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A Widespread Pruritic Rash With Facial Swelling and Black Streaks

A Widespread Pruritic Rash With Facial Swelling and Black Streaks Case A healthy girl aged 4 years presented with a 5-day history of a pruritic rash on her arms, neck, axillae, and face. The rash started as small pink bumps on her arms that spread to involve the axillae, neck, and upper chest. Four days prior to arrival, she developed significant redness and pruritus of her face. On arrival, her parents noted black streaks on her right arm, prompting an urgent emergency department evaluation. Treatment prior to presentation included diphenhydramine, cetirizine, and a 20-mg dose of prednisone without improvement. The patient was otherwise healthy with normal development and growth. She had a history of mild atopic dermatitis and was not taking any medications. She had no known history of drug allergy or contact allergy. The patient lived with her 2 siblings and both parents, who were all asymptomatic. She had no pets and no recent travel, and her vaccinations were up to date. On physical examination, the patient was actively scratching the involved skin. The bilateral arms, axillae, anterior neck, and face had poorly defined, blanching pink-red patches and edematous plaques without epidermal change (Figure, A). Jet black, well-defined, and slightly shiny linear streaks with peripheral erythema were noted on her right forearm, with smaller circular, black macules on the ipsilateral biceps and axilla (Figure, B). Figure. View LargeDownload Widespread pruritic eruption. A, Poorly defined, blanching pink-red patches and edematous plaques on the upper chest, neck, proximal arms, and face. B, Jet black, well-defined, and slightly shiny linear streaks with peripheral erythema on the right forearm. Box Section Ref ID What Is Your Diagnosis? Coxsackievirus A6–associated exanthem Phototoxic dermatitis (phytophoto) Black-spot poison ivy dermatitis Nickel contact dermatitis Read the Discussion. Discussion Diagnosis C. Black-spot poison ivy dermatitis. Discussion On further history, the patient recently started to spend significant amounts of time outdoors while at daycare and in the backyard at home. Additionally, her parents recalled similar black-colored spots on her clothes and her siblings. At the onset of the eruption, the parents decreased the length of the patient’s showers and avoided washing the most involved areas for fear of exacerbation. Further inspection of the eruption revealed involvement primarily of exposed skin. The black macules were geometrically shaped and sharply defined, without a stellate or retiform morphology. The primary symptom was itch without any associated skin tenderness. Given the history and examination findings, the clinical diagnosis was black-spot dermatitis due to Toxicodendron exposure. We were able to partially remove the black streaks in clinic with alcohol swabs. Given significant involvement and discomfort, we initiated a 3-week prednisone taper. We also recommended gentle showers daily with soap and water to wash off the black macules. On telephone follow-up, we learned the patient improved significantly. The black macules were difficult to fully remove and required about 7 to 10 days of gentle rubbing in the shower. The father also discovered a significant burden of poison ivy in the backyard, which was not present in prior years. Toxicodendron allergic contact dermatitis refers to a classic dermatitis following exposure to plants of the Anacardiaceae family, most commonly poison ivy (Toxicodendron radicans), poison oak (Toxicodendron diversilobum), and poison sumac (Toxicodendron vernix).1,2 The term Rhus dermatitis was previously used until recent evidence determined Toxicodendron as the correct genus.1 The antigen found in all of these plants is urushiol, which acts as both a direct irritant and an allergen.3 Urushiol is an oily substance that can penetrate clothes, shoes, and gloves and can remain on surfaces (with antigenic potential) for long periods.2,4 About 50% to 85% of the US population is sensitized to urushiol, and skin eruptions due to an allergic contact dermatitis require prior sensitization.2,5 On reexposure, the classic cutaneous findings develop in about 24 to 48 hours and include edematous pink-red plaques, papulovesicles, or bullae. These lesions are often asymmetrically distributed, linear, and streaking and favor exposed skin that has direct allergen exposure.2 The extremities are commonly involved first, although subsequent direct spread of urushiol can lead to an eruption of the face, genitalia, and remainder of the body. The overwhelming symptom is pruritus. The black-spot variant seen here has been uncommonly described in the literature.4,6-8 The black, lacquer-like streaks are the result of urushiol exposure to air after accumulating in high concentration.2,4,6 This distinct black deposition is pathognomonic for urushiol-producing plants and can involve the skin, clothes, or any other surface. Without treatment, the typical Toxicodendron dermatitis can last anywhere from 1 to 6 weeks.2 In the setting of early plant exposure, immediatly washing with soap and a washcloth can prevent a skin eruption. Otherwise, treatment of black-spot dermatitis is the same as a regular allergic contact dermatitis: topical or systemic corticosteroids depending on the severity of involvement. If systemic corticosteroids are needed, the taper should be prolonged over about 2 to 3 weeks to avoid dermatitis flare, as seen with shorter courses of corticosteroids. The patient should also be instructed to wash daily and gently scrub the black spots with a washcloth. The black spots are difficult to remove because of the hydrophobic properties of urushiol. Back to top Article Information Corresponding Author: Marilyn G. Liang, MD, Department of Dermatology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (marilyn.liang@childrens.harvard.edu). Conflict of Interest Disclosures: None reported. Additional Contributions: We thank the family for granting permission to publish this information. Section Editor: Samir S. Shah, MD, MSCE. References 1. James WD, Elston DM, Berger TG. Andrews’ Diseases of the Skin, Clinical Dermatology. Philadelphia, Pennsylvania: Saunders; 2011. 2. Gladman AC. Toxicodendron dermatitis: poison ivy, oak, and sumac. Wilderness Environ Med. 2006;17(2):120-128.PubMedGoogle ScholarCrossref 3. Gross M, Baer H, Fales H. Urushiols of poisonous anacardiaceae. Phytochemistry. 1975;14:2263-2266.Google ScholarCrossref 4. Kurlan JG, Lucky AW. Black spot poison ivy: a report of 5 cases and a review of the literature. J Am Acad Dermatol. 2001;45(2):246-249.PubMedGoogle ScholarCrossref 5. Marks JG. Poison ivy and poison oak allergic contact dermatitis. J Allergy Clin Immunol. 1989;9:497-506.Google Scholar 6. Mallory SB, Miller OF 3dU, Tyler WB. Toxicodendron radicans dermatitis with black lacquer deposit on the skin. J Am Acad Dermatol. 1982;6(3):363-368.PubMedGoogle ScholarCrossref 7. Guin JD. The black spot test for recognizing poison ivy and related species. J Am Acad Dermatol. 1980;2(4):332-333.PubMedGoogle ScholarCrossref 8. Paniagua CT, Bean AS. Black-spot poison ivy: a rare phenomenon. J Am Acad Nurse Pract. 2011;23(6):275-277.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Pediatrics American Medical Association

