Derm Dx: Rash following a sore throat - Clinical Advisor

Derm Dx: Rash following a sore throat

Slideshow

  • Guttate Psoriasis 1_0713 Derm Dx

  • Guttate Psoriasis 2_0713 Derm Dx

  • Guttate Psoriasis 3_0713 Derm Dx

  • Guttate Psoriasis 4_0713 Derm Dx

  • Guttate Psoriasis 5_0713 Derm Dx





A 20-year-old active-duty Marine presents with a three-day history of a multiple lesions on his trunk, back, arms and legs. The lesions all appeared on the same day. He complains of mild itching on a few of the lesions. He denies any systemic symptoms, sick contacts or close contact with anyone else, but does state he had a sore throat about 4 weeks ago.





On examination multiple small well-demarcated papular lesions with erythematous bases and a fine silvery scale are noted on his trunk, back and bilateral proximal extremities. The lesions spare his palms and soles, are monomorphic and in no particular pattern.

**This Derm Dx is reader-submitted! Special thanks to United States Navy LieutenantsErin B. Storie, DO, and Kevin J. Winegar, DO, for sharing this interesting case.**

Submit your own Derm Dx case and you’ll earn 300 Peer Network points just for sending it. If your case is published you’ll earn an extra 500 points.
The word guttate is derived from the Latin word gutta, meaning drop. As its name suggests, guttate psoriasis clinically presents acutely as small, drop-like, papules with an erythematous base covered by a fine silvery scale. These well-demarcated lesions can range...

Submit your diagnosis to see full explanation.

The word guttate is derived from the Latin word gutta, meaning drop. As its name suggests, guttate psoriasis clinically presents acutely as small, drop-like, papules with an erythematous base covered by a fine silvery scale.

These well-demarcated lesions can range from 1 mm to 10 mm in diameter and are primarily found on the trunk and proximal extremities, sparing the palms and soles. Lesions may also be found on the face, ears, scalp and distal extremities.

New lesions typically appear in the first month of the disease, followed by stability of the lesions in the second month; remission commonly begins after 60 days.1

Guttate psoriasis is often asymptomatic; however, mild pruritis may be reported. Chronic psoriatic signs such as nail pitting and ridging, as well as the “oil-drop” sign, are frequently absent as this is often the patient’s first manifestation of psoriasis.

Guttate psoriasis most commonly occurs in children and young adults aged younger than 30 years and may be seen one to three weeks following a group A β-hemolytic streptococcal (GAS) infection.2 A strong association of guttate psoriasis following perianal streptococcal infections in children has also been well established.3,4

Although the correlation of guttate psoriasis and streptococcal infections is much more common, other organisms such as Staphylococcus aureus, Candida albicans and Malassezia, have been implicated as well.5

Tumor necrosis factor-α (TNF-α) inhibitors and other immunomodulating drugs also have a strong association with the presentation of all types of psoriasis, including guttate psoriasis.6,7,8 Full resolution of the disease usually occurs from 12-16 weeks without treatment.

Patients frequently have no evidence of psoriasis for prolonged periods of time following complete resolution. Although guttate psoriasis is self-limiting and complete resolution is common, it is thought that it may be a precursor to the development of chronic plaque psoriasis in the future.

One study showed that 33% (5 out of 15) patients had chronic psoriasis 10 years following their initial presentation of acute guttate psoriasis.9 However, more studies are needed in order to fully establish this hypothesis.

Diagnosis

Given the distinct presentation of acute guttate psoriasis along with the common history of symptoms of a prior streptococcal infection, guttate psoriasis is largely a clinical diagnosis. Biopsy of one of the lesions can confirm psoriasis, but is often not necessary. Throat or perianal cultures can reveal the presence of Streptococcus species and an elevated antistreptolysin O titer can confirm a prior streptococcal infection.

The differential diagnosis of a rash of this type includes nummular dermatitis, tinea corporis, secondary syphilis and pityriasis rosea. Other diagnoses to consider are pityriasis lichenoides, atopic dermatitis, parapsoriasis, viral or drug exanthems and cutaneous T-cell lymphoma, all of which can be differentiated from guttate psoriasis in some way.

The plaques of nummular dermatitis are larger (from 1 cm to 5 cm in diameter), more coin shaped and less numerous. They have a thin, finer scale and are very pruritic.

The lesions of tinea corporis can vary in size, shape and distribution. Tinea corporis has the characteristic advancing raised scaly border and commonly has central clearing. Several lesions can coalesce to cover wide areas of the body.

With secondary syphilis, the patient will frequently have systemic complaints and the lesions do not spare the palms and soles. If syphilis is suspected, then syphilis serology should be conducted.

The lesions and distribution of pityriasis rosea are very similar to guttate psoriasis, however the scale of pityriasis rosea is ring within the border of the plaque, giving it its characteristic “collarette” appearance. Also, the plaques of pityriasis rosea are found along skin lines giving it the classic “Christmas-tree” pattern. A 2 cm to 10 cm round to oval lesion frequently appearing on the trunk, known as a herald patch, often precedes the eruptive phase of pityriasis rosea by a few days to several weeks. As with any dermatologic condition, a meticulous history and thorough physical exam, including all areas of the skin, is necessary for a diagnosis.

