Patterned Erythema
Patterned Erythema: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
Figurate
❑ Tinea corporis
❑ Urticaria
❑ Erysipelas
❑ Erythema migrans
❑ Secondary syphilis
❑ Livedo reticularis
❑ Erythema multiforme
❑ Cutaneous larva migrans
❑ Granuloma annulare
❑ Erythema marginatum
Photodistribution
❑ Sunburn
❑ Drugs
❑ Polymorphous light eruption
❑ Systemic lupus erythematosus
❑ Porphyria cutanea tarda
❑ Pellagra
Differentiate from Cellulitis
❑ Insect bite
❑ Acute gout
❑ Deep vein thrombophlebitis
❑ Erythema migrans
❑ Fixed drug eruption
❑ Pyoderma gangrenosa
❑ Sweet syndrome
❑ Necrotizing fasciitis
Diagnostic Approach
Sun-exposed areas of the face, the “V” of the neck (but not under the chin), and the dorsum of the hands and feet are common distributions for photodermatitis.
Clinical Findings
Tinea corporis It appears as a slowly expanding lesion with an active, scaling, erythematous border and central clearing.
Urticaria Transient and migratory, there are well-marginated polycyclic wheals, with raised red serpiginous borders and clear centers. They may merge into extensive wheals.
Erysipelas A circumscribed crimson area appears on the face with a smooth, shiny appearance, and then it rapidly expands. It is tender and warm to touch, and the patient is febrile.
Erythema migrans A single annular lesion develops 3 to 30 days after a bite from a tiny Ixodes tick. This lesion is red with a bluish center (and often a visible tick or bite mark). It gradually expands to greater than 10 cm, heralding Lyme disease. Associated symptoms include fever, headache, photophobia, and arthralgias.
Secondary syphilis The most common setting for annular lesions is on the face. They are distinguished by a central hyperpigmentation.
Livedo reticularis It appears with a lacy pattern of blue-purple on the legs. It is seen with cold exposure and connective tissue diseases (polyarteritis nodosa, lupus, rheumatoid arthritis, and dermatomyositis). A similar pattern in red may be caused by heat (erythema ab igne).
Erythema multiforme The pathognomic manifestation is the iris or target lesion, which usually appears on extensor surfaces. Sulfonamides are the classic precipitant although connective tissue disease and infections may also be the cause.
Cutaneous larva migrans An intensely pruritic, serpiginous, red, raised track advances on the foot of a patient who has acquired an animal hookworm by walking barefoot outdoors.
Granuloma annulare The border is made of flesh-colored or red-brown papules. It usually occurs on the extremities, but a disseminated form may occur in patients with diabetes.
Erythema marginatum The classic rash of rheumatic fever consists of pink-red, transient, flat truncal lesions. Associated symptoms such as fever, arthritis, chorea, and congestive heart failure are important clues.
Sunburn It is readily suspected and its distribution is determined by the lie of the clothing.
Drugs Sulfonamides, tetracyclines, food or medicine coloring agents, phenothiazines, thiazides, sulfonureas, quinolones, and griseofulvin are common causes. The reaction is characterized by a prompt intense burning and erythema, which is more intense than the usual sunburn, followed by desquamation and hyperpigmentation.
Polymorphous light eruption Exquisitely light sensitive, papules and vesicles erupt and coalesce in the spring, but tolerance builds in the summer.
Systemic lupus erythematosus Lupus may begin as an exaggerated sunburn or urticaria with sun exposure. Fever, fatigue, or arthralgias accompany it.
Porphyria cutanea tarda It presents in the third or fourth decade with fragile bullae and erosions on the dorsum of the hands, dark urine (with an orange-red fluorescence under examination using a Wood lamp when acidified), and mottled periorbital hyperpigmentation. Precipitating factors include alcohol and estrogens.
Pellagra Niacin deficiency is rare, but may occur in alcoholics or patients with a staple diet of corn, presenting as an erythematous, vesicular dermatitis and progressing to an intense hyperpigmentation, desquamation, leathery skin, and a powdery scale in sun-exposed areas.
Insect bite Ascertain a history of a bite, local pruritis, absence of fever or systemic symptoms.
Acute gout Involvement of foot or ankle, particularly 1st MTP (podagra), and repeated episodes is the classic presentation.
Deep vein thrombophlebitis The leg is swollen and tender in the calf, and with proximal DVT, into the popliteal space and medial thigh.
Fixed drug eruption A history of medication use, particularly NSAIDs, sulfonamides, tetracyclines, salicylates, barbiturates, and phenolphthalein laxatives is key. Acutely the lesion is erythematous and edematous with a grayish center or frank bullae. The hallmark is reoccurrence at the same location on re-exposure, as the name suggests, on the lips, face, genitalia, or acral areas.
Pyoderma gangrenosa Erythema occurs when the lesions begin as panniculitis, but they soon become nodular or bullous, then ulcerate.
Sweet syndrome Acute febrile neutrophilic dermatosis is associated with hematologic cancers. The lesions are tender, red, pseudovesiculated plaques with fever.
Necrotizing fasciitis Acute, rapidly developing infection of the deep fascia. Marked pain, tenderness, swelling and often crepitance, coincide with bullae and necrosis of the overlying skin. Anaerobic myonecrosis or gas gangrene is due to Clostridium perfringens. Rapidly progressive toxemic infection of previously injured muscle produces marked edema, crepitus, and brown bullae.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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