Rash R21.x0

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 29.10.2020

Synonym(s)

Exanthema diseases; Exantheme; Rash; Skin rash

Definition
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Exanthema" (from gr. exantheo I bloom) refers to a group of infectious and non-infectious, inflammatory, temporary "skin rashes". Exanthema is characterized by a dynamic, often intermittent course (either one or several episodes). They are generalized or spread over larger areas, usually symmetrical ( rubella, measles), less often asymmetrical (e.g. exanthema, unilateral laterothoracic in childhood). Exanthema is composed of different types of efflorescence (urticae, papules, vesicles, pustules). The dominating type is taken into account in the name for a more detailed clinical description: urticarial exanthema, macular exanthema, pustular exanthema, etc. If the course of an exanthema is characterised by multiple attacks, a "colourful" clinical aspect with different types of efflorescence may occur (example: varicella exanthema).

Classification
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Viral exanthema - normal immunocompetence (see also viral exanthema):
- Measles (Measles virus = Paramyxovirus)
- Rubella (German measles virus)
- rubella ( Erythema infectiosum) (Parvovirus B19)
- Exanthema subitum (HHV-6, HHV-7)
- Mononucleosis, infectious (Epstein-Barr virus)
- Pityriasis rosea (virus?)
- Adenovirus exanthema
- Unilateral laterothoracic exanthema (virus is not known: discussed are influenza virus, EBV, HHV-6, HHV-7)
- Exanthema, asymmetric, periflexural (virus?)
- Enterovirus exanthema
- Exanthema in Coxsackie virus infections
- Exanthema in echovirus infections
- Exanthema in rotavirus infections
- Exanthema in Hanta virus infections (Manchurian Songo fever)
- hand-foot and mouth disease (Coxsackie virus A16, more rarely A5, A7, A9, A10, B1-3, B5 and enterovirus 71)
- glove-sock syndrome (parvovirus B19, HHV-6 and HHV-7, CMV?, measles virus?).
Viral exanthema (vesicular) - normal immunocompetence:
- Varicella
- Fever, hemorrhagic (virus?).
Viral exanthema (maculo-papular/vesicular) - impaired immunocompetence:
- HIV-associated exanthema (in risk group)
- Cytomegalovirus infections (with immunosuppression)
- Eccema herpeticatum (HSV) (for atopic eczema)
- Zoster generalisatus (Varicella zoster virus) (in immunosuppression).
bacterial and other infectious exanthema:
- Bacterial and other infectious exanthema (moderately common):
  - Scarlet fever (Streptococcus pyogenes toxin)
  - Syphilis (Treponema pallidum)
  - Staphylococcus scarlet fever (Staphylococcus aureus toxins)
  - Toxic shock syndrome (Staphylococcus aureus toxins)
  - Lyell Syndrome
  - Lyme disease (Borrelia spp.).
- Bacterial and other infectious exanthema (rare):
  - Mycoplasma exanthema
  - Septic diseases with skin symptoms ( gonorrhoea, meningococcal meningitis, bacterial endocarditis)
  - Rickettsialpox ( typhus, febris quintana; ten-day fever and others)
  - Cat scratch disease (Bartonella henselae)
  - Psittacosis (Chlamydia psittaci)
  - Brucellosis (Bruzella spp.)
  - Q fever (Coxiella burneti)
  - Toxoplasmosis, exanthematic
  - M. Because (Leptospira icterohaemorrhagica)
  - Listeriosis (Listeria monocytogenes)
  - Paratyphoid (Salmonella paratyphi)
  - Typhoid (Salmonella typhi).
Parainfectious exanthema/enzyme defects (by frequency):
- Erythema exsudativum multiforme
- pityriasis lichenoides et varioliformis
- Pityriasis lichenoides chronica
- Purpura Beauty Enoch
- Leucocytoclastic vasculitis (see below vasculitis)
- Chronic pigment purpura
- Id reactions to candidoses or trichophytes
- Unilateral laterothoracic exanthema
- Erythema anulare centrifugum
- Gianotti-Crosti Syndrome
- Infantile, acute, hemorrhagic edema
- Kawasaki Syndrome
- Infantile acrolocalized papulo-vesicular syndrome
- Erythema gyratum repens
- Adolescent Anular lichenoid dermatitis
- Dermatitis, exudative discoid lichenoid
- Id reactions to tuberculosis (tuberculides) or leprosy
- post-vacinar exanthema
- Exanthema in trichinosis
- Carboxylase defect, multiple (rare, in infants)
- Mediterranean fever, familial (periodic fever syndrome)
- Muckle-Wells Syndrome.
Allergic/pseudoallergic:
- Urticarial, lichenoid, maculopapular, acne-like drug exanthema
- Acute or chronic urticaria
- Contact allergic eczema with exanthematic scattering reactions
- Urticarial exanthema after insect bites (e.g. wasp venom)
- Erythema neonatorum.
Idiopathic or neoplastic:
- Acute or chronic urticaria
- Urticaria vasculitis
- Hypereosinophilic dermatitis
- Dermatosis, acute febrile neutrophils (Sweet syndrome)
- Exanthematic cutaneous T-cell lymphomas
- Leukemias of the skin
- Castleman lymphoma
- Pustuloderm, toxic
- Psoriasis vulgaris (exanthematic)
- Pustulose, subcorneal (Sneddon-Wilkinson)
- lichen planus
- lichen nitidus
- Histiocytomas, generalized eruptive
- Dermatoarthritis, familial histiocytic
- Erythema scarlatiniforme desquamativum recidivans (?).
Exanthema in rheumatic diseases:
- CINCA syndrome (periodic fever syndrome)
- Tumor necrosis factor receptor associated periodic syndrome (periodic fever syndrome)
- Erythema anulare rheumaticum
- Breastfeeding Syndrome
- Still Syndrome, adult (AOSD).
Autoimmunological:
Toxic:
- Herxheimer's response
- TEN.
Pseudoexanthema due to external infections:
- Pseudomonas folliculitis (whirlpool dermatitis)
- Microsphere (generalized)
- Infant pityrosporum folliculitis
- Cercarial dermatitis
- Trombidiosis
- Harlequin discoloration (transient exanthema in infants).

