Those Bumps aren’t Moguls!An Algorithmic Approach to Rashes

David Robinson MDDepartment of Emergency Medicine

University of Texas Medical School at Houston31rst Annual Emergencies in Medicine Conference

Park City, Utah

General ‘Bump’ Terms• Rash: An eruption on the skin; more extensive than a single

lesion• Lesion: Single small, diseased area• Macule: Circumscribed area of change without elevation• Papule: Solid raised lesion ≤1 cm• Plaque: Circumscribed elevated confluence of papules ≥1 cm• Nodule: Solid raised lesion ≥1 cm • Pustule: Circumscribed area containing pus• Vesicle: Circumscribed fluid-filled area ≤1 cm• Bulla: Circumscribed fluid-filled area ≥1 cm• Petechia: Small red/brown macule ≤1 cm that does not blanche

4 Major Rash Algorithms

a. Erythematousb. Vesiculo-bullousc. Petechiae/Purpurad. Maculopapular

Your working at ABEM general when…

• ‘sick baby with red skin in room 5’

• Red Skin, ‘skin is peeling off – when I push on it’, blisters

• Fever

• The 2 key historical points?

Erythema (from the Greek erythros, meaning red) is redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin

Erythematous Rashes

Erythematous RashSpecial

Finding?Nikolsky

sign

Fever?Type of rash?

Erythematous Rash

Yes

YesStaphylococcal SSS

(children)TEN (adults)

NoTSS

Kawasaki disease Scarlet fever

No

Yes TEN

No Anaphylaxis Scombroid

Poisoning Alcohol Flush

Erythematous Rash with feverPositive Nikolsky Sign – the sick ones

• Staph SSS (children <5)– Aka dermatitis exfoliativa

neonatorum– Diffuse scarlatiniform

erythema– No mucous membranes– Shallow skin cleavage

• TEN (adults)– MC associated with sulfa

drugs– First around

face/eyesshoulders and UE– Mortality 30-35%

Erythematous Rash with feverNo Nikolsky sign

• Toxic Shock Syndrome– Diffuse erythematous rash

• Kawasaki Disease– High fever x 5 days– Red eyes, Cracked lips, Dry

tongue• Scarlet Fever

– Pink-red ‘sandpaper’ rash– Flushed face, strawberry

tongue– Follows sore throat or

impetigo

Erythematous RashSpecial

Finding?Nikolsky

sign

Fever?Type of rash?

Erythematous Rash

Yes

YesStaphylococcal SSS

(children)TEN (adults)

NoTSS

Kawasaki disease Scarlet fever

No

Yes TEN

No Anaphylaxis Scombroid

Poisoning Alcohol Flush

Erythematous Rash, No Fever and No Nikolsky Sign

• Anaphylaxis– 2 or more body systems

• Scombroid poisoning– Spoiled dark fleshed fish– Intense histamine reaction

30-40 min after ingestion– Flushing, headache, abd

cramps– Self limited, antihistamines

• Alcohol Flush– MC seen in Asians (East)– Self limited

http://dermatology.cdlib.org/126/case_presentations/scrombroid/ferran.html

Erythematous Rash, +/- Fever and (+) Nikolsky Sign

• Toxic Epidermal Necrolysis (TEN)– Associated with drugs– Life threatening shearing

of epidermis from dermis in more than 30% of body

– Affects mucous membranes

– TX: plasmaphoresis, IVIG, stop drug, ICU admit

http://dermatology.cdlib.org/126/case_presentations/scrombroid/ferran.html

A two-fer…

Bed 3• 6 yo with fluid filled vesicles

on face, scalp, torso, upper arms

• Fever• unvaccinated

Bed 9• 60 yo with sharp back and

chest pain• Blisters over specific area of

chest – follows dermatome• No fever

What are the diagnostic clues ? Fever and rash distribution

Vesiculo-Bullous RashDefinitions: Circumscribed fluid filled sac less than 1 cm (vesicle) or greater than 1 cm (bullous)

Vesicles of Hand, foot and mouth

Bullous erythema multiforme

Vesiculo-Bullous RashSpecial

Finding?Distribution

Fever?

Type of rash?

