Many common diseases such as atopic dermatitis, psoriasis, drug rashes, urticaria, viral exanthems, bug bites, and vitiligo present with lesions in multiple body regions. Less common disorders such as syphilis, erythema multiforme, Stevens–Johnson syndrome/toxic epidermal necrolysis, the immunobullous diseases, cutaneous T-cell lymphomas, and connective tissue disorders also present in multiple body locations.
Skin diseases affecting several anatomic sites simultaneously are listed in Table 37-1. Lesion distribution is frequently a very important clue to the diagnosis. For example, atopic dermatitis typically involves the flexor extremities, specifically the popliteal and antecubital fossae, whereas psoriasis vulgaris usually involves the elbows, knees, and extensor surfaces. It is still unclear why certain diseases have a predilection for specific anatomic locations.
| Disease | Epidemiology | History | Physical Examination |
|---|---|---|---|
| Inflammatory | |||
| Allergic contact dermatitis | Common F > M Age: any age | Pruritic Onset is hours to days after contact with allergen | Acute: papules and vesicles on an erythematous base (Figures 8-4 and 8-5) Chronic: xerosis, fissuring, hyperpigmentation, and lichenification (Figures 8-1, 8-2, 8-3) Typical locations: scalp, face, eyelids, earlobes, neck, hands wrists, or feet |
| Atopic dermatitis | Common M > F Age: usually presents in childhood but may persist | Pruritic Chronic course with exacerbations. Worse in winter. Personal or family history of atopy | Infants: red papules, scaly plaques and excoriations on cheeks, trunk and extensor extremities (Figure 8-7) Children and adults: red lichenified plaques, and excoriations (Figure 8-8) typically on neck, wrists, hands, ankles, feet, and flexor extremities, especially the antecubital and popliteal fossas |
| Nummular eczema | Common M > F Age: bimodal; peaks in young adults and the elderly | Pruritic Chronic waxing and waning course Associated with dry skin | Round, light pink, scaly, thin, 1-3 cm plaques (Figure 8-11) on trunk and extremities |
| Prurigo nodularis | Uncommon F > M Can be idiopathic or secondary to other underlying etiology | Pruritic. Persists for months to years. Variable patient insight. May admit to picking and/or scratching lesions | Solitary or multiple discrete well-demarcated dome-shaped hyperpigmented papules or nodules often in variable stages of healing on extensor extremities (Figure 26-2) |
| Psoriasis | Common M = F Age: any age, but peaks in young adulthood (20s) and middle aged adults (50s) | Asymptomatic to mildly pruritic Chronic. May have arthritis and family history of psoriasis | Red papules and plaques with silvery, thick, adherent scale on scalp, extensor extremities, elbows, knees, genitals, umbilicus, lower back, and retroauricular area (Figures 9-1, 9-2, 9-3) Nail pitting/dystrophy |
| Lichen planus | Uncommon F > M Age: 30-60 years | Pruritic. Lasts months to years May be drug-induced or associated with hepatitis C | Multiple variants; classically flat-topped, well-defined, polygonal, violaceous, shiny papules on volar wrists, shins, glans penis, back, scalp, and buccal mucosa in a symmetric distribution (Figures 9-10 to 9-11) |
| Erythema multiforme | Uncommon M > F Age: usually in children, adolescents, and young adults | Asymptomatic or pruritic may have associated fevers Recurrence associated HSV infections | Typical target lesions: papules with 3 zones of color on palms, soles, dorsal hands/feet, forearms, face, and genitals (Figures 23-1 and 23-3) |
| Infectious | |||
| Herpes zoster | Common M:F unknown Age: any age, but usually older than 50 years | Severe pain, pruritus, or paresthesias preceding eruption. Lasts 3-4 weeks | Grouped vesicles on an erythematous base. Usually located on the face or thorax in a unilateral dermatome (Figures 11-3 and 11-4) |
| Viral exanthem | Common M:F unknown Age: usually in children less than 20 years Enterovirus, more common in the summer months | Asymptomatic or associated with a prodrome of fever, malaise, rhinitis, sore throat, nausea, vomiting, diarrhea, or headache | Scarlatiniform: patchy generalized erythema with desquamation, most prominent in the body folds Morbilliform: macules and papules on the head, neck, trunk, and proximal extremities (Figure 27-9) |
| Tinea corporis | Uncommon M = F Age: all ages, but more common in children | Asymptomatic or mildly pruritic Associated with hot/humid weather, farming and crowded living conditions | Annular plaque(s) with a scaly, raised well-demarcated border and central clearing on any body location except palms and soles (Figure 10-4) |
| Syphilis (secondary) | Uncommon M > F Age: 15-40 years | Asymptomatic ulcer usually on glans penis followed weeks to months later by diffuse eruption on trunk Systemic symptoms may be present or shortly precede onset of eruption (fever, malaise, myalgia, and headache) Risk factors: men who have sex with men | Palms/soles: red-brown or ham colored macules or papules ± scale (Figure 12-7) Trunk: multiple diffuse pink macules or scattered, discrete, firm, red, scaly, well-defined papules in symmetrical distribution (Figure 12-6) Scalp: patchy or diffuse alopecia Oral mucosa: mucous patches Anogenital region: moist warty papules (condyloma lata) |
| Drug rashes and urticaria | |||
