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Ten Look Alike RashesMichelle DiBaise,
MPAS, PA-C, DFAAPA
Associate Clinical Professor
NAU PA Program
Facial Rash
Case 1 Case 2
Facial Rash
Case 1
28 year female
Progressive development of erythematous facial lesions x 6 months
Scaling, atrophy, and follicular plugging noted
Case 2
44 year old male
Rash and fine flaking on face, in the ears, scalp, and chest x 1 year
No pruritis
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Facial Rash
Case 1 Case 2
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Facial Rash
Discoid Lupus Seborrheic Dermatitis
Facial Rash
Case 1
ANA (NAP)
Punch biopsy for H&E and DIF
Treatment: Sun protection Hydroxychloroquine Corticosteroids and
other immunomodulators
Case 2
Topical shampoos and creams:
Ketoconazole
Selenium sulfide
Ciclopirox
Zinc pyrithione
Salicylic acid
Extensor Surface Rash
Case 1 Case 2
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Extensor Surface Rash
Case 1 Case 2
52 year old male
Small tear drop
plaques with silvery white scale
Elbows, knees,
buttocks/sacral area
Minimally pruritic
23 year old male
Multiple excoriations
with occasional vesicle
Elbows, knees,
buttocks/sacral area
Very pruritic
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Extensor Surface Rash
Case 1 Case 2
Extensor Surface Rash
Guttate PsoriasisDermatitis Herpetiformis
Extensor Surface Rash
Case 1 Case 2
Can be precipitated
by strep infection
Treat strep infection
Topical
corticosteroids
Vitamin D analogues
Phototherapy
Manifestation of Gluten enteropathy(Celiac disease)
Biopsy for IgA
Serum antibodies for Celiac
Gluten free diet
Dapsone
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New Lesion
Case 1 Case 2
New Lesion
Case 1 Case 2
52 year old female
Lesion developed rapidly over 4 months
Otherwise asymptomatic
63 year old male
Lesion developed slowly over the past 18 months
Occasionally bleeds when traumatized
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New Lesion
Case 1 Case 2
New LesionAmelanoticMelanoma
Basal Cell Carcinoma
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New Lesion
Case 1 Case 2
Biopsy if uncertain of diagnosis
Follow up with excision
Referral to: Mohs surgeon
Oncology
Follow up every 3 months for the first year
Biopsy or excision initially depending on size of lesion
Follow up every 6 12 months for skin exam
Itchy Rash
Case 1 Case 2
Itchy Rash
Case 1 Case 2
49 year old male
Indurated, pruritic plaques with cigarette paper appearance
Developed over the course of the past 2 years
Unresponsive to topical steroids
68 year old male
Non-indurated, pruritic plaques
KOH negative
Comes and goes
Worse in humid weather
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Itchy Rash
Case 1 Case 2
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Itchy RashCTCL (Mycosis Fungoides) Nummular Eczema
Itchy Rash
Case 1 Case 2
Biopsy with T cell
typing
Sezary cell count once CTCL
confirmed on biopsy
Referral to oncology
Check feet and groin for underlying fungal infection (Id reaction)
Treat underlying infection Topical steroids to
nummular dermatitis Emollients Tar preparations Topical immunomodulators Phototherapy
Drug Reaction?
Case 1 Case 2
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Drug Reaction?
Case 1 Case 2
78 year old female
Lesions present for 15 months, never migrate nor disappear
Stop all medications and re-introduction one at a time
No change in rash
History of CML
28 year old female
Lesions present, migrate and disappear within 24 hours
Mild pruritis
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Drug Reaction?
Case 1 Case 2
Drug Reaction?
Leukemia Cutis Acute Urticaria
Drug Reaction?
