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Eliminating Apprehension of Rashes: Developing Diagnostic Expertise

This article explores the physical characteristics of non-infectious and infectious exanthems, distinguishing between non-serious and life-threatening rashes. It provides a diagnostic approach for evaluating and treating these rashes, helping to eliminate apprehension.

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Eliminating Apprehension of Rashes: Developing Diagnostic Expertise

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  1. Eliminating Apprehension of Rashes: Developing Diagnostic Expertise Melissa Cometti, DNP (c), CWOCN, CFCN, BSN Melissa Livingston, DNP (c), BSN, ADN

  2. Objectives • Recognize physical characteristics of non-infectious and infectious exanthems • Distinguish non-serious exanthems from life threatening exanthems • Develop differential diagnoses based upon type of exanthem presentation • Develop clinical approach for evaluation and initial treatment management of non-infectious and infectious exanthems

  3. Nearly 2,200 diseases and disorders affect the skin with approximately 1 in 3 people in the United States being affected by a skin condition at any given time Lyons, F. (2012). Solving skin rash in primary care: Use of a diagnostic decision tree . Advanced Healthcare Network 3(4). Retrieved from http://nurse-practitioners-and-physician-assistants.advanceweb.com/Archives/Article-Archives/Solving-Skin-Rash-In-Primary-Care.aspx

  4. Skin disorders affect 20% to 30% of the U.S. population Economic burden is an estimated $96 billion dollars • Lyons, F. (2012). Solving skin rash in primary care: Use of a diagnostic decision tree . Advanced Healthcare Network 3(4). Retrieved from http://nurse-practitioners-and-physician-assistants.advanceweb.com/Archives/Article-Archives/Solving-Skin-Rash-In-Primary-Care.aspx

  5. Skin Structure • Largest organ of the body • Skin structure includes the epidermis, dermis, subcutaneous tissues, hair, nails, sebaceous glands, sweat glands • Protects the body from damage or injury • Maintain body temperature • Sensation • Vitamin D synthesis • Immune surveillance

  6. Exanthems • Any interruption of skin integrity precipitated by abnormal cellular dysfunction, infection, inflammation, and systemic diseases • Multitude of etiologies exist from inflammatory, allergies, contact, bacterial, fungal, autoimmune, and even genetic • Management and treatment depends on the underlying cause of the rash

  7. Categorization of Rashes • Inflammatory Atopic dermatitis Contact dermatitis Stasis dermatitis Seborrheic dermatitis Eczema Rosacea Urticaria Erythema multiforme 2) Bacterial Cellulitis Acne Impetigo Hidradenitis suppurativa Balanitis Folliculitis Meningococcemia 3) Fungal Candidiasis Tinea corporis/versicolor

  8. Categorization of Rashes 4) Viral Roseola Molluscum contagiosum Warts Pityriasis rosea Herpes simplex/zoster 5) Autoimmune Lupus Psoriasis 6) Parasitic Scabies 7) Miscellaneous Keratosis pilaris Melasma Lichen planus Idiopathic thrombocytopenia purpura

  9. Challenges for Diagnosis • Different condition produce similar rashes • Single skin condition results in different presentations • Time constraints • Insufficient tool to guide diagnosis of rashes

  10. History • Recent Travel • outside of United States, tropical • Environmental exposure • sun, contact, animals, occupation • Exposure to illness • Familial history • allergies, asthma • Sexual history • Complete medical history • current or chronic disease, renal failure, obstructive jaundice, liver damage, anemia, leukemia • Trauma

  11. History • Medications • oral, herbal, topical, illicit • Pain • duration, intensity, length • Pruritus • location, intensity • Previous skin problems • location, timeframe, medical condition • Recurrent rash • exacerbating/alleviating factors

  12. Location • Scalp- Seborrheic dermatitis, Tinea • Face – Melasma, Rosacea, Acne, Roseola, Impetigo • Torso- Seborrheic dermatitis, Pityriasis rosea, Tinea versicolor, Eczema, Roseola, Molluscum contagiosum • Arms – Keratosis pilaris, Psoriasis, Eczema, Hidradenitis suppurativa, Molluscum contagiosum • Hands/Palms- Secondary syphilis, Erythema multiforme, Rickettsia infection, Scabies, Kawasaki disease, Rocky Mountain Spotted Fever

  13. Location • Genitals – Scabies, Candidiasis, Herpes simplex, Balanitis, Secondary syphilis • Legs – Psoriasis, Stasis dermatitis, Eczema, Meningococcemia • Feet/Soles - Secondary syphilis, Erythema multiforme, Rickettsia infections, Scabies, Tinea, Kawasaki disease, Rocky Mountain Spotted Fever

