Photo Quiz

Diffuse, Pruritic, Papular Rash

 


FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.


FREE PREVIEW. Purchase online access to read the full version of this article.

Am Fam Physician. 2013 Nov 1;88(9):605-606.

A 34-year-old man presented with a pruritic, erythematous, papular rash that appeared two days earlier. The rash started on his trunk and back, then progressed to his arms and the proximal portion of his legs. He did not have pain, burning, or a tingling sensation. He did not have a fever or other systemic symptoms, and the review of systems was otherwise unremarkable. He did not have sick contacts and was not using any new medications, soaps, lotions, or detergents. He ate a salad with shiitake mushrooms, pine nuts, and organic corn the day his symptoms started.

Physical examination revealed diffuse, linear papules over the extremities and trunk (see accompanying figure). There was no tenderness, induration, warmth, scaling, or exudate.

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Dermatitis herpetiformis.

B. Erythema multiforme.

C. Flagellate dermatitis.

D. Serpentine dermatitis.

E. Stevens-Johnson syndrome.

Discussion

The answer is C: flagellate dermatitis. Flagellate dermatitis is a diffuse rash that most commonly occurs after exposure to the chemotherapeutic agent bleomycin, but it can also occur with shiitake mushroom ingestion.1,2 It presents as multiple linear, pruritic papules that become erythematous with excoriation. The rash is often located on the extremities and trunk. Similar cutaneous manifestations occur in patients with dermatomyositis, Still's disease, and human immunodeficiency virus infection.2

The diagnosis of flagellate dermatitis is clinical and based on the history and appearance of the rash. The dermatitis usually begins within the 24 to 48 hours after ingestion of raw or partially cooked shiitake mushrooms, and has an average duration of eight days.2 In contrast, symptoms associated with bleomycin use occur up to nine weeks after initial exposure and can last up to six months after discontinuation.1,2 The rash is treated by eliminating exposure to the causative agent, and with topical and oral steroids and antihistamines. Patch testing is not recommended, and skin biopsies are nonspecific.2

Dermatitis herpetiformis is an intensely pruritic papulovesicular rash on the trunk and extremities. It is an autoimmune disease with a clear association to celiac disease and gluten sensitivity. Only 15% of patients with the rash have digestive manifestations of celiac disease.3 Both entities have similar pathophysiology and subsequent gluten-sensitive enteropathy. The rash dissipates with withdrawal of gluten from the diet.

Erythema multiforme usually manifests as target-shaped lesions on the hands, soles, and extremities. It is the result of a type IV hypersensitivity reaction to an infection, connective tissue process, or medication use (classically nonsteroidal anti-inflammatory drugs, antiepileptics, sulfonamides, or antibiotics), or it can be idiopathic.4

Serpentine dermatitis is associated with intravenous administration of chemotherapeutic agents, most commonly with fluorouracil. The rash has a similar morphology to flagellate dermatitis, but with a hyperpigmented pattern that follows an underlying vein proximal to an intravenous infusion site.5

Stevens-Johnson syndrome is a more serious and possibly life-threatening form of erythema multiforme. It can lead to skin blistering and possibly desquamation, and involves mucosal areas, especially the mouth and lips. Fever, malaise, and upper respiratory tract symptoms are common in the days preceding Stevens-Johnson syndrome. The condition is commonly associated with use of certain medications, especially antibiotics and sulfa drugs, but can also be triggered by viral infections, such as herpes simplex virus, influenza, and Epstein-Barr virus.4

View/Print Table

Summary Table

ConditionCharacteristics

Dermatitis herpetiformis

Intensely pruritic papulovesicular lesions on the trunk and extremities; associated with celiac disease

Erythema multiforme

Target-shaped lesions on the hands, soles, and extremities; usually appears after exposure to certain medications or viral infections

Flagellate dermatitis

Multiple linear, pruritic papules often on the extremities and trunk that become erythematous with excoriation; associated with shiitake mushroom ingestion or bleomycin use

Serpentine dermatitis

Hyperpigmented rash that follows an underlying vein proximal to an infusion site; associated with intravenous administration of chemotherapeutic agents, most commonly fluorouracil

Stevens-Johnson syndrome

Skin blistering, and sometimes desquamation; involves mucosal areas, especially the mouth and lips; associated with certain viral infections and antibiotic use

Summary Table

ConditionCharacteristics

Dermatitis herpetiformis

Intensely pruritic papulovesicular lesions on the trunk and extremities; associated with celiac disease

Erythema multiforme

Target-shaped lesions on the hands, soles, and extremities; usually appears after exposure to certain medications or viral infections

Flagellate dermatitis

Multiple linear, pruritic papules often on the extremities and trunk that become erythematous with excoriation; associated with shiitake mushroom ingestion or bleomycin use

Serpentine dermatitis

Hyperpigmented rash that follows an underlying vein proximal to an infusion site; associated with intravenous administration of chemotherapeutic agents, most commonly fluorouracil

Stevens-Johnson syndrome

Skin blistering, and sometimes desquamation; involves mucosal areas, especially the mouth and lips; associated with certain viral infections and antibiotic use

Address correspondence to Carlton J. Covey, MD, FAAFP, at carlton. covey@us.af.mil. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force Medical Department or the U.S. Air Force at large.

REFERENCES

show all references

1. Diao DY, Goodall J. Bleomycin-induced-flagellate dermatitis. CMAJ. 2012;184(11):1280....

2. Girard C, Bessis D. Flagellate dermatitis. Arch Dermatol. 2012;146(11):1301–1306.

3. Ingen-Housz-Oro S. Dermatitis herpetiformis: a review [in French]. Ann Dermatol Venereol. 2011;138(3):221–227.

4. Exanthems and drug eruptions In: Habif TP, ed Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 5th ed. New York, NY: Mosby; 2010:541–580.

5. Pujol RM, Rocamora V, Lopez-Pousa A, et al. Persistent supravenous erythematous eruption: a rare local complication of intravenous 5-fluorouracil therapy. J Am Acad Dermatol. 1998;39(5 pt 2):839–842.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

A collection of Photo Quizzes published in AFP is available at http://www.aafp.org/afp/photoquiz.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.



 

Copyright © 2013 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Dec 1, 2016

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article