A 53-year-old man presented with a 5-day history of a diffuse scaly rash and reported a sore throat and fever 2 weeks earlier. Distinctively after the rash onset, he began presumptively receiving penicillin V potassium for streptococcal pharyngitis because of a culture-positive family contact. The patient reported worsening of the rash despite therapy. Our physical examination was remarkable for a pink maculopapular scaly rash, most prominent on the trunk and extremities, sparing the palms and soles (Figure 1, Figure 2). His antistreptolysin O titer level was 571 IU/mL (reference range <200 IU/mL).
Figure 2. Scaly rash. Used with permission of Jody A. Vogel, MD, Department of Emergency Medicine, Denver Health Medical Center, Denver, CO.
Diagnosis
Guttate psoriasis
The patient was diagnosed with guttate psoriasis, which is most commonly observed in children and young adults. It is strongly associated with antecedent or concomitant streptococcal infection1 and often occurs 1 to 2 weeks after streptococcal pharyngitis or a viral upper respiratory infection.2 Typically, this rash manifests as scaly, droplike pink papules appearing primarily on the trunk and the extremities, sparing the palms and soles.2, 3 Guttate psoriasis can be mistaken for a drug rash if the patient is evaluated before the development of scale, particularly in individuals who have been treated with antibiotics for the streptococcal infection.1 Throat cultures to evaluate for streptococcal infection should be obtained, and increased antistreptolysin O titer levels are common.2 Guttate psoriasis may resolve spontaneously in a few weeks or may require phototherapy to expedite resolution.3 The patient's rash spontaneously resolved within 6 weeks of onset.
References
1. 1Chalmers RJG, O'Sullivan T, Owen CM, et al.Interventions for guttate psoriasis. Cochrane Database Syst Rev. 2000;2:CD001213.
2. 2Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. Philadelphia, PA: Mosby; 2004;.
3. 3Fitzpatrick TB, Johnson RA, Wolff K. Color Atlas and Synopsis of Clinical Dermatology: Common and Serious Diseases. New York, NY: McGraw Hill; 2001;.
Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
For the diagnosis and teaching points, see page 424.
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