Those Bumps aren’t Moguls!
An Algorithmic Approach to Rashes
David Robinson MD
Department of Emergency Medicine
University of Texas Medical School at Houston
31rst 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. Erythematous
b. Vesiculo-bullous
c. Petechiae/Purpura
d. 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?
Erythematous Rashes
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 Rash
Type of rash?
Fever?
Special
Finding?
Nikolsky sign
Yes
Staphylococcal SSS
(children)
TEN (adults)
Yes
No
Erythematous Rash
TSS
Kawasaki disease
Scarlet fever
Yes
TEN
No
Anaphylaxis
Scombroid Poisoning
Alcohol Flush
No
Erythematous Rash with fever
Positive 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/eyesshoulders and
UE
– Mortality 30-35%
Erythematous Rash with fever
No 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 Rash
Type of rash?
Fever?
Special
Finding?
Nikolsky sign
Yes
Staphylococcal SSS
(children)
TEN (adults)
Yes
No
Erythematous Rash
TSS
Kawasaki disease
Scarlet fever
Yes
TEN
No
Anaphylaxis
Scombroid Poisoning
Alcohol Flush
No
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
What are the diagnostic clues ?
Bed 9
• 60 yo with sharp back and
chest pain
• Blisters over specific area of
chest – follows dermatome
• No fever
Fever and rash distribution
Vesiculo-Bullous Rash
Definitions: Circumscribed fluid filled sac less
than 1 cm (vesicle) or greater than 1 cm (bullous)
Bullous erythema multiforme
Vesicles of Hand, foot and mouth
Vesiculo-Bullous Rash
Type of
rash?
Fever?
Special
Finding?
Necrotizing fasciitis
Hand, Foot, and Mouth
Distribution
Localized
Varicella/Chicken Pox
Small Pox
Disseminated GC
Yes
Purpura Fulminans/ DIC
Diffuse
Vesiculo-Bullous
Rash
Bullous Pemphigus
Pemphigus Vulgaris
Diffuse
No
Contact Dermatitis
Zoster
Localized
Burns
Dyshidrotic Eczema
Vesiculo-Bullous rash
Febrile 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 rash
Febrile 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 Rash
Type of
rash?
Fever?
Special
Finding?
Necrotizing fasciitis
Hand, Foot, and Mouth
Distribution
Localized
Varicella/Chicken Pox
Small Pox
Disseminated GC
Yes
Purpura Fulminans/ DIC
Diffuse
Vesiculo-Bullous
Rash
Bullous Pemphigus
Diffuse
No
Pemphigus Vulgaris
Contact Dermatitis
Zoster
Localized
Burns
Dyshidrotic Eczema
Vesiculo-Bullous rash
Not 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
Vesiculo-Bullous rash
Not Febrile and Diffuse
• 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
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?
Petechial / Purpuric rash
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
Type of
rash?
Fever?
Special
Finding?
Meningiococcemia
Palpable?
Disseminatd GC
Endocarditis
RMSF
Palpable
Yes
HSP
TTP
Purpura
Fulminans/DIC
Petechial /
Purpuric Rash
Not palpable
HSP
ITP
Not palpable
No
Vasculitis
Palpable
Palpable
•
•
•
•
•
Petechial / Purpuric rash
Febrile and…
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 / Purpuric
Febrile 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 rash
Type of
rash?
Fever?
Special
Finding?
Meningiococcemia
Palpable?
Disseminatd GC
Endocarditis
RMSF
Yes
Palpable
HSP
TTP
Purpura
Fulminans/DIC
Petechial /
Purpuric Rash
Not palpable
HSP
ITP
Not palpable
No
Vasculitis
Palpable
Petechial / Purpuric rash
Not 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 elevation
Papule: Solid raised lesion ≤1 cm
Nodule: Solid raised lesion ≥1 cm
Plaque: Circumscribed elevated confluence of papules ≥1 cm
Morbilliform: has both macular and papular features
Drug eruption
Pityriasis
Maculopapular Rash
Type of rash?
Fever /
ill?
Yes
Special
Finding?
Distribution?
other
finding?
Yes:
Central
SJS, EM
Target
lesions?
Peripheral
Maculopapular
Viral exanthum
Lyme Disease
(erythema migrans)
No:
Meningococcemia
RMSF Syphilis
Lyme disease
(erythema migrans)
Rash
Flexor:
Peripheral
No
Scabies, Eczema
Lesion
Distribution?
Extensor:
Psoriasis
Central
Drug reaction
Pityriasis
Maculopapular Rash and Fever
Type of rash?
Fever /
ill?
Yes
Special
Finding?
Distribution?
other
finding?
Yes:
Central
SJS, EM
Target
lesions?
Peripheral
Maculopapular
Viral exanthum
Lyme Disease
(erythema migrans)
No:
Meningococcemia
RMSF Syphilis
Lyme disease
(erythema migrans)
Rash
Flexor:
Peripheral
No
Scabies, Eczema
Lesion
Distribution?
Extensor:
Psoriasis
Central
Drug reaction
Pityriasis
Maculopapular Rash
with 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 Rash
with Fever and Peripheral Distribution
Target Lesions
• Stevens-Johnson Syndrome (SJS)
– Caused from drugs,
infections, malignancies
No Target Lesions
• Meningococcemia
• RMSF
• Syphilis
• Lyme Disease
• Erythema multiforme
Clinical presentation, history, and presence of toxicity
or neurologic deficits will clue the practitioner to the
correct diagnosis
Maculopapular Rash and No fever
Type of rash?
Fever /
ill?
Yes
Special
Finding?
Distribution?
other
finding?
Viral exanthum
Lyme Disease
(erythema migrans)
Yes:
Central
SJS, EM
Peripheral
Target
lesions?
No:
Meningococcemia
RMSF Syphilis
Lyme disease
(erythema migrans)
Maculopapular
Rash
Flexor:
Peripheral
No
Scabies, Eczema
Lesion
Distribution?
Extensor:
Psoriasis
Central
Drug reaction
Pityriasis
Maculopapular Rash
No 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 Rash
No 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
Bonus clues to bump identification
Clues to Diagnosis Rash
Patient Age
0 to 5 years: Meningococcemia, Kawasaki disease, viral exanthem
>65 years: Pemphigus vulgaris, sepsis, meningococcemia, TEN, SJS, TSS
Rash Characteristics
Diffuse erythema: Staphylococcal SSS, staphylococcal or streptococcal TSS,
necrotizing fasciitis
Mucosal lesions: EM major, TEN, SJS, pemphigus vulgaris
Petechiae/purpura: Meningococcemia, necrotizing fasciitis, vasculitis, DIC,
RMSF
Symptom
Hypotension Meningococcemia, TSS, RMSF, TEN, SJS
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