CASE REVIEW

A rash starting on the palms and solesVinod E Nambudiri physician 1 2, Navya S Nambudiri physician 3, Rosalynn M Nazarian pathologist 4,Sandy S Tsao dermatologist 2

1Department of Internal Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; 2Department of Dermatology, Massachusetts GeneralHospital, Boston; 3Cooperative Medical College, Cochin, Kerala, India; 4Department of Pathology, Massachusetts General Hospital

A 23 year old man presented with a rash eight weeks afteremigrating to the United States. One week after immigrationhe had a sore throat, dysphagia, and mild subjective fevers,which resolved in 10 days. Two weeks later, he developed apapular eruption starting on his hands and feet. He had noarthralgia, myalgia, or systemic symptoms. He took no drugs,had no allergies, no family history of skin eruptions, and noclose contacts with a similar rash.He was evaluated at an urgent care clinic one week after theeruption started. The rash was mainly on his palms and solesbut was spreading to the arms and legs. Blood was sent forantibodies to Rocky Mountain spotted fever (RMSF) andcoxsackievirus. Given the life threatening nature of RMSF, hewas treated empirically with seven days of doxycycline withoutimprovement; both tests were negative.Over the next two weeks the rash spread diffusely, becomingmildly pruritic, and he presented to our institution for evaluation.His vital signs were within normal limits and he had no erythemaof the oral mucosa or lymphadenopathy. Hundreds of pinkpapules with silvery scale measuring 2-3 mm in diameter werenoted on his face, palms and dorsal hands, arms, trunk, legs,and feet (fig 1). Linear lesions in areas of excoriation were seenin the right antecubital fossa.

Fig 1 Pink papules with scale on the palms (A) and chest(B). Note the lesions overlying a linear excoriation on theright 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 ofthe epidermis, neutrophilic microabscess formation, dilatedsuperficial dermal blood vessels, and overlying parakeratotichyperkeratotic scale.

Questions1.What are the differential diagnoses for rashes on the palmsand soles?2. What is the diagnosis and what phenomenon do the linearlesions 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 thereferral criteria to dermatology?

Answers1. What are the differential diagnoses forrashes on the palms and soles?Short answerInfections such as coxsackievirus, syphilis, Rocky Mountainspotted fever, scabies, and tinea; inflammatory dermatoses suchas psoriasis, eczema, erythema multiforme, and mycosisfungoides, and drug eruptions.

DiscussionFirst determine whether the process is consistent with a primaryinfection or other cause. Viruses (coxsackievirus), bacteria(rickettsia, treponema), fungi (dermatophytes), and parasites(scabies) can all cause eruptions of the palms and soles.Non-infectious causes include common inflammatorydermatoses (eczema, psoriasis), reactive processes (erythemamultiforme, keratodermas), cutaneous adverse drug reactions,

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

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BMJ 2015;351:h5452 doi: 10.1136/bmj.h5452 (Published 19 October 2015) Page 1 of 3

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and primary neoplastic processes (mycosis fungoides). Historyand the physical examination provide important clues to thediagnosis.

2. What is the diagnosis and whatphenomenon do the linear lesions in areas ofexcoriation demonstrate?Short answerThe history, clinical presentation, laboratory findings, andhistopathology are consistent with a diagnosis of guttatepsoriasis. The development of skin lesions in trauma sites isknown as the Koebner phenomenon.

DiscussionGuttate psoriasis is a benign inflammatory dermatosischaracterized by numerous eruptive papules and plaques on thetrunk and extremities. It is most common in children and youngadults. The lesions derive their name from the Latin guttae(drops), which reflects their diffuse sprinkled distribution. Theinitially thin pink plaques develop an increasingly silvery scale,which reflects the epidermal hyperplasia and hyperkeratosisseen on biopsy (fig 2). This helps distinguish guttate psoriasisfrom other diagnoses including acute viral exanthemata, eczema,morbilliform drug eruptions, and pityriasis rosea.Psoriasis is one of several inflammatory skin diseases that showexacerbation or development of new lesions in areas of skintrauma. Termed the Koebner phenomenon after the Germandermatologist Heinrich Koebner who first described it,koebnerization is also be seen in lichen planus, vitiligo, pityriasisrubra pilaris, and lichen sclerosus among other dermatoses.

