A 28-year-old woman comes to the office due to worsening of a skin rash on her back and arms for the past 2 weeks. She has had no associated pain or pruritus. During her teenage years, the patient had comedonal acne on her face, which resolved with topical medications. She was diagnosed with systemic lupus erythematosus 2 years ago and is on oral prednisone due to a recent exacerbation with pain and swelling in the small joints of the hands. The patient also takes hydroxychloroquine and as-needed nonsteroidal anti-inflammatory drugs. She does not use tobacco, alcohol, or illicit drugs. She works in a dry-cleaning facility. The patient is sexually active with her boyfriend and has an intrauterine device for contraception. Temperature is 37 C (98.6 F), blood pressure is 130/86 mm Hg, and pulse is 78/min. Skin examination shows uniform-appearing, 1- to 3-mm, erythematous papules across her back, shoulders, and upper arms. There is mild symmetric synovitis in the hands and wrists, but the remainder of the physical examination is unremarkable. Which of the following is the most likely cause of this patient's skin rash?

Question

A 28-year-old woman comes to the office due to worsening of a skin rash on her back and arms for the past 2 weeks.  She has had no associated pain or pruritus.  During her teenage years, the patient had comedonal acne on her face, which resolved with topical medications.  She was diagnosed with systemic lupus erythematosus 2 years ago and is on oral prednisone due to a recent exacerbation with pain and swelling in the small joints of the hands.  The patient also takes hydroxychloroquine and as-needed nonsteroidal anti-inflammatory drugs.  She does not use tobacco, alcohol, or illicit drugs.  She works in a dry-cleaning facility.  The patient is sexually active with her boyfriend and has an intrauterine device for contraception.  Temperature is 37 C (98.6 F), blood pressure is 130/86 mm Hg, and pulse is 78/min.  Skin examination shows uniform-appearing, 1- to 3-mm, erythematous papules across her back, shoulders, and upper arms.  There is mild symmetric synovitis in the hands and wrists, but the remainder of the physical examination is unremarkable.  Which of the following is the most likely cause of this patient's skin rash?

Quizplus · Accepted Answer

11ec25c8_d38c_f536_bc81_b38135aa0299_MD0003_00 This patient has an acute papular inflammatory rash consistent with drug-induced acne, also called steroid-induced folliculitis or steroid acne. Drug-induced acne is typically associated with systemic glucocorticoids but can also be caused by topical glucocorticoids, glucocorticoid-sparing agents (eg, azathioprine, cyclosporine), and a variety of other drugs (eg, anticonvulsants, antituberculous drugs). In contrast to acne vulgaris (which displays lesions in various stages of development and typically occurs on the face in adolescents), drug-induced acne can be seen in any age group, is characterized by monomorphic papules without associated comedones, and commonly involves the upper back, shoulders, and upper arms (Choice A). Some patients may have small pustules, but lesions are found in the same stage of development, and scarring cystic and nodular lesions are not seen. Drug-induced acne does not respond to typical acne treatment but improves rapidly on discontinuation of the offending agent. acne vulgaris comedones (Choice B) Chloracne is a severe skin disorder caused by exposure to halogenated hydrocarbons (eg, occupational exposure to the pollutant dioxin). It is characterized by inflammatory nodules and large comedones affecting the head, neck, and axillae. Chloracne (Choice C) Common dermal manifestations of systemic lupus erythematosus include an erythematous malar rash, discoid plaques and ulcers, and generalized photosensitivity. malar rash discoid plaques and ulcers (Choice D) Disseminated gonococcal infection typically presents with a vesiculopustular rash, tenosynovitis, and migratory polyarthralgias. Most patients are febrile (unlike in this case), and the skin lesions are predominantly found on the distal extremities and usually last only a few days. (Choice E) Herpes simplex virus infection presents with clusters of vesicles and ulcers on an erythematous base, typically in the perioral or genital areas. Educational objective: Drug-induced acne is a common side effect of systemic glucocorticoids and is characterized by monomorphic papules without associated comedones, cysts, or nodules. Drug-induced acne does not respond to typical acne treatment but improves rapidly on discontinuation of the offending agent. References: Drug-induced acneiform eruption. (http://www.ncbi.nlm.nih.gov/pubmed/21668032)

A 28-Year-Old Woman Comes to the Office Due to Worsening