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A Young Male with a Rash of Scales

A Young Male with a Rash of Scales

  • A young male has a rash after having a strep throat.
    11-year-old Mike is brought in for a scaly rash that started several days ago. He had a sore throat last week and was treated for “Strep throat” based on a rapid strep test and confirmed by a positive culture. He has not had any skin problems in the past other than dandruff.
  • A scaly rash is asymptomatic. PMH noncontributory.
    The family history and Mike’s past medical history are non- contributory. His main concern is this unsightly, but asymptomatic rash.
  • A closer look shows the tear-drop shaped scales are symmetrical on his trunk and proximal extremities.
  • A closer look shows the tear-drop shaped scales are symmetrical on his trunk and proximal extremities.
  • Papulosquamous lesions have a silvery scale.
    On closer inspection, we see that the rash consists of 0.5mm-1mm ovoid-to-slightly-round papulosquamous lesions with a silvery scale. The scale is quite adherent and attempts to scrape the lesions result in punctate bleeding.
  • We have an adherent silvery scale; we have an antecedent upper respiratory infection with documented group A Streptococcus. Could it be: Seborrheic dermatitis Onychomycosis Squamous cell carcinoma Nummular eczema Lichen planus Lichen simplex chronicus Mycosis fungoides? Or, perhaps, this is a near perfect story for a diagnosis other than one listed above.
  • Answer: Guttate psoriasis. Most often occurs in children and young adults (less than 30 years of age). The silvery scale with punctate bleeding (Auspitz sign) is a tip off. Remember there is a spectrum of disease for psoriasis, so guttate psoriasis is not predictive of extensive disease.
  • Most often seen in persons younger than 30 years of age. Preceding strep infections (including perianal strep) are reported commonly. Viral infections can trigger the rash. It is thought that specific streptococcal proliferative factor effects the keratinocytes…the Koebner phenomenon - an isomorphic response to trauma? Rash follows within 2 to 3 weeks of infection. May be first appearance of psoriasis in a previously unaffected person or exacerbation of existing disease.
  • Triggers to consider: Upper respiratory infections. Streptococcal infections other than tonsillitis. Stress injury to the skin. Certain drugs (eg, antimalarials, ß-blockers). Guttate psoriasis often comes on quite suddenly. More common (including recurrence) in patients with weakened immunity: Autoimmune disorders (including rheumatoid arthritis), AIDS, chemotherapy for cancer
  • Treatment: Topicals are the preferred treatment for guttate psoriasis (eg, steroid cream,vitamin D and coal tar applications) Patients often find it tedious to apply to multiple small lesions. If topical treatment fails, refer to dermatologist for phototherapy. Phototherapy with ultraviolet light B (UVB) or PUVA (psoralen/ultraviolet light A) has proven very effective. Systemic agents are prescribed only rarely and in severe cases. A short course of a systemic agent may lead to rapid and prolonged clearing.

Mike is 11-years-old and is accompanied by his mother who is very worried about a rash that appeared quite suddenly and has spread over his trunk and his arms. Other than dandruff, he has no history of skin problems. Mike has no other symtpoms, but he is very concerned about the way the rash looks; he says it's "scaly." The slides above offer you a close look at Mike's "scales" and some history. Put the pieces together and, what's your diagnosis?

 

References: 

Altman K. Guttate psoriasis. Medscape http://emedicine.medscape.com/article/1107850-overview#a1 August 27, 2015.  

Chalmers RJ, O'Sullivan T, Owen CM, Griffiths CE. Interventions for guttate psoriasis. Cochrane Database Syst Rev. 2000;(2):CD001213.

Herbst RA, Hoch O, Kapp A, Weiss J. Guttate psoriasis triggered by perianal streptococcal dermatitis in a four-year-old boy. J Am Acad Dermatol. 2000;42(5 Pt 2):885-887. 

Leung DY, Travers JB, Giorno R. Evidence for a streptococcal superantigen-driven process in acute guttate psoriasis. J Clin Invest. 1995;96:2106-2112.

Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008;58:826-850.

Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol. 2009;60:643-659.

U.S. Department of Health and Human Services:  Psoriasis –The Assessment and Management of Psoriasis (2012).  htttp://www.guideline.gov/content.aspx?id=38575&search=guttate+psoriasis. Accessed on August 27, 2015.  

Villeda-Gabriel G, Santamaria-Cogollos LC, Perez-Lorenzo R. Recognition of Streptococcus pyogenes and skin autoantigens in guttate psoriasis. Arch Med Res. 1998; 29:143-148.

Comments

Guttate psoriasis

Lorelei @

Guttate psoriasis

Sharon @

Guttate psoriasis

oyakhire @

Gutta tell Psoriasis

Nkechi @

Drug reaction

Ratnabali @

Guttate psoriasis folllowing strep

John @

The rash persisted for over six weeks treated with topical steroids

Dorothy @

Guttate paoriasis. ..I actually had this after an episode of strep

Dorothy @

pityriasis versocolor

Kristina @

Guttate psoriasis

Greta @

pityriasis rosea

Daniel @

Ichtyosis

Elizabeth @

Drug reaction...

Dr. Arnold @

scabes

DARRELL @

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