| Morbilliform drug eruption | Common F > M Age: any age, but less commonly in children | Asymptomatic or pruritic. Begins 1 day to 3 weeks after taking offending agent. Antibiotics, anticonvulsants, and NSAIDs are the most common causes | Small pink macules and papules starting on the trunk and pressure-bearing areas spreading diffusely with a symmetric distribution on trunk and extremities with prominence in body folds (Figure 14-6) |
| Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) | Rare M = F Age: any age, but usually adults Increased risk in older patients and those with HIV/AIDS High mortality | Painful 1-14 day prodrome with mucosal irritation The most common offending agents are allopurinol, carbamazepine, lamotrigine, NSAIDs, phenobarbital and sulfonamide, taken within 4 weeks of rash | Erythematous, purpuric, dusky, targetoid macules, and patches that expand and coalesce. Lesions develop necrotic centers and flaccid bullae with a positive Nikolsky sign. Mucous membranes are commonly involved (Figures 24-4, 24-5, 24-6, 24-7) Lesions are widely distributed with prominence on trunk and face |
| Urticaria | Common M = F Age: any age, but chronic urticaria is more common in adults | Pruritic Individual lesions last less than 24 h. Acute urticaria may last up to 6 weeks | Pink edematous plaques (wheals) with no surface changes such as scales or crust. Can occur on any body area (Figures 14-1 and 14-2) |
| Bullous disorders | |||
| Bullous pemphigoid | Uncommon M = F Age: 60-80 years | Pruritus with or without blisters | Initially, pruritic urticarial plaques without blisters; later tense bullae arise usually on the trunk and proximal flexural extremities (Figure 22-1). Mucous membrane involvement in <20% of cases |
| Pemphigus vulgaris | Rare M = F Age: 40-60 years High mortality | Painful blisters and erosions on the skin No pruritus ± Mucous membrane involvement Patients may complain of pharyngitis and/or dysphagia | Painful flaccid bullae with a positive Nikolsky sign and crusted erosions with a wet base usually on head, upper trunk and intertriginous areas (Figure 22-4). Mucosal lesions may involve the oral cavity (Figure 22-5), pharynx, larynx, genitals, esophagus, or conjunctiva |
| Dermatitis herpetiformis | Uncommon M > F Age: any age, but most commonly 20-60 years | Severe episodic pruritus Associated with a gluten-sensitive enteropathy | Grouped pink crusted papules and erosions on extensor extremities, elbows, knees, buttocks, scalp, and neck in a symmetric distribution (Figure 22-8). Vesicles rarely seen due to excoriation |
| Connective tissues disease | |||
| Generalized acute cutaneous lupus erythematosus | Uncommon F > M Age: any age, but most commonly 30-40 years of age. Associated with systemic lupus erythematosus (SLE). High morbidity | Pruritus or burning Duration: weeks to months Maybe related to sun exposure Associated with fevers, fatigue, oral ulcers, and other systemic findings consistent with SLE | Red clustered papules, urticarial plaques, and patchy erythema with variable scale Typical locations: photosensitive distribution, involving the forehead, malar eminence, bridge of the nose, neck upper chest and dorsal hands, classically sparing the skin overlying the joints (Figure 24-5) |
| Dermatomyositis | Rare F > M Age: bimodal; peaks at ages 5-10 and 50 years of age Associated with malignancy in approximately 20% of adult cases | Asymptomatic or pruritic Chronic course Associated with photosensitivity, scalp pruritus/burning and symmetric proximal muscle weakness | Macular violaceous erythema located periorbitally (heliotrope sign), chest, lateral thighs, back, and shoulders. Flat-topped violaceous papules (Gottron’s papules) overlying the knuckles and interphalangeal joints as well as elbows and knees Periungual erythema may be present (Figure 24-6) |
| Neoplastic | |||
| Mycosis fungoides (cutaneous T-cell lymphoma) | Uncommon M > F Age: usually in middle-aged adults | Asymptomatic or mild pruritus Onset: months to years with chronic course Very slow or absent disease progression | Well-defined eczematous or psoriasiform patches and plaques that may progress to thicker plaques, nodules, or erythroderma usually distributed asymmetrically with a predilection for sun-protected sites, especially the buttocks |
| Pigmentation | |||
| Vitiligo | Common M = F Age: any age | Asymptomatic Chronic course Personal or family history of autoimmune disease | Well-demarcated depigmented macules and patches typically on dorsal hands, ventral wrists, extensor forearms, genitals and face, favoring the perioral and periocular regions (Figures 21-1 and 21-2) |
| Other | |||
| Bug bites | Common M = F Age: any age, but usually in childhood, adolescents, and young adulthood | Pruritic Most are aware of bug bites, but when the reaction is delayed or occurs during sleep patients may not know they were bitten | Erythematous papules, bullae, or urticarial plaques (Figure 14-5). Typically located on exposed sites such as the head, neck, lower legs, and arms |
| Scabies | Common M = F Any age, but more common in children | Intense pruritus. Chronic symptoms until treated | Multiple excoriated papules on finger webs, volar wrist, flexural areas, elbows, knees, and genitals (Figures 13-1, 13-2, 13-3, 13-4, 13-5) |
| Granuloma annulare | Common F > M Age: children and young adults, but depends on the type. Several variants exist | Asymptomatic Lasts months to years. May cause aesthetic concern. Recurrence is common | Skin colored or erythematous papules generally without surface change, solitary or multiple on extensor extremities and dorsal hands and feet (Figure 24-9) |
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