Large erythematous patch as the presenting manifestation of meningococcemia.

Meningococcemia commonly presents with a petechial rash and a transient macular or papular rash is sometimes present. This report describes a patient with meningococcemia who presented with an atypical erythematous patch over the right hemithorax, petechial rash, and a normal platelet count. The patient was treated with broad-spectrum antibiotics and his condition rapidly improved. He was discharged showing complete resolution of his rash with no neurologic sequelae.     

Malnutrition-associated rash of cystic fibrosis

Rash is a rare presenting sign of cystic fibrosis (CF) complicated by protein-calorie malnutrition. We measured essential fatty acid (EFA) levels in the serum of a 4-month-old girl with an erythematous, desquamating, periorificially accentuated rash in association with malnutrition and her 2-year-old sister who was diagnosed concurrently with CF but had no rash or signs of malnutrition. Both patients had biochemical evidence of EFA deficiency, suggesting that development of the rash is multifactorial. Clinical presentation, management, and possible modes of pathogenesis of the rash are reviewed. Pathogenesis of the rash appears to involve a complex interaction among deficiencies of EFAs, zinc, protein, and possibly copper, leading to disordered prostaglandin metabolism or cytokine production, or free radical-induced damage to cellular membranes due to a lack of nutrient-derived protective antioxidants.     

Higher severity grade of erlotinib-induced rash is associated with lower skin phototype

Background. Epidermal growth factor receptor inhibitors (EGFRIs) are associated with a characteristic papulopustular rash, an adverse event considered to be a class effect of these agents. Erlotinib, a small‐molecule EGFRI, causes a papulopustular rash in 68–75% of patients. The limited reported data suggest that deleterious effects of ultraviolet radiation (UVR) may enhance the development of EGFRI‐induced rash. Because the level of the biological pigment melanin correlates with increased protection against UVR, we hypothesized that lighter levels of skin pigmentation are associated with greater severity of rash. Aim. To characterize the relationship between skin phototype (SPT) and rash severity. Methods. A retrospective chart review was conducted of 40 patients on erlotinib. Skin sensitivity to UVR was categorized using the Fitzpatrick SPT classification scheme. Grading of rash was performed using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI‐CTCAE), version 3. Results. There was an inverse relationship between SPT and rash severity. Grade 0 was seen in the majority of patients with SPT V/VI, grade 1/2 in the majority of patients with SPT III/IV, and grade 3/4 rash in the majority of patients with SPT I/II (grade 0: 7% SPT I/II, 32% SPT III/IV and 50% SPT IV/V; grade 1/2: 33%, 63% and 50%, respectively; grade 3/4: 60%, 5% and 0%, respectively) (P < 0.01, Fisher exact test). Conclusions. Prevention and management of cutaneous side‐effects from EGFR inhibitors is important to achieve maximum patient compliance and therapeutic benefit. The results of this study suggest that SPT may be an independent predictive factor for EGFRI‐induced papulopustular rash, thus pre‐therapy counselling and early intervention are important.     

Sparing of leprosy macule in ampicillin hypersensitivity rash

A case of tuberculoid leprosy is reported in a middle aged female, who presented with generalised erythematous maculopapular rash which followed ampicillin therapy. In spite of extensive and severe involvement of the skin all over the body by erythema and rash, the hypopigmented patch of leprosy on the face did not show any erythema or rash and stood out more clearly as an island of pale area in the midst of large area of erythema on the face. The possible mechanism of non development of erythema and rash in the patch is discussed.     

Clinical features and treatment of epidermal growth factor inhibitor-related late-phase papulopustular rash

