TheGeneralizedRash:PartI.

DifferentialDiagnosis
Table1.
CommonCausesofGeneralizedRash
CONDITION

KEYCLINICALFEATURES

TESTS

Atopic
dermatitis

Dryskinprurituserythemaerythematouspapules
excoriationsscalinglichenificationaccentuationof
skinlineskeystodiagnosisarepruritus,eczematous
appearanceoflesions,andpersonalorfamilyhistory
ofatopy12

Skinbiopsyisnonspecificand
notoftendone*

Contact
dermatitis

Erythemaedemavesiclesbullaeinlinearor
geometricpatterncommoncausesincludecosmetics,
topicalmedications,metal,latex,poisonivy,textiles,
dyes,sunscreens,cement,food,benzocaine,
neomycin13keystodiagnosisarelinearorgeometric
patternanddistributionoflesions

Skinbiopsyisnonspecificand
notoftendone,*butitcanhelp
excludeotherconditions

Drug
eruption

Manypatterns,butmostcommonlymaculopapular
(95%ofcases)14commoninpatientstaking
allopurinol(Zyloprim),betalactamantibiotics,
sulfonamides,anticonvulsants,angiotensinconverting
enzymeinhibitors,nonsteroidalantiinflammatory
drugs,hypoglycemics,andthiazidediuretics,butcan
occurwithalmostanydrug14usuallyappearswithin1
to4weeksofinitiatingdrugkeytodiagnosisistiming
ofrashappearanceinrelationtodruguse14

Skinbiopsyisusually
nonspecificandnotoften
done*15

Erythema
multiforme

Round,duskyredlesionsthatevolveintotarget(iris)
lesionsover48hoursstartsonbacksofhandsand
feetandonextensorsurfacesofarmsandlegs
symmetricmayinvolvepalms,soles,oralmucous
membranes,orlipskeytodiagnosisispresenceof
targetlesions

Skinbiopsyisgenerally
diagnosticandoccasionally
donebiopsyshouldbetaken
fromtheerythematous(not
blistered)portionofthetarget16

Fifthdisease

Slappedcheekappearancewithsparingof

ParvovirusB19serologyskin

Fifthdisease
(i.e.,
erythema
infectiosum)

Slappedcheekappearancewithsparingof
periorbitalareasandnasalbridgeuniquefishnet
patternerythemaonextremities,trunk,andbuttocks
keystodiagnosisinchildrenareslappedcheek
appearanceandnetlikerash,andinadultsare
arthralgiasandhistoryofexposuretoaffectedchild

ParvovirusB19serologyskin
biopsyisnonspecificandrarely
done*

Folliculitis

Multiplesmallpustuleslocalizedtohairfolliclesonany
bodysurfacekeytodiagnosisishairfollicleatcenter
ofeachlesion

Skinbiopsyisoftendiagnostic
butnotoftendone*

Guttate
psoriasis

Pinpointto1cmscalingpapulesandplaquesontrunk
andextremitiesoftenprecededbystreptococcal
pharyngitis1to2weeksbeforeeruption17keysto
diagnosisarescalingandhistoryofstreptococcal
pharyngitis17

Throatcultureantistreptolysin
Otiterearlyskinbiopsymay
notbediagnosticandisnot
oftendone*

Insectbites

Urticarialpapulesandplaqueskeystodiagnosisare
outdoorexposure(usually)anddistributionoflesions
whereinsectsarelikelytobite

Skinbiopsyisnonspecificand
notoftendone*

Keratosis
pilaris

Pinpointfollicularpapulesandpustuleson
posterolateralupperarms,cheeks,anteriorthighs,or
buttocks18keystodiagnosisareupperarm
distribution,absenceofcomedones,andtinypalpable
lesions

Skinbiopsycanbediagnostic
butisnotoftendone*

Lichen
planus

Violaceousflattoppedpapulesandplaques
commonlyonanklesandwrists5P's(pruritic,planar,
polygonal,purpleplaques)Wickhamstriae(reticular
patternofwhitelinesonsurfaceoflesions)19lacy
whitebuccalmucosallesionsKoebnerphenomenon
(developmentoftypicallesionsatthesiteoftrauma)
keystodiagnosisarepurplecoloranddistributionof
lesions20

Skinbiopsyisdiagnosticand
oftendone

Miliariarubra
(i.e.,prickly
heat,heat
rash)

Erythematousnonfollicularpapulesassociatedwith
heatexposureorfeverlesionsonback,trunk,neck,
oroccludedareaskeystodiagnosisarehistoryof
heatexposureanddistributionoflesions

Skinbiopsycanbediagnostic
butisnotoftendone*

Nummular
eczema

Sharplydefined,2to10cm,coinshaped,
erythematous,scaledplaqueslesionsondorsal
handsandfeet,extensorsurfacesofarmsandlegs,
flanks,andhipskeytodiagnosisissharplydefined,
round,erythematous,scaledlesions