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Etiopathogenesis
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Due to their morphology, some exanthema are characteristic of certain viral and bacterial infections (measles, scarlet fever). Others accompany as "parainfectious" exanthems various infectious diseases (e.g. Gianotti-Crosti syndrome). Exanthema also occurs in allergic, pseudoallergic and rheumatic diseases. Exanthems can be classified according to their etiology:

- Infectious exanthema
  - Viral exanthema (most common form of exanthema in children)
  - Bacterial and other infectious exanthema
- Parainfectious exanthema/enzyme defects
- Allergic/pseudoallergic exanthema
- Idiopathic exanthema
- Exanthema for rheumatic diseases
- Autoimmunological exanthema
- Toxic exanthema
- Pseudoexanthema caused by external infections

Efflorescence(s)
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Exanthema can include all types of efflorescence. They usually show a synchronous monomorphism. A typical exception is varicella or PLEVA ( Pityriasis lichenoides et varioliformis acuta) with a synchronous polymorphism. Typical for varicella is the "starry sky" (several thrusts or continuous thrust activity over a longer period of time).

Differential diagnosis
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For practical reasons of differential diagnosis, exanthema diseases can also be classified according to their main age of manifestation:

neonatal exanthema
Exanthema in pre-school and school age
Adult exanthema.

Note(s)
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When assessing an exanthema, the first and most important step towards a valid diagnosis is the basic distinction between an infectious and a non-infectious exanthema. Careful analysis of signs of infection such as fever, AZ disorder, lymphadenopathy, hepatosplenomegaly, blood count and the evaluation of an infection scenario can help here. Only after exclusion of an infectious exanthema can a non-infectious exanthema be considered. The most frequent infectious exanthema are viral exanthema.