Treatment

There is no general consensus on specific treatment guidelines for guttate psoriasis. Many studies have been done with a wide array of treatment plans, all with varying results. There is evidence to support the use of broadband and narrow-band ultraviolet B phototherapy, as well as a psoralen-ultraviolet A (PUVA) radiation treatment for more resistant cases, which has been shown to accelerate the clearance of the lesions.10,11,12

Topical corticosteroids are commonly prescribed for their anti-inflammatory and vasoconstrictive properties. However, they may be cumbersome to apply if the distribution of lesions is significant. As with other steroid responsive skin disease, care must be taken in prescribing the correct potency for the size and location of the lesions.

Additional studies have shown improvement in the acute episodes of guttate psoriasis with various agents including topical retinoids, tar, surgical tonsillectomy, use of antibiotics and infusions of n-3 fatty acid rich lipid emulsion.13,14,15,16

However, other studies and literature reviews found no clear benefit to the use of certain antibiotics, or tonsillectomy in the improvement of psoriasis.17,18,19

Given that the condition resolves spontaneously in a few weeks to months without any treatment, reassurance and emollients may be sufficient.

Erin B. Storie, DO, and Kevin J. Winegar, DO, are Lieutenants in the United States Navy.

References

  1. Baker BS, Powles AV, Fry L. “A possible role for vaccination in the treatment of psoriasis?” G Ital Dermatol Venereol. 2008; 143(2):105-117.
  2. >Nahary L, Tamarkin A, Kayam N et al. “An investigation of antistreptococcal antibody responses in guttate psoriasis.” Arch Dermatol Res. Sep 2008;300(8):441-9.
  3. Ulger Z, Gelenava T, Kosay Y et al. “Acute guttate psoriasis associated with streptococcal perianal dermatitis.” Clin Pediatr. 2007; 46(1):70-2.
  4. Ledoux M, Chazerain V, Saiag P et al. “Streptococcal perianal dermatitis and guttate psoriasis.” Ann Dermatol Venereol. 2009;136(1):37-41.
  5. Fry L, Baker BS. “Triggering psoriasis: the role of infections and medications.” Clin Dermatol. 2007; 25(6):606-15.
  6. Ma HL, Napierata L, Stedman N, et al. “Tumor necrosis factor alpha blockage exacerbates murine psoriasis-like disease by enhancing Th17 function and decreasing expansion of Treg cells.” Arthritis Rheum. 2010; 62: 430-40.
  7. de Gannes GC, Ghoreishi M, Pope J et al. “Psoriasis and pustular dermatitis triggered by TNF-α inhibitors in patients with rheumatologic conditions.” Arch Dermatol. 2007; 143:223-31.
  8. Brigant F, Clavel G, Chatelain D, Lok C, Chaby G. “Letter: A case of generalized guttate psoriasis induced by entanercept with relapse after abatacept.” Dermatol Online J. 2011;17(6):11.
  9. Martin BA, Chalmers RJ, Telfer NR. “How great is the risk of further psoriasis following a single episode of acute guttate psoriasis?” Arch Dermatol. 1996;132(6):717-8.
  10. Thappa DM, Laxmisha C. “Suit PUVA as an effective and safe modality of treatment in guttate psoriasis.” J Eur Acad Dermatol Venereol. 2006;20(9):1146-7.
  11. Borroni G, Vignati G, Zaccone C et al. “Photofibrosis: a further histopathological change induced by PUVA therapy via the mast cell in guttate psoriasis. Preliminary report.” Acta Derm Venereol Suppl (Stockh). 1994;186:159-61.
  12. Koek MB, Buskens E, van Weelden H et al. “Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomized controlled non-inferiority trial (PLUTO study).” BMJ. 2009;338:b1542.
  13. 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(4):643-59.
  14. Rosenberg EW, Noah PW, Zanolli MD, et al. Use of rifampin with penicillin and erythromycin in the treatment of psoriasis. Preliminary report. J Am Acad Dermatol. May 1986;14(5 Pt 1):761-4.
  15. Wilson JK, Al-Suwaidan SN, Krowchuk D et al. “Treatment of psoriasis in children: is there a role for antibiotic therapy and tonsillectomy?” Pediatr Dermatol. 2003;20(1):11-5.
  16. Chalmers RJ, O’Sullivan T, Owen CM et al. “A systematic review of treatments for guttate psoriasis.” Br J Dermatol. 2001;145(6):891-4.
  17. Dogan B, Karabudak O, Harmanyeri Y. “Antistreptococcal treatment of guttate psoriasis: a controlled study.” Int J Dermatol. 2008;47(9):950-2.
  18. Owen CM, Chalmers RJ, O’Sullivan T et al. “A systematic review of antistreptococcal interventions for guttate and chronic plaque psoriasis.” Br J Dermatol. 2001;145(6):886-90.
  19. Vincent F, Ross JB, Dalton M, Wort AJ. “A therapeutic trial of the use of penecillin V or erthyromycin with or without rifampin in the treatment of psoriasis.” J Am Acad Dermatol. 1992;26:458-61.
Next hm-slideshow in Clinical Quiz