Skinbiopsyisnonspecificand
notoftendone,*butitmayhelp
excludeotherdiagnoses

Pityriasis
rosea

Discrete,roundtooval,salmonpink,5to10mm
lesionsChristmastreepatternonbackoften(17to
50%)precededbysolitary2to10cmoval,pink,scaly
heraldpatch21keystodiagnosisareovalshape,
orientationwithskinlines,anddistinctivescale

Skinbiopsyisnonspecificand
notoftendone,*butitmayhelp
excludeotherdiagnosesrapid
plasmareagintestingis
optionaltoruleoutsecondary
syphilis

Psoriasis
(plaque
psoriasis)

Thick,sharplydemarcated,roundoroval,
erythematousplaqueswiththicksilverywhitescale
lesionsonextensorsurfaces,elbows,knees,scalp,
centraltrunk,umbilicus,genitalia,lowerback,or
glutealcleftpositiveAuspitzsign(removalofscale
producesbleedingpoints)Koebnerphenomenon
keystodiagnosisaredistinctivescaleanddistribution
oflesions22

Skinbiopsycanbediagnostic
butisnotoftendone*

Roseola(i.e.,
exanthem
subitum,
sixth
disease)

Suddenonsetofhighfeverwithoutrashorother
symptomsinachildyoungerthan3yearsasfever
subsides,pink,discrete,2to3mmblanching
maculesandpapulessuddenlyappearontrunkand
spreadtoneckandextremitieskeytodiagnosisis
highfeverfollowedbysuddenappearanceofrashas
feverabruptlyresolves23

Skinbiopsyisnonspecificand
notoftendone*

Scabies

Discrete,smallburrows,vesicles,papules,and
pinpointerosionsonfingers,fingerwebs,wrists,
elbows,knees,groin,buttocks,penis,scrotum,axillae,
beltline,ankles,andfeetkeystodiagnosisare
distributionoflesions,intensepruritus,andpositive
mineraloilmount

Mineraloilmountisroutinely
donetoidentifymitesoreggs
skinbiopsyisusually
nonspecificandnotoftendone*

Seborrheic

Erythematouspatcheswithgreasyscalelesions

Skinbiopsyisnonspecificand

Seborrheic
dermatitis

Erythematouspatcheswithgreasyscalelesions
behindearsoronscalpandscalpmargins,external
earcanals,baseofeyelashes,eyebrows,nasolabial
folds,centralchest,axillae,inframammaryfolds,groin,
andumbilicuskeystodiagnosisaregreasyscaleand
distributionoflesions

Skinbiopsyisnonspecificand
notoftendone*

Tinea
corporis

Flat,red,scalylesionsprogressingtoannularlesions
withcentralclearingorbrowndiscolorationkeysto
diagnosisareannularlesionswithcentralclearingand
positiveKOHpreparation

KOHpreparationisroutinely
doneskinbiopsycanbe
diagnostic24butisnotoften
done*

Urticaria(i.e.,
hives)

Discreteandconfluent,raised,edematous,roundor
oval,waxingandwaninglesionswithlargevariationin
sizemayhaveerythematousborder(flare)andpale
center(wheal)patientmayhavehistoryofdrug,food,
orsubstanceexposurekeytodiagnosisisdistinctive
appearanceofedematouslesions

Skinbiopsyisnonspecificand
notoftendone*

Varicella

Vesiclesonerythematouspapules(dewdroponrose
petalappearance)allstages(papules,vesicles,
pustules,crusts)arepresentatthesametimeandin
closeproximitykeystodiagnosisarecropsoflesions
indifferentstages,systemicillness,andexposureto
personswiththeinfection

Diagnosisisusuallyclinical,but
realtimepolymerasechain
reactionassayofskinlesionor
directfluorescentantibody
testingofskinscrapingscould
bedone25skinbiopsyisoften
diagnosticbutcannot
distinguishherpeszosteror
herpessimplex,andisnot
oftendone*

Viral
exanthem,
nonspecific

Blanchable,red,sometimesconfluentmaculesand
papulesmaybeindistinguishablefromdrug
eruptions26keystodiagnosisarenonspecific
generalizedmaculopapularrashinachildwith
systemicsymptoms(fever,diarrhea,headache,
fatigue)

Skinbiopsyisnonspecificand
notoftendone*

KOH=potassiumhydroxide.

*Skinbiopsyisoftennotperformedbecausethehistologyisnonspecificorbecauseabiopsyisusually
notneededfordiagnosis.
Rashesthatcanhaveseriousconsequencesforthepatientorpregnantcontactsofthepatient.
Informationfromreferences12through26.
PhotographsMarySeaburyStone,MD.

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