Maculopapular rash with fine peeling in open fields ("sandpaper skin")

Specialty: Pediatrics.

• Scarlatiniform rash
• suspected scarlet fever
• sandpaper rash

Why it occurs

• Scarlet fever (skin reaction mediated by erythrogenic toxins A, B or C secreted by Streptococcus pyogenes or group A beta-hemolytic streptococcus, associated with acute pharyngotonsillitis)
• Staphylococcal scalded skin syndrome or Ritter's disease (mediated by exfoliative toxins of Staphylococcus aureus, presents with diffuse erythema and early epidermal detachment with positive Nikolsky sign)
• Streptococcal or staphylococcal toxic shock syndrome (severe superantigen-mediated systemic reaction with diffuse macular erythema, hypotension, and multiple organ failure)
• Kawasaki disease in exanthematous phase (multisystem vasculitis of medium-caliber vessels that presents with polymorphous desquamative rash, prolonged fever and lymphadenopathy)
• Drug hypersensitivity reaction or pharmacoderma (such as drug-induced hypersensitivity syndrome or DRESS).

Initial workup

Throat swab for rapid detection of group A streptococcus antigen (Rapid Streptococcus Test or Strep A) and throat exudate culture. Blood analysis with complete blood count (leukocytosis with neutrophilia), acute phase reactants (elevated CRP and ESR), antistreptolysin O titer (ASLO, marker of previous streptococcal infection). Urgent transthoracic Doppler echocardiogram if Kawasaki disease is suspected to evaluate the morphology of the coronary arteries. Culture of body fluids (blood cultures, wound cultures, or secretions) if staphylococcal etiology is suspected.

Standard management

• Penicillin V potassium or Phenoxymethylpenicillin — oral treatment of choice for streptococcal scarlet fever; dose of 250 mg every 12 hours in children under 27 kg and 500 mg every 12 hours in adults, during a strict 10-day cycle to eradicate the germ and prevent acute rheumatic fever
• Amoxicillin — oral alternative with excellent palatability; dose of 50 mg/kg/day in a single daily dose or divided every 12 hours for 10 days
• Penicillin G benzathine — indicated in case of oral intolerance or suspicion of poor therapeutic compliance; single dose of 600,000 IU IM in children under 27 kg and 1,200,000 IU IM in adults
• Intravenous cloxacillin or cefazolin (indicated of choice in case of suspected staphylococcal scalded skin syndrome; cloxacillin dose of 100-150 mg/kg/day IV).