Vesiculo-Bullous Rash

Yes

Localized

Necrotizing fasciitisHand, Foot, and Mouth

Diffuse

Varicella/Chicken PoxSmall Pox

Disseminated GCPurpura Fulminans/ DIC

NoDiffuse

Bullous PemphigusPemphigus Vulgaris

Localized

Contact DermatitisZosterBurns

Dyshidrotic Eczema

Vesiculo-Bullous rashFebrile and Localized

• Necrotizing Fasciitis– Rapidly progressing– Polymicrobial, gpA strept

IV ABX

• Hand, Foot and Mouth– Children <10– Coxsackie A16– Vesicles to hands, feet– Symptomatic tx

http://upload.wikimedia.org/wikipedia/commons/6/6a/Necrotizing_fasciitis

Vesiculo-Bullous rashFebrile and Diffuse

• Varicella/ Chicken pox• Smallpox

– Variola v– Born after 1972?

• Disseminated GC– Also seen as palpable purpura

• Purpura Fulminans / DIC– Fever, shock, rapid SQ hemorrhage,

tissue necrosis, DIC– MC meningococcal or G(-) organisms– Trauma, multiorgan failure

Vesiculo-Bullous RashSpecial

Finding?Distribution

Fever?

Type of rash?

Vesiculo-Bullous Rash

Yes

Localized

Necrotizing fasciitisHand, Foot, and Mouth

Diffuse

Varicella/Chicken PoxSmall Pox

Disseminated GCPurpura Fulminans/ DIC

NoDiffuse

Bullous PemphigusPemphigus Vulgaris

Localized

Contact DermatitisZosterBurns

Dyshidrotic Eczema

Vesiculo-Bullous rashNot Febrile and Localized

• Contact Dermatitis– Often linear at point of

irritation• Zoster

– VZV– Follows dermatome pattern

• Burns• Dyshidrotic Eczema

– Pruritic blisters on hands and feet, possibly scaly

– Unknown etiology

• Bullous Pemphigus (~60s)– Neg Nikolsky’s, pruritic– Oral lesions in 1/3

• Pemphigus Vulgaris (>40 y)– Autoimmune blistering of skin

(flaccid bullae) and mucous membranes

– Penicillamine, ACE inh– Treat as burns,

immunosuppressant therapy

Vesiculo-Bullous rashNot Febrile and Diffuse

Hey Doc…I got these Bumps on my skin

• Afebrile • What are the

distinguishing features for these ‘bumps’

• Are they Bumps?– Palpable or

Nonpalpable?• Do they Blanch?

Petechia: small (< 3 mm) red or purple spot on body due to minor hemorrhage of blood vessel

Purpura: Larger hemorrhagic lesions (3-10mm)

Ecchymosis: largest (>10mm)

Petechial / Purpuric rash

Petechial / Purpuric rashSpecial

Finding?Palpable?

Fever?Type of rash?

Petechial / Purpuric Rash

Yes

Palpable

MeningiococcemiaDisseminatd GC

EndocarditisRMSFHSP

Not palpable

TTPPurpura

Fulminans/DICHSP

NoNot palpable

ITP

PalpableVasculitis

Petechial / Purpuric rashFebrile and…

Palpable• Meningococcemia

– Hemorrhagic, petechial with bullae– From endotoxin release

• Disseminated GC• Endocarditis

– Osler’s nodes, roth spots, palpable purpura

• RMSF– Early: Small, flat non-pruritic

macules on wrists forearms and ankles

– Late: spreads to trunk, petechial• HSP

– Kids (2-10)– Vascular palpable purpura– Assoc. GI and joint pain

Petechial / PurpuricFebrile and Not Palpable

• TTP– Microangiopathic hemolytic anemia,

neurologic sx, HUS– Tx with plasma exchange,

immunosuppressants– 2° TTP assoc with ca, platelet agg inh,

immunosuppresants, HIV, SLE

• Purpura Fulminans / DIC– Associated with G- sepsis– Debridement, eschar/amput often necessary

• HSP (anaphylactoid purpura)– Systemic vasculitis, children– Associated with infection (pharyngitis)– Triad: purpura, arthritis, abd pain

Petechial / Purpuric rashSpecial

Finding?Palpable?

Fever?Type of rash?

Petechial / Purpuric Rash

YesPalpable

MeningiococcemiaDisseminatd GC

EndocarditisRMSFHSP

Not palpable

TTPPurpura

Fulminans/DICHSP

NoNot palpable

ITP

PalpableVasculitis

Petechial / Purpuric rashNot Febrile and…

Palpable• Vasculitis

– Vascular damage to capillary sized vessels

Not Palpable• ITP (idiopathic thrombocytopenic

purpura)– Autoimmune in 60%– ½ new cases in children, 70% end in remission

What are these bumps?Macule: Circumscribed area of change without elevationPapule: Solid raised lesion ≤1 cmNodule: Solid raised lesion ≥1 cmPlaque: Circumscribed elevated confluence of papules ≥1 cmMorbilliform: has both macular and papular features

Pityriasis

Drug eruption

Maculopapular Rash

other finding?

