RASH BEHAVIOR STEPHEN G. MALLETTE, D.O.,F.A.O.C.D. ATHENS, ALABAMA

17 year old male presents with an over two month breakout on his back. He is an acne patient who has been well controlled until recently. Currently using minocycline 100mg BID, Cleocin pads to back QD, and benzaclin QHS to face. The breakout seems to be getting worse.

PITYROSPORUM FOLLICULITIS Often induced by acne treatment but can also occur in athletes or those treated with oral steroid. Be suspicious when acne suddenly worsens! The easiest treatment since usually the chest and back or involved is oral diflucan 150mg once a week for four weeks. Usually will recur in an acne patient so maintenance is usually required. Topical sulfur wash Benzoyl peroxide Topical antifungal Stop oral antibiotic!

52 year old male presents with a pruritic rash for three weeks on his wrists and spreading to his feet. He is on no new medicines. The rash does not respond to OTC treatment.

LICHEN PLANUS Look for oral lesions as well as nail involvement. Biopsy is helpful as the condition can take months to resolve Treatment for skin includes topical steroid, light therapy and protopic. For stubborn lichen planus oral tapered steroid can be used. Cyclosporine, Cellcept and Imuran can be used. Accutane works in some cases as well. For oral disease protopic is helpful as well as intralesional kenalog. Kenalog in oral base can be used as well. Cyclosporine mouthwash can be compounded as well.

48 year old male presents with rash on his back that comes and goes. Has been occurring on and off for years. Topical Elocon usually gets rid of it but it doesn't seem to work any more. No other lesions present.

PARAPSORIASIS Looks like eczema but doesn't really itch as much. Sometimes previous biopsies are consistent with eczema. Management includes topical steroid and light therapy Can progress to CTCL. Not that common!

A 24 year old male presents with a pruritic rash of 3 days duration. Recently was started on amoxicillin for URI. The rash has slowly spread involving the trunk, arms and legs.

EXANTHEMATOUS DRUG REACTION Usually occurs within 14 days of start of medication. Make sure that you differentiate this from other more severe reactions such as anaphylaxis, SJS, etc. There are many types such as lichenoid, photosensitive, psoriasiform, eczematous. Can mimic many conditions. Treatment includes stopping the offending agent first. Antihistamines help the itch associated with the reaction and oral steroids can help clear the reaction faster.

A 39 year old male presents with a history of a pruritic rash on his left leg that has become slightly painful. He has been applying Lidex cream to the area for 4 weeks with no improvement. He has a several year history of eczema in this area and it usually responds to Lidex cream.

MAJOCCHI'S GRANULOMA This is a deep dermatophyte folliculitis brought on by topical steroid use or being immunocompromised. Can be set off by Lotrisone use as well. The treatment includes stopping the topical steroid and placing the patient on oral Lamisil or Diflucan for 2 to 6 weeks. Lamisil is 250mg once a day. I like to use Diflucan 200mg for one week on and off until clear. In patients who require chronic steroid use for chronic conditions, I change them to protopic or compounded triamcinolone with spectazole.

17 year old female presents with a rash on her chest and back for 5 months. It does not itch and won't respond to OTC treatment with moisturizers, soaps, acne treatment or scrubbing. The patient has also used antifungal treatments with no effect.

CONFLUENT AND RETICULATED PAPILLOMATOSIS This is an uncommon condition that typically affects young patients. It has exacerbations and remissions. Uncertain etiology The most effective treatment is Minocycline 100mg BID. Oral and topical retinoids can be tried as well.

A twenty year old male presents with an extremely pruritic rash that started on his hands and has spread to his axilla and groin. He has not traveled recently and no one at home is itching. He has tried multiple OTC treatments which include oral Benadryl and hydrocortisone with no improvement.

SCABIES The patient can't sit still they itch so much. There is not always a clear exposure. Permethrin 5% applied at night and repeat in one week is the treatment of choice. Itching May last up to a month after being treated. Oral ivermectin is given in severe and recalcitrant cases. Comes as 3mg tablets. 12mg one time dose for 51kg to 65kg person and repeated in one week. 15mg for 65kg to 79kg and repeat in one week.

57 year old female presents with pruritic and painful rash under her breasts for the last 7 weeks. She has tried hydrocortisone and tinactin with no improvement. She has poorly controlled diabetes. She has used no new soaps or detergents.

INTERTRIGO Usually occurs in the warmer months but can be more frequent in the obese. Athletes as well. Occurs in any skin fold. Can become secondarily infected with bacteria or yeasts. Treatment includes both acute and prevention. For the acute antifungal gels and powders are helpful. Also Atrapro gel is helpful as maintenance and acute treatment. For maintenance, zinc oxide paste and powders help. There is a zinc oxide spray that works great as well.

CONCLUSION These are common presentations of some uncommon and common rashes. The differential diagnosis of each rash can be long. History and location are important factors in diagnosis. Rashes are not easy, even for the dermatologist!