  14. Goldstein, B., Goldstein, A. (2015). Approach to dermatologic diagnosis. Figure 1 A-B: Common disorders encountered during physical examination of skin, front/back.UpToDate. Retrieved from http://www.uptodate.com/contents/approach-to-dermatologic-diagnosis

  15. Physical Examination • Visual inspection • Distribution • localized, generalized • Pattern recognition • discrete, confluent, linear * Koebner reaction • Color • erythema, purpura, petechiae, ecchymosis, telangiectasia • hypo/hyperpigmentation • Morphology • size, shape

  16. Morphology Skin Lesions Wound Care Education Institute (2015). Skin lesion reference guide. Retrieved from https://woundcare.leadpages.co/lesionguideald/

  17. Physical Examination • Palpation of the skin • texture changes • edema, depth, fixation, induration • temperature • Dermatological signs: * Blanching – erythema result of vasodilation * Nikolsky sign- easy separation of epidermis from dermis * Dermographism- stroking or rubbing produces hyper-histamine response

  18. Documentation • History • travel, familial, illness • Skin lesion • morphology skin lesion table • Distribution • localized, generalized • Symptoms • pruritus, painful, exudate, fever • Alleviated factors • antihistamines, topical corticosteroids, analgesics • Diagnostic labs/test • swab cultures, skin biopsy, patch testing, Wood’s lamp, microscope, CBC, ESR, ANA, serology testing

  19. Concerning Factors for Rash • Fever • Blister • Painful • Infected • Spreads suddenly/rapidly • Systemic/widespread

  20. Diagnostic Decision Tree Lyons, F. (2012). Solving skin rash in primary care: Use of a diagnostic decision tree. Advanced Healthcare Network 3(4) [online source]. Retrieved from http://nurse-practitioners-and-physician-assistants.advanceweb.com/Archives/Article-Archives/Solving-Skin-Rash-In-Primary-Care.aspx

  21. Pediatric Case Study • HPI: A 3 year old male toddler presents to the primary care clinic with discrete vesicles in a centralized pattern location on the face with a satellite erosion on the right hand worsening over the last 3 days. Scattered within the ruptured vesicles are scaled, honey-crusted erosions that are mildly pruritic and tender to touch. • Family History: 1 younger sibling, lives with mother/father who are in good health, no smoking, alcohol use, or illicit drugs, possible sick contacts at daycare 5 days a week • Medical History: No medication, no recent travel, normal birth • NKDA • Vaccinations: Up to date

  22. Pediatric Case Study • ROS: Denies fever, diarrhea, loss of appetite (poor food intake), abdominal pain, no recent infections, runny nose, or sore throat • Physical Examination • General: Mild distress, picking at crusted erosions • HEENT: Moist mucous membranes, ruptured vesicles measuring 0.5 cm diameter with scattered honey crusted erosions measuring 1.5 cm to nose, lower portion of lip, and right cheek • CVS: RRR, No M/R/G • Lungs: CTA, no wheezing, rales, rhonchi, no increased work of breathing • Abdomen: Soft, non-tender, not distended, normoactive BS • Skin: Scaled honey crusted erosion to right hand measuring 1 cm • Extremities: Moving all extremities with 5/5 sensation and strength

  23. Pediatric Case Study – Decision Tree • History • Potential sick contacts – daycare • Younger sibling • Location • Nose, lower portion of lip, right cheek • Right hand • Physical Assessment • Scaled, honey crusted erosions within ruptured vesicles measuring from 0.5 cm to 1 cm

  24. Pediatric Case Study - Impetigo • Treatment • Mupirocin 2% ointment active against S pyogenes and S. aureus, including CA-MRSA • Apply topically 3 times a day for 5 days • Cephalexin orally for at least 7 days up to 14 days • Education • Contagious for 24 hours until antimicrobial therapy is initiated • Draining lesions should be covered • Strict handwashing

  25. Adult Case Study • HPI: A 62 year old female presents the urgent care complaining of a pruritic rash to her right upper forearm and both lower legs that has progressed to a burning sensation with increased redness over the last 2 weeks. • Family History: Lives alone, widowed and retired, son lives next door • Social History: Gardens daily growing her own vegetables, no illicit drug use, alcohol use, or smoking; no recent travel • Medical History: Hypertension, osteoporosis on- Lisinopril 10 mg orally daily, Alendronate 70 mg orally once weekly on Sunday • NKDA • Vaccinations: Influenza, PCV 13 and PPSV23, and shingles

