Differentials
Drug rash with eosinophilia and systemic symptoms (DRESS)
SIGNS / SYMPTOMS
Presents with fever, rash, lymphadenopathy, arthralgias, hepatitis, nephritis, carditis, eosinophilia, and atypical lymphocytes.[19][66][67]
Most frequent causative agents are phenytoin, phenobarbital and carbamazepine, and the sulfonamides.[19][68]
More frequent among black people.
It takes 2-6 weeks from beginning the drug therapy to onset of rash.[3]
INVESTIGATIONS
Skin biopsy and clinical presentation; CBC may show eosinophilia; LFTs may be elevated if hepatitis present.
Staphylococcal scalded skin syndrome
SIGNS / SYMPTOMS
Disease of infancy or early childhood (Ritter disease).
Bacterial endotoxin disrupts the epidermis but without necrosis or inflammation.[24]
INVESTIGATIONS
CBC, blood and wound cultures, and skin biopsy.
Toxic shock syndrome
SIGNS / SYMPTOMS
Either Staphylococcus or Streptococcus can be the origin of the infection, presenting with signs of sepsis and a sunburn-like rash.
INVESTIGATIONS
CBC, blood and wound cultures, and skin biopsy.
Graft-versus-host disease
SIGNS / SYMPTOMS
Patients develop a rash, but the skin in graft-versus-host disease does not slough off as readily as it does in SJS or TEN.
Patients who have been transplanted develop a rash as a result of rejection rather than a drug-induced reaction, although grade IV skin manifestations can be as severe as in TEN. Ocular lesions are rare.[24]
INVESTIGATIONS
CBC and skin biopsy.
Vesicant/blister agent poisoning
SIGNS / SYMPTOMS
Clinical effects such as erythema and blisters will occur immediately with phosgene oxime or lewisite or be delayed for 2-24 hours with mustard gas.[69]
INVESTIGATIONS
Skin biopsy.
Erythema multiforme
INVESTIGATIONS
Skin biopsy.
Burns, skin
SIGNS / SYMPTOMS
Result of trauma with destruction of the epidermis and dermis to variable degrees.[19]
INVESTIGATIONS
Skin biopsy if there is not a good history.
Paraneoplastic pemphigus
Generalized bullous fixed drug eruption
Acute generalized exanthematous pustulosis
SIGNS / SYMPTOMS
Fever, neutrophilia, acute sterile pustules, erythema, facial edema.[72]
INVESTIGATIONS
Skin biopsy.
Coxsackievirus A6
SIGNS / SYMPTOMS
No drug intake; fever; papulovesicles on hands, tongue, buttocks, mouth ulcers.[73]
INVESTIGATIONS
Skin biopsy; virus in skin and blister fluid.
Chikungunya fever
SIGNS / SYMPTOMS
Resolves usually within 1 week. Vesicles; bullae; few smaller, superficial erosions. Mucositis generally absent; if present, mild erosions that heal in 3 or 4 days. Child active, playful, eating well. Nelson severity index score 8-10 (moderately sick or not sick).[74]
INVESTIGATIONS
IgM anti-chikungunya virus antibodies; histopathology; Nelson severity index.
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