A Widespread Pruritic Rash With Facial Swelling and Black Streaks

JAMA Pediatrics , Volume 170 (6) – Jun 1, 2016

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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6203
eISSN
2168-6211
DOI
10.1001/jamapediatrics.2015.3741
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Abstract

Case A healthy girl aged 4 years presented with a 5-day history of a pruritic rash on her arms, neck, axillae, and face. The rash started as small pink bumps on her arms that spread to involve the axillae, neck, and upper chest. Four days prior to arrival, she developed significant redness and pruritus of her face. On arrival, her parents noted black streaks on her right arm, prompting an urgent emergency department evaluation. Treatment prior to presentation included diphenhydramine, cetirizine, and a 20-mg dose of prednisone without improvement. The patient was otherwise healthy with normal development and growth. She had a history of mild atopic dermatitis and was not taking any medications. She had no known history of drug allergy or contact allergy. The patient lived with her 2 siblings and both parents, who were all asymptomatic. She had no pets and no recent travel, and her vaccinations were up to date. On physical examination, the patient was actively scratching the involved skin. The bilateral arms, axillae, anterior neck, and face had poorly defined, blanching pink-red patches and edematous plaques without epidermal change (Figure, A). Jet black, well-defined, and slightly shiny linear streaks with peripheral erythema were noted on her right forearm, with smaller circular, black macules on the ipsilateral biceps and axilla (Figure, B). Figure. View LargeDownload Widespread pruritic eruption. A, Poorly defined, blanching pink-red patches and edematous plaques on the upper chest, neck, proximal arms, and face. B, Jet black, well-defined, and slightly shiny linear streaks with peripheral erythema on the right forearm. Box Section Ref ID What Is Your Diagnosis? Coxsackievirus A6–associated exanthem Phototoxic dermatitis (phytophoto) Black-spot poison ivy dermatitis Nickel contact dermatitis Read the Discussion. Discussion Diagnosis C. Black-spot poison ivy dermatitis. Discussion On further history, the patient recently started to spend significant amounts of time outdoors while at daycare and in the backyard at home. Additionally, her parents recalled similar black-colored spots on her clothes and her siblings. At the onset of the eruption, the parents decreased the length of the patient’s showers and avoided washing the most involved areas for fear of exacerbation. Further inspection of the eruption revealed involvement primarily of exposed skin. The black macules were geometrically shaped and sharply defined, without a stellate or retiform morphology. The primary symptom was itch without any associated skin tenderness. Given the history and examination findings, the clinical diagnosis was black-spot dermatitis due to Toxicodendron exposure. We were able to partially remove the black streaks in clinic with alcohol swabs. Given significant involvement and discomfort, we initiated a 3-week prednisone taper. We also recommended gentle showers daily with soap and water to wash off the black macules. On telephone follow-up, we learned the patient improved significantly. The black macules were difficult to fully remove and required about 7 to 10 days of gentle rubbing in the shower. The father also discovered a significant burden of poison ivy in the backyard, which was not present in prior years. Toxicodendron allergic contact dermatitis refers to a classic dermatitis following exposure to plants of the Anacardiaceae family, most commonly poison ivy (Toxicodendron radicans), poison oak (Toxicodendron diversilobum), and