache, and runny nose, followed by a pruritic rash on the face ("slapped cheek"), as well as on the torso and extremities.[8,9] The disease is typically self-limited (7-10 days) and resolves without complications or sequelae in children. The virus may also result in acute or persistent arthropathy, as well as so-called gloves-and-socks syndrome, characterized by papular, purpuric eruptions on the hands and feet. In addition, the virus may trigger an acute cessation of red blood cell production, with transient aplastic crisis, chronic red cell aplasia, or hydrops fetalis resulting. Cases in pregnant women can cause congenital anemia in the fetus/newborn.
Patients with human immunodeficiency virus (HIV) or blood disorders such as iron deficiency anemia, sickle cell disease, or thalassemia are at increased risk.[10] Treatment is generally supportive on a case-by-case basis.[8,9] Patients who develop arthralgia may be treated with oral analgesics; those who suffer from pruritus may use antihistamines or topical antipruritic lotions.
Image from Wikimedia Commons | James Heilman, MD.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
This patient presented with complaints of a solitary, salmon-colored macule that enlarged over several days to become a patch with fine scales and a well-demarcated border. Over the next several weeks, a generalized exanthem developed with bilateral, symmetrical macules 0.5-1.5 cm in diameter; it was oriented along cleavage lines and was characterized by mild to moderate pruritus. What is the cause of this pruritic dermatologic manifestation?
Image from Wikimedia Commons | James Heilman, MD.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
Answer: Pityriasis rosea
Pityriasis rosea is a benign papulosquamous disease that occurs most often in the spring and fall, like many viral exanthems.[11] It begins as a solitary macule that is 2-10 cm in diameter, termed a "herald" or "mother" patch (yellow arrow); after several days, more lesions ("daughter" patches) appear on the torso and extremities.[11,12] The generalized exanthem typically lasts for 6 weeks (range, 4-8 weeks; occasionally >8 weeks).[11,12] Immunologic data suggest a viral etiology. Treatment is largely symptomatic for relief of pruritus, with topical steroids and oral antihistamines used.[11,12]
Image courtesy of Justin Finch, MD.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
The above skin infection is generally limited to the epidermis and expands in a centrifugal pattern. Patients may be asymptomatic or complain of a pruritic or burning sensation. The lesion appears as an erythematous, scaly plaque that may enlarge rapidly (shown). Scales, crust, papules, vesicles, or bullae may develop along the advancing border.
What is this skin manifestation?
Image from Wikimedia Commons | James Heilman, MD.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
Answer: Tinea corporis
Tinea is a superficial dermatophyte infection characterized by scaly, inflammatory or non-inflammatory patches. Tinea on the feet is termed tinea pedis ("athlete's foot"); on the body, tinea corporis; on the head/scalp, tinea capitis; and on the groin, tinea cruris ("jock itch").[13,14] Tinea may be caused by one of three dermatophytes: Trichophyton (most common),[14,15]Microsporum,[14,15] and Epidermophyton.[15] These micro-organisms preferentially inhabit warm, moist areas of the skin and may spread by skin contact or by contact with contaminated items or infected animals.[13,14] The diagnosis may be made with a potassium hydroxide (KOH) preparation from a skin scraping
Image from Wikimedia Commons | RafaelLopez.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
Cellulitis (shown) is a non-necrotizing bacterial infection of the dermis and hypodermis.[25,26] The most common organisms involved are Streptococcus pyogenes and Staphylococcus aureus. Small breaks in the skin allow organisms to gain entrance to the dermis and multiply.[25,26] In rare cases, particularly in immunocompromised patients, hematogenous or metastatic seeding may occur.[26] Patients commonly report fevers, chills, pain, swelling, tenderness, erythema, and warmth.[25,26] The borders of cellulitis are typically not elevated or sharply demarcated.[26] In general, uncomplicated cases may not require laboratory studies;[26] for more severe infections, obtain blood cultures (or fluid cultures from lesions), complete blood counts, and other tests as needed.[25,26]
Image courtesy of Brett Sloan, MD.
Eight Skin Rashes You Need to Know
Lars Grimm, MD, MHS | February 20, 2023 | Contributor Information
Folliculitis is inflammation within the wall and ostia of one or more hair follicles. Typically, it appears as a pruritic rash comprising multiple, small papules on an erythematous base, each pierced by a central hair.[28,29] Most common sites are the face, scalp, neck, groin, and genital area. Different causes have been identified, including infection, trauma, friction, perspiration, and occlusion. The most common pathogen is S aureus,[28,29] although gram-negative organisms have been found in patients on long-term antibiotic therapy, and Pseudomonas may be found in patients who use hot tubs or wet suits.[29] The image shown is of patient who used a hot tub two days ago. The diagnosis of folliculitis is generally clinical, and the condition is typically self-limited.[29]
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Contributor Information
Author
Lars Grimm, MD, MHS
Associate Professor
Department of Diagnostic Radiology
Duke University Medical Center
Durham, NC
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Editors
Mark P Brady, PA-C
Adjunct Faculty and Preceptor
Physician Assistant Program
University of New England;
Physician Assistant
Department of Emergency Medicine
Cambridge Hospital, Cambridge Health Alliance
Cambridge, MA
Disclosure: Mark P Brady, PA-C, has disclosed no relevant financial relationships.
Michael Stuart Bronze, MD
Professor and Chairman, Stewart G. Wolf Endowed Chair in Internal Medicine
Department of Medicine
University of Oklahoma Health Science Center
Oklahoma City, OK
Disclosure: Michael Stuart Bronze, MD, has disclosed no relevant financial relationships.
John Heinegg, RN
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: John Heinegg, RN, has disclosed no relevant financial relationships.
Reviewer
Brett Sloan, MD, FAAD
Professor of Dermatology
University of Connecticut School of Medicine
Residency Site Director
Connecticut Veterans Affairs Healthcare System
Assistant Clinical Professor
Yale University School of Medicine
Editor-in-Chief, Journal of the American Academy of Dermatology Case Reports
Disclosure: Brett Sloan, MD, FAAD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, adviser, consultant, or trustee for: Journal of the American Academy of Dermatology; UpToDate; Medical Review Institute of America.
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References
Chickenpox (varicella): about chickenpox. Centers for Disease Control and Prevention. Reviewed: October 21, 2022. Available at: https://www.cdc.gov/chickenpox/about/index.html. Accessed: February 9, 2023.
Shingles (herpes zoster): treating shingles. Centers for Disease Control and Prevention. Reviewed: December 9, 2020. Available at: http://www.cdc.gov/shingles/about/treatment.html. Accessed: February 9, 2023.
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