Papulopustular rash, an acneiform rash, appears on the seborrheic region during the first to second week of treatment with an epidermal growth factor receptor inhibitor (EGFRi). The rash gradually disappears after the fourth week; however, it persists or newly develops in other regions during EGFRi treatment. Because Staphylococcus aureus is frequently isolated from late-phase papulopustular rash, we assessed the incidence of bacterial infection and treatment outcomes of patients with late-phase papulopustular rash. Sixty-four cases treated with an EGFRi over 4 weeks who presented with papulopustular rash were assessed retrospectively. The median duration of EGFR inhibitor treatment was 5 months. Grade 2 and 3 papulopustular rash was observed in 47 and eight cases, respectively. Bacterial culture was performed in 51 cases, 50 of which yielded positive results: methicillin-sensitive S. aureus in 29, methicillin-resistant S. aureus in 14, Staphylococcus species in five, Pseudomonas aeruginosa in three, and other in four cases. Of the S. aureus isolates, 42% were resistant to minocycline and 40% to levofloxacin. After treatment with topical and/or oral antibiotics without topical corticosteroids, the papulopustular rash rapidly improved by an average of 2.9 ± 3.4 weeks. However, use of a combination of antibiotics and a topical corticosteroid prolonged the recovery period to an average of 18.9 ± 11.4 weeks. In conclusion, folliculitis that develops over 4 weeks after the initiation of EGFRi treatment is typically caused by staphylococcal infection. Bacterial culture is necessary due to the high rate of antibiotic resistance. It is important to distinguish late- from early-phase papulopustular rash and to treat using different approaches.     

Skin rash during erlotinib for advanced non-small cell lung cancer: is age a clinical predictor?

The aim of this study was to evaluate the intensity and the duration of acneiform skin rash in young and elderly patients, to define a possible relationship between age and skin rash. We retrospectively analyzed all consecutive patients with advanced NSCLC who developed acneiform skin rash during erlotinib treatment at our Clinical Oncology Unit from June 2006 to May 2011. We divided the general case study into two subgroups: young and elderly patients (≥65 years) and we compared clinical, pathological and therapeutical characteristics of both subgroups. Among 25 patients affected by advanced NSCLC treated with erlotinib during the reference period, 19 patients (76.0 %) developed acneiform skin rash. Fourteen (73.7 %) of 19 patients were elderly. The majority of elderly patients has developed acneiform skin rash (82.4 vs 62.5 %). In addition, in elderly patients, acneiform skin rash has a higher intensity (for mild rash 7.1 vs 20.0 %, for moderate rash 57.1 vs 60.0 %, for severe rash 35.7 vs 20.0 %) and longer duration, especially for mild and moderate rash (for mild rash 154 vs 40 days, for moderate rash 120 vs 76 days, for severe rash 31 vs 85 days). The univariate analysis showed no statistical significant difference in OS between young and elderly patients (p = 0.191), such as age, does not seem to influence the appearance (p = 0.386), duration (p = 0.455) and grade of acneiform skin rash (p = 0.765). In conclusion, we can affirm that age is an insufficient predictor of acneiform skin rash during erlotinib treatment in advanced NSCLC and does not seem to statistically influence the appearance, duration and grade of skin rash.     

Cutaneous changes in trichinellosis seen in Japan

Since 1974, three outbreaks of human trichinellosis have been reported from Japan with a total of 87 cases. A characteristic skin rash was seen together with muscle pain, fever, malaise, periorbital edema and marked eosinophilia. The rash appeared in all cases as fine red maculopapular plaques with an urticarial character. Although the reason for the high frequency of the rash is obscure, it seemed to be one of the most valuable symptoms of human trichinellosis in Japan.     

Rash related to use of scented products. A questionnaire study in the Danish population. Is the problem increasing?

Fragrances are used in many types of cosmetic and household products, which are an important part of everyday life in modern society. The aim of the current investigation was to describe the frequency of self-reported rash due to scented products in a random sample of the adult Danish population. Further, it was determined whether risk of self-reported 1st-time rash from scented products had increased during the past 15 years compared to the preceding period. The sample consisted of 1537 persons, 801 female and 736 male, above the age of 15 years. The participants were interviewed person-to-person to obtain a general health profile, and in this connection, questions were asked concerning rash related to the use of scented products. 28.6% (440/1537) had on some occasion experienced rash from scented products, 10.6% had experienced rash within the year prior to interview. A multivariate analysis showed that women had a significantly increased risk of reporting rash from scented products compared to men (odds ratio: 1.56, p<0.0001). Furthermore, it was shown that individuals below the age of 40 years had a significantly increased risk of reporting rash from scented products compared to older age groups. The risk of reporting 1st-time rash occurring after 1978 was significantly increased (odds ratio: 2.34, p<0.0001), as compared to the preceding period. This may be taken as indicative of an increasing problem with scented products, involving potentially severe public health implications.     