  26. Adult Case Study • ROS: Denies palpitations, shortness of breath, dysuria, chills, fever, diarrhea, loss of appetite (poor food intake), abdominal pain, no recent infections • Physical Examination • General: Mild distress, scratching arms • HEENT: Moist mucous membranes, PERRL • CVS: RRR, No M/R/G, no edema • Lungs: Clear to upper lobes bilaterally, slightly diminished to lower lobes bilaterally • Abdomen: Soft, non-tender, not distended, BS normoactive • Skin: Annular, erythematous papular lesions with a central clearance noted to be diffuse in distribution to right upper forearm; annular, erythematous scaled lesions with raised border to lower extremities bilaterally diffuse in distribution • Musculoskeletal: Moving all extremities with 5/5 sensation and strength; normal gait • Neuro: No anxiety or restlessness, cooperative and pleasant

  27. Adult Case Study • History • 2 week onset, daily gardening, no recent travel, had shingles, pneumonia, and influenza vaccinations • Location • Right upper forearm, lower legs bilaterally • Physical Assessment • Annular, erythematous papular lesions with a central clearance noted to be diffuse in distribution to right upper forearm; annular, erythematous scaled lesions with raised border to lower extremities bilaterally diffuse in distribution

  28. Adult Case Study – Tinea corporis • Diagnostic tests • Dermatophyte infection • KOH (potassium hydroxide) preparation with skin scrapings from active border • Hyphae visualization under microscope • Treatment • Clotrimazole 1% topically twice daily for 2-4 weeks • Ketoconazole 1% topically once daily for 2-4 weeks • Systemic: terbinafine 250mg orally daily for 1-2 weeks • Education • Mode of transmission • Anthropophilic, geophilic (gardening), zoophilic, fomites • Hand washing

  29. Can Rashes Predict the Health of Your Body? Yeast (Candidiasis) Vitamin C (Scurvy) Niacin Deficiency (Pellagra) Diabetes (Acanthosis nigricans) Cardiac (Infective Endocarditis)

  30. Can Rashes Predict the Health of Your Body? • Pulmonary(Sarcoidosis) • Chronic Kidney Disease (Uremic frost) • Organ (Scleroderma) • Celiac Disease (Dermatitis herpetiformis) • Lupus (Lupus erythematosus) • Cancer (Mycosis fungoides)

  31. Life Threatening Exanthems • Pediatric • Kawasaki disease • Children younger than 8 years, blanching macular trunk, groin, diaper area; hyperemic oral mucosa • Scarlet fever • Fever, vomiting, headache, abdominal pain, pastia lines (petechiae in antecubital and axillary folds), follows strep or skin infection • Staphylococcal scalded skin syndrome • Children younger than 6 years, painful, sandpaper erythema flexural areas progress to bullae, Nikolsky sign • Adult • Necrotizing fasciitis • Hemolytic streptococcal gangrene, subcutaneous air, rapidly progress, any area, surgical debridement • Stevens-Johnson Syndrome • Vesiculobullous lesions on eyes, mouth, genitalia, palms, soles; fever, pain, Nikolsky sign • Meningococcemia • Non-blanching petechiae, palpable purpura, necrotic centers, spares palms/soles • Lyme disease • Generalized macular lesions extremities, crease, history of outdoor activity, common northeastern U.S.

  32. Life Threatening Exanthems

  33. Developing Diagnostic Expertise • Pregnancy • Striae gravidarum • Late 2nd, early 3rd trimester, primigravidas • Risk factors – younger age, familial history, mechanical skin stress • Treatment- limited success with topical creams • Viral • Pityriasis rosea, chickenpox, shingles, measles, Parvovirus B19 (Fifth Disease) • Darker skin • Fitzpatrick skin Types III to VI • Hypo/hyperpigmentation

  34. References • American Academy of Dermatology (2017). Rash 101 in adults: When to seek treatment. Retrieved from https://www.aad.org/public/diseases/rashes/rash-in-adults • Barss, V. (2015). Avoiding infections in pregnancy: Beyond the basics. UptoDate. Retrieved from http://www.uptodate.com/contents/avoiding-infections-in-pregnancy-beyond-the-basics • Ely, J. & Stone, M. (2010). The generalized rash: Part I. differential diagnosis. American Family Physician 81(6), 726-734. • Ely, J. & Stone, M. (2010). The generalized rash: Part II. diagnostic approach. American Family Physician 81(6), 735-739.

