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May 2009
By Kirkland Lau, DO, and Stephen M. Schleicher, MD
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CASE:
A 43-year-old woman presents to your emergency department with a rash that she first noticed on her anterior thighs one week ago. The rash subsequently spread to her arms and trunk and was characterized by erythema, vesiculation of the calves and ankles, and islands of sparing.
Her history is significant for Charcot-Marie-Tooth disease and several food allergies. The only medication that she takes is carisoprodol on an as-needed basis. Three days before the rash appeared she began taking a dietary supplement that she had purchased on the Internet. A skin biopsy reveals eosinophils and you initiate treatment with diphenhydramine and methylprednisolone.
WHAT IS YOUR DIAGNOSIS? |
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Although the cause of the rash was never determined, a reaction to either carisoprodol, which has been linked to severe skin reactions, or the dietary supplement seems most likely. The eosinophils in the biopsy findings support the diagnosis of a hypersensitivity reaction. Note that the differential diagnosis for an extensive dermatitis manifesting islands of sparing also includes pityriasis rubra pilaris, a condition of unknown etiology. Oral rechallenge could confirm the diagnosis of an adverse reaction to carisoprodol but is certainly not recommended. Acute reactions of this nature often warrant therapy with parenteral steroids and antihistamines. |
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Dr. Lau is an associate with a division of the DermDx Centers for Dermatology in Reading, Pennsylvania. Dr. Schleicher is director of the DermDOX Center in Hazelton, Pennsylvania, a clinical instructor of dermatology at the Philadelphia College of Osteopathic Medicine and Kings College in Wilkes-Barre, Pennsylvania, and an associate professor of medicine at the Commonwealth Medical School in Scranton, Pennsylvania. He is also a member of the EMERGENCY MEDICINE editorial board.
Emerg Med 41(5):23-24, 2009
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