Man With Rash

Article Outline

• Diagnosis
  • Guttate psoriasis
• References
• Copyright

[Ann Emerg Med. 2009;53:418.]

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).

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• Figure 1. 

  Maculopapular rash.

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• Figure 2. 

  Scaly rash. Used with permission of Jody A. Vogel, MD, Department of Emergency Medicine, Denver Health Medical Center, Denver, CO.

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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.

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References 

1. Chalmers RJG, O'Sullivan T, Owen CM, et al. Interventions for guttate psoriasis. Cochrane Database Syst Rev. 2000;2:CD001213
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2. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. Philadelphia, PA: Mosby; 2004;
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3. Fitzpatrick TB, Johnson RA, Wolff K. Color Atlas and Synopsis of Clinical Dermatology: Common and Serious Diseases. New York, NY: McGraw Hill; 2001;
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