Morbiliform (Maculo-papular) rash

Question 1

Description of Morbiliform rash

Answer 1

Maculo-papular rash, 
Erythematous patches, 
Typically Exanthematous, 
Symmetrical
Blanchable on pressure

1. Macules - Flat skin lesion 1 cm - Plaque and if large and firm - Nodule
2. Pustules - purulent fluid within sac
3. Vesicles - clear fluid within sac, if >1 cm - Bullae
4. Urticaria - wheal or hives

Question 2

Ddx of Morbiliform rash and fever

Answer 2

1. Adverse Drug Eruptions (Antibiotics, anticonvulsants, Allopurinol), Drug rxn and Eosinophilia and Systemic Sx (DRESS)
   2.Viral Infections:
   Measles, Rubella, Slap cheek Syndrome/ 5th disease, Roseola /6th disease
2. Bacterial infections:
   Scalet fever, Mycoplasma infection, Meningoccaemia, Staphylococcal scalded skin syndrome, Toxic shock syndrome
3. Kawasaki disease
4. Connective Tissue Disease e.g. SLE and Dermatomyositis and JIA
5. Acute- graft vs host disease
6. Anaphylactic reaction
7. Toxic Epidermal Necrolysis (TEN) and Steven Johnson Syndrome (SJS)

Question 3

Examination steps of Morbiliform rash

Answer 3

1. General: ?well ?fever
2. Good exposure
3. Assess skin rash - describe Morphology and distribution, ?Blanchable, Scratch marks (pruiritis)
4. Face (Malar / Helicotrope rash / Slap cheeks)
5. Eyes (Conjunctivitis)
6. Mouth (Mucosal lesions, Koplick spots, Strawberry tongue , Tonsillitis)
7. Neck (Lymphadenopathy (KD and SF))
8. Hands (Desequamation (KD and SF))
9. Feet (Joint swelling and pain (B19))

Question 4

Measles

Answer 4

The “brick-red” maculopapular rash often begins on the head and neck area and spreads centrifugally. Patients also complain of fever, cough, coryza, and conjunctivitis. Koplik’s spots, tiny punctate elevated white buccal mucosa lesions located adjacent to the lower molars, are pathognomonic of measles and can precede the rash by 24 to 48 hours.

Question 5

Rubella

Answer 5

The rash resembles measles, but the patient does not appear to be sick; prominent postauricular, posterior cervical, and/or suboccipital adenopathy also assists in the diagnosis

Question 6

Erythema infectiosum or “5th disease” (human parvovirus B19)

Answer 6

Children, unlike adults, often develop a characteristic rash with a “slapped cheeks” appearance

Question 7

Roseola infantum (human herpesvirus 6 or 7)

Answer 7

Primarily seen in infants and young children, is characterized by high fever for three to four days, followed by generalized maculopapular rash that spreads from the trunk to the extremities but spares the face

Question 8

Infectious mononucleosis (Epstein-Barr virus or cytomegalovirus)

Answer 8

Maculopapular rash, usually occurring after administration of ampicillin, in older children, adolescents, or young adults with pharyngitis, fever, lymphadenopathy

Question 9

HIV infection

Answer 9

A transient, maculopapular, nonpruritic rash, located on the trunk or face, may occur in the acute retroviral syndrome, two to four weeks after the primary HIV infection. Fever, sore throat, malaise, headache, lymphadenopathy, and mucocutaneous ulceration are accompanying symptoms.

Question 10

Scarlet fever

Answer 10

Coarse, sandpaper-like, erythematous, blanching rash, occurring most commonly in the setting of pharyngitis from group A streptococcus infection

Question 11

Mycoplasma infection

Answer 11

Mild erythematous maculopapular or vesicular rash, most commonly accompanying respiratory tract infections. Rarely, erythema multiforme or Stevens-Johnson syndrome.

Question 12

Juvenile idiopathic arthritis and adult-onset Still disease

Answer 12

Evanescent, salmon pink maculopapular rash occurring with fever. The rash predominantly involves the trunk and extremities, but can also involve the palms, soles, and occasionally the face.

Question 13

Acute cutaneous lupus erythematosus

Answer 13

Widespread morbilliform eruption often focused over the extensor aspects of the arms and hands. Typically precipitated or exacerbated by exposure to UV light.

Question 14

Investigation of Maculo-papular rash

Answer 14

1. Bloods - CBC (Esinophilia), LFTs and RFTs (DRESS/ TENS/ SJS), CRP, ASOT
2. NPA for viral serology
3. ANA for autoimmune disease
4. +/- Skin Bx
5. +/- Patch test

Question 15

Mx of Maculo-papular rash

Answer 15

1. Withdraw offending drugs
2. Symptomatic relief - Antihistamines (Piriton/ Cetirizine) and Topical steroids (High potency)
3. Educate patients about warning signs of more severe hypersensitivity reactions. These include high fever, facial edema, mucosal symptoms, skin tenderness, and blistering
4. Avoidance