Special Finding?

Distribution?

Fever / ill?Type of rash?

Maculopapular

Rash

YesCentral

Viral exanthum Lyme Disease

(erythema migrans)

Peripheral

Target lesions?

Yes: SJS, EM

No: Meningococcemia

RMSF Syphilis Lyme disease

(erythema migrans)

No

CentralDrug reaction

Pityriasis

PeripheralLesion

Distribution?

Flexor:Scabies, Eczema

Extensor:Psoriasis

Maculopapular Rash and Fever

other finding?

Special Finding?

Distribution?

Fever / ill?Type of rash?

Maculopapular

Rash

YesCentral

Viral exanthum Lyme Disease

(erythema migrans)

Peripheral

Target lesions?

Yes: SJS, EM

No: Meningococcemia

RMSF Syphilis Lyme disease

(erythema migrans)

No

CentralDrug reaction

Pityriasis

PeripheralLesion

Distribution?

Flexor:Scabies, Eczema

Extensor:Psoriasis

Maculopapular Rashwith Fever and Central distribution

• Viral exanthum– From Gr: ‘breaking out’– Measles, rubella, erythema

infectiosum, roseola…

• Lyme Disease (erythema migrans)– Target lesions (EM) 3-30 d

after bite– Progresses to neuro (10-15%),

cardiac complications

Maculopapular Rashwith Fever and Peripheral Distribution

Target Lesions• Stevens-Johnson Syndrome (SJS)

– Caused from drugs, infections, malignancies

• Erythema multiforme

No Target Lesions• Meningococcemia• RMSF• Syphilis• Lyme Disease

Clinical presentation, history, and presence of toxicity or neurologic deficits will clue the practitioner to the correct diagnosis

Maculopapular Rash and No fever

other finding?

Special Finding?

Distribution?

Fever / ill?Type of rash?

Maculopapular

Rash

YesCentral

Viral exanthum Lyme Disease

(erythema migrans)

Peripheral

Target lesions?

Yes: SJS, EM

No: Meningococcemia

RMSF Syphilis Lyme disease

(erythema migrans)

No

CentralDrug reaction

Pityriasis

PeripheralLesion

Distribution?

Flexor:Scabies, Eczema

Extensor:Psoriasis

Maculopapular RashNo Fever and Central Lesions

• Drug Reaction– Fixed or centrally located

• Pityriasis rosea– Assoc. with URI, ha, n,v– Herald’s Patch (2-10 cm

oval red) seen– Last 6 weeks

Maculopapular RashNo Fever and Peripheral Lesions

Lesions on Flexor Surfaces• Scabies

• Eczema

Lesions on Extensor Surfaces• Psoriasis

– Immune mediated, pruritic– Red and white scaly plaques,

patches– 30% with arthritis– Tx with ointments, cr,

phototherapy

Clues to Diagnosis RashPatient Age0 to 5 years: Meningococcemia, Kawasaki disease, viral exanthem>65 years: Pemphigus vulgaris, sepsis, meningococcemia, TEN, SJS, TSS

Rash CharacteristicsDiffuse erythema: Staphylococcal SSS, staphylococcal or streptococcal TSS, necrotizing fasciitisMucosal lesions: EM major, TEN, SJS, pemphigus vulgarisPetechiae/purpura: Meningococcemia, necrotizing fasciitis, vasculitis, DIC, RMSF

SymptomHypotension Meningococcemia, TSS, RMSF, TEN, SJS

Bonus clues to bump identification

Key Summary Points

• Rash with fever is a bad thing• Organize rashes to the 4 major types:– erythematous– macular/papular– petechial/purpura– vesicular-bullous

• Secondary signs (Nikolsky, distribution, location (peripheral vs central, extensor vs flexor)

Now, go hit those bumps

References and Acknowledgments• Hanson, S, Nigro, J. Pediatric Dermatology. Medical Clinics of

North America. 82(6):1381-1403, 1998• Lampell, MS.Childhood Rashes that Present to the ED. Pediatric

EM Practice. EBMedicine.net 4:3,2007• CDC homepage (www.cdc.gov/meningitis)• Papulosquamous Diseases. dermatitis

emedicine.medscape.com/article/1108312-overview• Murphy-Lavoie, HM. “Approach to Rashes”. Notes from lecture

Oct 27,2008 . ACEP Scientific Assembly• Special thanks to Dr. Ronald Rapini, MD Chair, Dermatology at

University of Texas Medical School at Houston for various photos