Case Review A rash starting on the palms and soles

Information sourced from BMJ:

BMJ 2015;351:h5452
[Link to free full-text BMJ article PDF]

Endgames

Case Review

A rash starting on the palms and soles

Vinod E Nambudiri, Navya S Nambudiri, Rosalynn M Nazarian, et al.

Correspondence to: V E Nambudiri vinod.nambudiri@gmail.com

[EXCERPTS]

A 23 year old man presented with a rash eight weeks after [immigrating] to the United States. One week after immigration he had a sore throat, dysphagia, and mild subjective fevers, which resolved in 10 days. Two weeks later, he developed a papular eruption starting on his hands and feet. He had no arthralgia, myalgia, or systemic symptoms. He took no drugs, had no allergies, no family history of skin eruptions, and no close contacts with a similar rash.

He was evaluated at an urgent care clinic one week after the eruption started. The rash was mainly on his palms and soles but was spreading to the arms and legs. Blood was sent for antibodies to Rocky Mountain spotted fever (RMSF) and coxsackievirus. Given the life threatening nature of RMSF, he was treated empirically with seven days of doxycycline without improvement; both tests were negative.

Over the next two weeks the rash spread diffusely, becoming mildly pruritic, and he presented to our institution for evaluation. His vital signs were within normal limits and he had no erythema of the oral mucosa or lymphadenopathy. Hundreds of pink papules with silvery scale measuring 2-3 mm in diameter were noted on his face, palms and dorsal hands, arms, trunk, legs, and feet (fig 1). Linear lesions in areas of excoriation were seen in the right antecubital fossa.

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Fig 1 
Pink papules with scale on the palms (A) and chest (B). Note the lesions overlying a linear excoriation on the right distal upper arm just proximal to the antecubital fossa

Anti-streptolysin O and anti-DNase-B titers were both raised (695 IU/mL (reference value <530) and 706 IU/mL (<300), respectively). Skin biopsy of a lesion showed hyperplasia of the epidermis, neutrophilic microabscess formation, dilated superficial dermal blood vessels, and overlying parakeratotic hyperkeratotic scale.

Questions

  1. What are the differential diagnoses for rashes on the palms and soles?
    2. What is the diagnosis and what phenomenon do the linear lesions in areas of excoriation demonstrate?
    3. How does the antecedent pharyngitis relate to the rash?
    4. How can this condition be treated?
    5. In patients who present to primary care, what are the referral criteria to dermatology?

Answers

  1. 1. What are the differential diagnoses for rashes on the palms and soles?

Short answer

Infections such as coxsackievirus, syphilis, Rocky Mountain spotted fever, scabies, and tinea; inflammatory dermatoses such as psoriasis, eczema, erythema multiforme, and mycosis fungoides, and drug eruptions.

  1. What is the diagnosis and what phenomenon do the linear lesions in areas of excoriation demonstrate?

Short answer

The history, clinical presentation, laboratory findings, and histopathology are consistent with a diagnosis of guttate psoriasis. The development of skin lesions in trauma sites is known as the Koebner phenomenon.

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Fig 2 
Skin biopsy from the upper arm showed psoriasiform hyperplasia of the epidermis, parakeratotic scale, and dilated superficial dermal blood vessels, consistent with psoriasis (A). Dense neutrophilic collections in the upper epidermis—termed Munro’s microabscesses and spongiform pustules of Kogoj—were also noted (B). Hematoxylin and eosin stain; original magnification ×10

  1. How does the antecedent pharyngitis relate to the rash?

Short answer

Acute guttate psoriasis has been associated with preceding streptococcal pharyngitis.

  1. How can this condition be treated?

Short answer

Treatments include topical corticosteroids, topical vitamin D analogs, topical coal tar, and ultraviolet B phototherapy. Prognosis is good—the disease course is limited in most patients, with a minority developing chronic disease or plaque psoriasis.

  1. In patients who present to primary care, what are the referral criteria to dermatology?

Short answer

Consider referral to dermatology if the diagnosis of an acute eruption is uncertain, there has been no response to initial treatment, or specific treatments administered by dermatologists are being considered.

Patient outcome

The eruption cleared after a course of topical mid-potency steroids (triamcinolone acetonide 0.1% ointment) and topical calcipotriol. The disease has not relapsed after one year.

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