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

3. How does the antecedent pharyngitis relateto the rash?Short answerAcute guttate psoriasis has been associated with precedingstreptococcal pharyngitis.

DiscussionA preceding streptococcal infection is seen in more than halfof patients who develop acute guttate psoriasis.1 Our patient’sraised anti-streptolysin-O and anti-DNase-B titers confirmedrecent streptococcal infection. It has been proposed that theunmasking of antigens by the streptococcal infection triggersan inflammatory response that ultimately results in guttatepsoriasis. Flares of psoriasis have also been associated withepisodes of stress,2 and our patient’s recent immigration mayhave contributed to the eruption.

4. How can this condition be treated?Short answerTreatments include topical corticosteroids, topical vitamin Danalogs, topical coal tar, and ultraviolet B phototherapy.Prognosis is good—the disease course is limited inmost patients,with a minority developing chronic disease or plaque psoriasis.

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DiscussionThe first line treatment for guttate psoriasis is usually mid tohigh potency topical corticosteroids.3 The addition of a topicalvitamin D analog such as calcipotriol may also be helpful as asteroid sparing agent, particularly when a large body surfacearea is affected. Coal tar is another topical treatment option. Fortopical resistant disease, phototherapy using narrow band orbroad band ultraviolet B radiation is often effective. Severe orrefractory cases may require oral retinoids or anti-inflammatoryagents such as methotrexate. Treatment with oral antibioticstargeted at streptococci has not helped clear guttate psoriasis,even with evidence of recent streptococcal infection.4Cliniciansshould suspect guttate psoriasis when evaluating an eruptivescaly rash after recent pharyngitis.

5. In patients who present to primary care,what are the referral criteria to dermatology?Short answerConsider referral to dermatology if the diagnosis of an acuteeruption is uncertain, there has been no response to initialtreatment, or specific treatments administered by dermatologistsare being considered.

DiscussionMany acute eruptions and skin lesions are first encountered inprimary care. Atopic dermatitis, plaque psoriasis, and seborrheicdermatitis are common skin conditions that are often diagnosedand managed exclusively in primary care. Dermatologists offeradditional expertise in the diagnosis and management of bothroutine and less common cutaneous conditions. Patients should

be referred if there is diagnostic uncertainty or if an acuteeruption presents with an unusual morphology or with widelyrapid dissemination. If an eruption does not respond to initialtreatment, consider consultation with a dermatologist fordiagnostic or therapeutic guidance. If the diagnosis is clear buta treatment administered by dermatologists is being considered(such as ultraviolet phototherapy), timely referral to adermatologist can help patients access effective treatment mostefficiently.

Patient outcomeThe eruption cleared after a course of topical mid-potencysteroids (triamcinolone acetonide 0.1% ointment) and topicalcalcipotriol. The disease has not relapsed after one year.

Competing interests: We have read and understood BMJ policy ondeclaration of interests and declare the following interests: None.Provenance and peer review: Not commissioned; externally peerreviewed.Patient consent obtained.

1 Naldi L, Peli L, Parazzini F, et al. Family history of psoriasis, stressful life events, andrecent infectious disease are risk factors for a first episode of acute guttate psoriasis:results of a case-control study. J Am Acad Dermatol 2001;44:433-8.

2 Al’Abadie MS, Kent GG, Gawkrodger DJ. The relationship between stress and the onsetand exacerbation of psoriasis and other skin conditions. Br J Dermatol 1994;130:199-203.

3 Chalmers RJ, O’Sullivan T, Owen CM, et al. A systematic review of treatments for guttatepsoriasis. Br J Dermatol 2001;145:891-4.

4 Dogan B, Karabudak O, Harmanyeri Y. Antistreptococcal treatment of guttate psoriasis:a controlled study. Int J Dermatol 2008;47:950-2.

Cite this as: BMJ 2015;351:h5452© BMJ Publishing Group Ltd 2015

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BMJ 2015;351:h5452 doi: 10.1136/bmj.h5452 (Published 19 October 2015) Page 3 of 3

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