Association between EGFR gene polymorphisms,skin rash and response to anti‐EGFR therapy in metastatic colorectal cancer patients

Cetuximab and panitumumab are epidermal growth factor receptor (EGFR) inhibitors used in metastatic colorectal cancer (mCRC). Most patients develop a papulopustular rash that may predict tumor response to treatment. EGFR gene polymorphisms may also determine tumor response and appearance of skin rash. We hypothesized an association between EGFR gene polymorphisms, papulopustular rash and response to anticancer treatment. Four EGFR polymorphisms (?216, ?191, CA‐SSR, R521K) were analysed in 51 patients with mCRC receiving anti‐EGFR. Severity of cutaneous rash and tumor response was measured following standard scales. We report an association between SNP‐216 and tumor response (P = 0.003): no tumor progression occurred in TT genotype. Moreover, 92.3% of the responder patients developed skin rash, 62.9% of them presenting a grade ≥2 (P = 0.015). Thus, although underpowered, our preliminary data suggest that SNP‐216 polymorphism of the EGFR gene could be useful in predicting tumor response and the appearance of severe skin rash might also be associated.     

Koebner's Phenomenon in Childhood Henoch‐Schönlein Purpura: A Report of Two Cases

Koebner's phenomenon occurs rarely in connection with Henoch‐Schönlein purpura (HSP). We report two children with HSP who developed Koebner's phenomenon on the second day after the onset of rash. The first was an 11‐year‐old girl with rheumatic heart disease who presented with abdominal pain for 1 month and subsequently developed rash and nephritis. The second patient was a 7‐year‐old girl who presented with rash and polyarthritis. To the best of our knowledge, Koebner's phenomenon in childhood HSP has not been reported.     

Acute infectious erythemas in children: a clinico-microbiological study

One-hundred children with an acute illness comprising fever and widespread erythematous rash were prospectively studied to determine whether clinical presentations are helpful in defining the causative agent and to identify the most appropriate microbiological specimens. An infectious agent was identified in 65 children; 72% were viruses, 20% were bacteria, 5% were Mycoplasma pneumoniae and in 3% both viruses and bacteria were detected. The most common infectious agents were picornaviruses, an atypical presentation of measles and Group A beta-haemolytic Streptococcus. Different patterns of rash occurred with each of these infections. The clinical presentation of a child with an acute febrile illness and rash was unhelpful in defining the causative agent. Routine management should include a throat swab for bacterial investigation and in selected cases a blood sample for IgM viral titres.     

Dermatitis and the newborn rash of hyper-IgE syndrome

OBJECTIVE: To characterize the dermatitis, the newborn rash, and cutaneous findings in hyper-IgE syndrome, also known as Job's syndrome. DESIGN: Prospective and retrospective evaluation and treatment of cutaneous manifestations in patients with a clinical diagnosis of hyper-IgE syndrome (HIES). Analysis of the newborn rash encountered in this population. SETTING: Dermatology clinic at the National Institutes of Health, Bethesda, Md. PATIENTS: Forty-three patients seen in our clinic between January 1998 and August 2003 who had a clinical diagnosis of HIES. INTERVENTIONS: The UK Working Party's Diagnostic Criteria for Atopic Dermatitis were used to assess for atopic dermatitis in this population. To assess the newborn rash, we performed a retrospective chart review and an in-person or telephone interview of the parent or caregiver of each patient. RESULTS: Twenty-eight (65%) of 43 patients fulfilled the criteria for atopic dermatitis. Thirty-five (81%) of 43 patients reported a newborn rash. Eight (19%) of 43 were born with the rash; 23 (53%) of 43 had acquired the rash within 7 days; 32 (74%) of 43 within 14 days; 34 (79%) of 43 within 30 days; and 35 (81%) of 43 had the rash within 35 days of birth. CONCLUSIONS: The dermatitis in HIES resembles classic atopic dermatitis but may have distinctive features. A newborn rash is almost always a presenting sign of HIES. After the newborn period, skin findings include retroauricular fissures, external otitis, infected dermatitis of the axillae and groin, folliculitis of the upper back and shoulders, cutaneous abscesses, mucocutaneous candidiasis, and in some patients pitted scarring of the face.     

