Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs



Medical Problems - Dermatology - Papulosquamous Lesions (B4)

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There are several conditions to be aware of when considering papulosquamous skin conditions in teens. These are rashes that are are slightly raised and have a scaly component. The first is the condition below: This teen below has pityriasis rosea .

Pityriasis rosea usually starts with Herald's patch and can then spread over the trunk and extremities. The condition is a self-limited disorder of unknown cause that frequently occurs during adolescence. It is usually non pruritic or only slightly pruritic. There are usually no associated systemic symptoms. The lesions are oval, salmon colored papular and macular, 1 to 2 cm scaly lesions. They tend to follow the body's lines of cleavage in a sort of "Christmas tree" distribution similar to the picture above. The Herald's patch is usually larger at about 2 to 6 cm and this patch comes 2 to 21 days before the other lesions. Below is example of a Heralds patch.

heralds patch
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Another papulosquamous type lesion is tinea corporis . The lesion below looks like tinea corporis but is in fact a hearld's patch in someone with pityriasis rosea.

tinea corporis
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papulosquamous lesion
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On to another papulosquamous lesion.

This demonstrates both hypopigmentation in top area and hyperpigmentation in bottom area. This is tinea versicolor. Tinea versicolor is usually hypopigmented or hyperpigmented macules or patches typically over the upper trunk and arms and occasionally on the face and neck. It is caused by Pityrosporum orbiculare . The lesions are usually asymptomatic. Humidity, hyperhidrosis, heredity, diabetes mellitus and systemic corticosteroids can all predispose someone to this condition.

The diagnosis can be made by the observation of hyphae and spores (spaghetti and meatballs) on potassium hydroxide wet mount. A Wood's light examination is helpful in showing yellowish or brownish fluorescence. Treatment can include topical treatments such as selenium sulfide 2.5% shampoo, ketoconazole 2% shampoo, zinc pyrithione shampoo or soap, sulfursalicylic acid. These are usually used in the shower or overnight as tolerated daily for 2 weeks, then several times a month for maintenance. Topical antifungals of the imidazole class also can be used but are expensive for large areas of involvement. Systemic fluconazole 400 mg as a single dose and 200 mg itraconazole daily for 5-7 days have been shown to be effective in treatment of tinea versicolor. However, these medications have not been approved in the United States for the treatment of tinea versicolor.

Below is another example of tinea versicolor. Some other significant hypopigmented lesions in adolescents include vitiligo which is apigmented not hypopigmented and pityriasis alba which usually is slight hypopigmented lesions with nonsharp borders on the cheeks of older children and young adolescents.

tinea versicolor
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Below is another rash in the differential of papulosquamous lesions and that is a drug eruption secondary to drug allergy

drug eruption secondary to drug allergy
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Below is another rash in the differential of papulosquamous lesions. This teen came in with a several day history of pharyngitis, fever and fatigue. In addition, the teen was sexually active. She was thought to have a strep infection and scarlet fever and given an injection of penicillin in the emergency room. About 30 minutes later she had shaky chills.

syphilis rash
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This is a picture of the teen's hands.

palmar rash
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This is a classic presentation of secondary syphilis and the teen probably had a Jarisch-Herxhimer reaction. This occurs following lysis of spirochetes after treatment of syphilis. The teen had a high titer positive VDRL test.

One other example of a papulosquamous differential is shown below. This is an uncommon presentation of a relatively common disease. That is psoriasis presenting with a diffuse psoriatic eruption.

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More typical lesions of psoriasis include those below

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Psoriasis can also occur in the genitals. Note the pitting of the nail on the right. This is the first condition that will be demonstrated with pitting of the nails.

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This last papulosquamous lesion is common in adolescents. It is characterized by a sharp inflammatory edge and central clearing.

tine cruris
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This lesion above is tinea cruris another dermatophyte lesion. It can be pruritic and is treated with topical antifungals.

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Copyright (©) 2004-2013 Lawrence S. Neinstein, University of Southern California . All rights reserved. Republication or redistribution of the text, table, graphs and photos is expressly prohibited. The University of Southern California shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.