  35. References • Farahnik, B., Park, K., Kroumpouzos, G., & Murase, J. (2016). Striae gravidarum: Risk factors, prevention, and management. International Journal of Women’s Dermatology [online]. Retrieved from http://www.sciencedirect.com/science/article/pii/S2352647516300272 • Goldstein, B., Goldstein, A. (2015). Approach to dermatologic diagnosis. UpToDate. Retrieved from http://www.uptodate.com/contents/approach-to-dermatologic-diagnosis • Lyons, F. (2012). Solving skin rash in primary care: Use of a diagnostic decision tree. Advanced Healthcare Network 3(4) [online source]. Retrieved from http://nurse-practitioners-and-physician-assistants.advanceweb.com/Archives/Article-Archives/Solving-Skin-Rash-In-Primary-Care.aspx

  36. References • Ofori, A. & Corona, R. (2017). What’s new in dermatology. UptoDate. Retrieved from https://www.uptodate.com/contents/whats-new-in-dermatology • Uphold, C. & Graham, M. (2013). Clinical guidelines in family practice (5th ed.). Gainesville, F.L: Barmarrrae Books Inc. • Watkins, J. (2013). Skin rashes, part 1: skin structure and taking a dermatological history. Practice Nursing, 24(1), 30-34. Retrieved from http://libezp.nmsu.edu:2125/ehost/pdfviewer/pdfviewer?vid=4&sid=1637ca64-33bd-48b3-a30b-1c84c024b23d%40sessionmgr102&hid=119 • Watkins, J. (2013). Skin rashes, part 2: Distribution and types of rashes. Practice Nursing, 24(3), 124-128. Retrieved from http://libezp.nmsu.edu:2125/ehost/detail/detail?vid=11&sid=1637ca64-33bd-48b3-a30b-1c84c024b23d%40sessionmgr102&hid=119&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=107991622&db=ccm

  37. References • Watkins, J. (2013). Skin rashes, part 3: Localized rashes. Practice Nursing, 24(5), 235-242. Retrieved from http://libezp.nmsu.edu:2125/ehost/detail/detail?vid=12&sid=1637ca64-33bd-48b3-a30b-1c84c024b23d%40sessionmgr102&hid=119&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=108013789&db=ccm • Watkins, J. (2013). Diagnosing rashes, part 4: generalized rashes with fever. Practice Nursing, 24(7), 335-341. Retrieved from http://libezp.nmsu.edu:2125/ehost/pdfviewer/pdfviewer?vid=16&sid=1637ca64-33bd-48b3-a30b-1c84c024b23d%40sessionmgr102&hid=119

  38. References • Watkins, J. (2013). Diagnosing rashes, part 5: itchy rashes. Practice Nursing, 24(9), 438-445. Retrieved from http://libezp.nmsu.edu:2125/ehost/pdfviewer/pdfviewer?vid=17&sid=1637ca64-33bd-48b3-a30b-1c84c024b23d%40sessionmgr102&hid=119 • Watkins, J. (2013). Diagnosing rashes, part 6: itchy rashes in specific conditions. Practice Nursing, 24(11), 556-561. Retrieved from http://libezp.nmsu.edu:2125/ehost/pdfviewer/pdfviewer?vid=20&sid=1637ca64-33bd-48b3-a30b-1c84c024b23d%40sessionmgr102&hid=119

  39. References • Watkins, J. (2014). Diagnosing rashes, part 7: purpuric rashes. Practice Nursing, 25(1), 23-28. Retrieved from http://libezp.nmsu.edu:2125/ehost/pdfviewer/pdfviewer?vid=23&sid=1637ca64-33bd-48b3-a30b-1c84c024b23d%40sessionmgr102&hid=119 • Watkins, J. (2014). Diagnosing rashes, part 9: annular rashes. Practice Nursing, 25(5), 230-238. Retrieved from http://libezp.nmsu.edu:2125/ehost/pdfviewer/pdfviewer?vid=25&sid=1637ca64-33bd-48b3-a30b-1c84c024b23d%40sessionmgr102&hid=119 • Watkins, J. (2014). Diagnosing rashes, part 10: linear skin rashes. Practice Nursing, 25(7), 344-350. Retrieved from http://libezp.nmsu.edu:2125/ehost/pdfviewer/pdfviewer?vid=26&sid=1637ca64-33bd-48b3-a30b-1c84c024b23d%40sessionmgr102&hid=119 • Wound Care Education Institute (2015). Skin lesion reference guide. Retrieved from https://woundcare.leadpages.co/lesionguideald/

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