Case 1 Case 2
Biopsy
Referral to oncology
Attempt to identify allergen
Remove offending agent
H1 blockers
Epinephrine
IM steroids
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Eyelid Rash
Case 1 Case 2
Eyelid Rash
Case 1 Case 2
23 year old female
Dry, flaky, itchy rash
on eyelids x 2 months
Occasionally burns
or stings
History of allergic
rhinitis
52 year old male
Discoloration in
periorbital area x 6 months
Noted difficulty
walking up stairs and carrying groceries
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Eyelid Rash
Case 1 Case 2
Eyelid Rash
Eczema Dermatomyositis
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Eyelid Rash
Case 1 Case 2
Consider patch testing for allergic contact dermatitis
Apply emollients
Immunomodulatoragents
Avoid irritants
Laboratory:
ANA (NAP)
CK and aldolase
CXR
Muscle biopsy
EMG
MRI
Acneiform Eruption
Case 1 Case 2
Acneiform Eruption
Case 1 Case 2
54 year old male
Pruritic papules on
the chest and upper back x 3 weeks
Mineral oil scraping
negative for mites or scybala
16 year old male
Papules and pustules on chest and upper back x 1 year
Some lesions are tender
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Acneiform Eruption
Case 1 Case 2
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Acneiform Eruption
Grovers Disease (Transient Acantholytic Dermatosis) Acne Vulgaris
Acneiform Eruption
Case 1 Case 2 Usually self-limited
Avoid activities that trigger flares
High potency topical corticosteroids
Moisturizers and emollients
Antihistamines Vitamin D analogues
Antibacterial soap
Topical retinoid
Topical antibiotic
Benzoyl peroxide
If no improvement consider oral antibiotics
Depigmentation
Case 1 Case 2
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Depigmentation
Case 1 Case 2 18 year old female Oval circumscribed area of
induration with a waxy, ivory color surrounded by a violaceous halo over the lateral malleolus
Initially the lesion was erythematous before the current appearance
The center is atrophic Lesion has been present for
6 months
12 year old male
Macular depigmentation on left side of neck
No induration or atrophy noted
Appears to have follicular repigmentation at the periphery
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Depigmentation
Case 1 Case 2
Depigmentation
Morphea Vitiligo
Depigmentation
Case 1 Case 2 Biopsy to confirm if
there is a doubt in the diagnosis
ANA (NAP)
Emollients, topical corticosteroids, vitamin D analogues
Possible physiotherapy if contractures across the joint line
Association with other autoimmune disorders: Thyroid disease, pernicious
anemia, SLE, Type I DM, and Addisons disease
TSH, FBG
Topical corticosteroids Topical calcineurin
inhibitors UV therapy Skin grafting Depigmentation
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Pustular Rash
Case 1 Case 2
Pustular Rash
Case 1 Case 2
36 year old female
Multiple, firm, white lesions x 9 months
Periorbital area
Otherwise asymptomatic
53 year old male Blisters that easily
rupture, scarring and firm white lesions on the dorsum of the hands especially after sun exposure
Hirsutism on the cheeks and forearms
Patient has a history of heavy alcohol use
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Pustular Rash
Case 1 Case 2
Pustular Rash
MiliaPorphyria CutaneaTarda
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Pustular Rash
Case 1 Case 2
Extraction with needle or 11-blade and comedoneextractor
Topical retinoid
Associated with excess alcohol consumption, estrogen use, hepatic siderosis, hepatitis C, HIV, and smoking
Test urine and/or plasma porphyrins
Repeated phlebotomy Hydroxychloroquine if
phlebotomy not tolerated
Hyperpigmented rash
Case 1 Case 2
Hyperpigmented rash
Case 1 Case 2 18 year old male Grayish-blue, hyper-
keratotic papules, located on the chest x 8 months
Lesions coalesce to form plaques centrally and a net-like pattern peripherally
KOH negative Otherwise asymptomatic
18 year old male
Hyperpigmented, velvety plaques on the chest and back
Worse when weather is hot and humid
Has re-occurred over the past three summers
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Hyperpigmented rash
Case 1 Case 2
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Hyperpigmented rashConfluent and Reticulated Papillomatosis of Gougerot and Carteaud
HyperpigmentedTinea Versicolor
Hyperpigmented rash
Case 1 Case 2
Minocycline
Keratolytic agents
Oral, and topical forms of vitamin A
Oral and topical retinoids
Topical mupirocin
70% alcohol swabbing
KOH shows hyphae and spores (spaghetti and meatballs)
Malassezia species
Topical antifungals:
Ketoconazole
Topical terbinafine
Topical ciclopirox
Selenium sulfide
Systemic therapy:
Itraconazole
Fluconazole
Reserved for patients with recalcitrant tinea versicolor or widespread disease
References DelRosso, J.Q. (2011). Adult seborrheic dermatitis: a status
report on practical topical management. Journal of Aesthetic Dermatology,4(5), 32-38.
Emedicine: emedicine.medscape.com
Habif, T.P. (2010). Clinical Dermatology, 5th Ed., Mosby, elsevier, Inc.
Wolff, K., Johnson, R.A., & Saavedra, A. (2013). Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 7th Ed., McGraw-Hill Professional.
UpToDate: uptodate.com