Paediatric necrolytic migratory erythema as a presenting sign of glucagonoma syndrome

Glucagonoma syndrome is an extremely rare pancreatic neuroendocrine tumour often associated with necrolytic migratory erythema. While glucagonomas are neoplasms of adulthood, we report the first case in a paediatric patient. We present the case of a 15‐year‐old girl with a 4‐year history of a rash, consistent with necrolytic migratory erythema, found to have a localized glucagonoma. Immediately following resection of the tumour, there was complete resolution of her rash and systemic symptoms. Detection of the cutaneous rash of necrolytic migratory erythema can aid in the early diagnosis of a glucagonoma, as well as the prevention of metastatic disease. To our knowledge, this is the first reported paediatric patient with glucagonoma syndrome.     

Fever with rash in a child in India

Fever with rash is common among children and are seen by both dermatologists and pediatricians. Most of them are benign viral exanthems without much clinical significance. This article gives an overview of the infectious and noninfectious causes of fever with rash in children and how to diagnose them, with special emphasis on the Indian scenario as well. It also differentiates them from fever with rash caused by drugs. This review emphasizes that although benign in many cases, it is necessary to identify the signs of serious illnesses to prevent mortality or sequelae.     

Photo-onycholysis due to sparfloxacin

This paper describes a case of sparfloxacin-induced photodermatitis associated with photo-onycholysis in a 36-year-old man. He was being treated with sparfloxacin, streptomycin, ethambutol and pyrazinamide for pulmonary tuberculosis. He developed an exaggerated sunburn-like rash over the face and the dorsa of hands and feet, and painful onycholysis of finger- and toe-nails. Withdrawal of sparfloxacin resulted in resolution of the skin rash and nail tenderness.     

Cryopyrin-associated periodic syndrome: a case report and review of the Japanese literature

Cryopyrin-associated periodic syndrome is an autoinflammatory syndrome caused by mutations of the CIAS1 gene (currently named NLRP3), and is characterized by periodic attacks of an urticaria-like rash, fever, head-ache, conjunctivitis and arthralgia. We report here a case of a 1-year-old boy with cryopyrin-associated periodic syndrome, which manifested as a recurrent skin rash in the postnatal period. Genetic analysis revealed a missense mutation of the CIAS1 gene in the mother and infant.     

Contact allergy due to lichens in patients with a history of photosensitivity

Ten patients with a history of photosensitivity and of a rash showed abnormal reactions to long-wave UVR. The rash occurred particularly in areas exposed to light, though other areas were occasionally involved. The development of the rash could in all patients be related to contact with lichens and although exposure to sunlight usually led to an aggravation of symptoms, some patients, particularly forestry workers, showed exacerbations even during the winter. Positive responses were observed in both irradiated and non-irradiated patch tests with different species of lichen and in several patients irradiation precipitated a stronger response. These findings suggest that lichens can cause both contact and photocontact dermatitis. The suspected allergens contained in these lichens are atranorin, physodalic and pysodic acids.     

The rash with maculopapules and fever in adults

There is a broad differential diagnosis for the presentation of fever and maculopapular rash in an adult. Although some causative conditions are benign, others are medical emergencies that require prompt diagnosis. We describe various conditions that result in a fever and maculopapular rash in adults. These include infectious processes (meningococcemia, infectious mononucleosis, West Nile virus, zika virus, rubella, primary human immunodeficiency virus, parvovirus B19, ebolavirus), tick-borne illnesses (Rocky Mountain spotted fever, ehrlichiosis), and hypersensitivity reactions (exanthematous drug reactions). We also provide an algorithm to aid in the diagnosis of the patient with fever and maculopapular rash. Such conditions that can occur in adults but are seen predominantly in children are discussed in the article “Rash with maculopapules and fever in children” of this issue.     

Outbreak of Rash in Children Associated with Recreational Mud Exposure

Abstract: We conducted an investigation of a rash outbreak in children who attended the “Mud Mania Festival.” The mean incubation period of illness was 26 hours, and mean duration was 4.3 days. Time spent in mud was associated with the extent of rash in a dose–response fashion. The cultures from lesions of two unrelated cases yielded Enterobacter cloacae.