poison sumac (Toxicodendron vernix).1,2 The term Rhus dermatitis was previously used until recent evidence determined Toxicodendron as the correct genus.1 The antigen found in all of these plants is urushiol, which acts as both a direct irritant and an allergen.3 Urushiol is an oily substance that can penetrate clothes, shoes, and gloves and can remain on surfaces (with antigenic potential) for long periods.2,4 About 50% to 85% of the US population is sensitized to urushiol, and skin eruptions due to an allergic contact dermatitis require prior sensitization.2,5 On reexposure, the classic cutaneous findings develop in about 24 to 48 hours and include edematous pink-red plaques, papulovesicles, or bullae. These lesions are often asymmetrically distributed, linear, and streaking and favor exposed skin that has direct allergen exposure.2 The extremities are commonly involved first, although subsequent direct spread of urushiol can lead to an eruption of the face, genitalia, and remainder of the body. The overwhelming symptom is pruritus. The black-spot variant seen here has been uncommonly described in the literature.4,6-8 The black, lacquer-like streaks are the result of urushiol exposure to air after accumulating in high concentration.2,4,6 This distinct black deposition is pathognomonic for urushiol-producing plants and can involve the skin, clothes, or any other surface. Without treatment, the typical Toxicodendron dermatitis can last anywhere from 1 to 6 weeks.2 In the setting of early plant exposure, immediatly washing with soap and a washcloth can prevent a skin eruption. Otherwise, treatment of black-spot dermatitis is the same as a regular allergic contact dermatitis: topical or systemic corticosteroids depending on the severity of involvement. If systemic corticosteroids are needed, the taper should be prolonged over about 2 to 3 weeks to avoid dermatitis flare, as seen with shorter courses of corticosteroids. The patient should also be instructed to wash daily and gently scrub the black spots with a washcloth. The black spots are difficult to remove because of the hydrophobic properties of urushiol. Back to top Article Information Corresponding Author: Marilyn G. Liang, MD, Department of Dermatology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (marilyn.liang@childrens.harvard.edu). Conflict of Interest Disclosures: None reported. Additional Contributions: We thank the family for granting permission to publish this information. Section Editor: Samir S. Shah, MD, MSCE. References 1. James WD, Elston DM, Berger TG. Andrews’ Diseases of the Skin, Clinical Dermatology. Philadelphia, Pennsylvania: Saunders; 2011. 2. Gladman AC. Toxicodendron dermatitis: poison ivy, oak, and sumac. Wilderness Environ Med. 2006;17(2):120-128.PubMedGoogle ScholarCrossref 3. Gross M, Baer H, Fales H. Urushiols of poisonous anacardiaceae. Phytochemistry. 1975;14:2263-2266.Google ScholarCrossref 4. Kurlan JG, Lucky AW. Black spot poison ivy: a report of 5 cases and a review of the literature. J Am Acad Dermatol. 2001;45(2):246-249.PubMedGoogle ScholarCrossref 5. Marks JG. Poison ivy and poison oak allergic contact dermatitis. J Allergy Clin Immunol. 1989;9:497-506.Google Scholar 6. Mallory SB, Miller OF 3dU, Tyler WB. Toxicodendron radicans dermatitis with black lacquer deposit on the skin. J Am Acad Dermatol. 1982;6(3):363-368.PubMedGoogle ScholarCrossref 7. Guin JD. The black spot test for recognizing poison ivy and related species. J Am Acad Dermatol. 1980;2(4):332-333.PubMedGoogle ScholarCrossref 8. Paniagua CT, Bean AS. Black-spot poison ivy: a rare phenomenon. J Am Acad Nurse Pract. 2011;23(6):275-277.PubMedGoogle ScholarCrossref

Journal

JAMA PediatricsAmerican Medical Association

Published: Jun 1, 2016

Keywords: prurigo,neck,erythema,forearm

References