A rash starting on the palms and soles

A 23 year old man presented with a rash eight weeks after emigrating to the United States. One week after immigration he had a sore throat, dysphagia, and mild subjective fevers, which resolved in 10 days. Two weeks later, he developed a papular eruption starting on his hands and feet. He had no arthralgia, myalgia, or systemic symptoms. He took no drugs, had no allergies, no family history of skin eruptions, and no close contacts with a similar rash.

He was evaluated at an urgent care clinic one week after the eruption started. The rash was mainly on his palms and soles but was spreading to the arms and legs. Blood was sent for antibodies to Rocky Mountain spotted fever (RMSF) and coxsackievirus. Given the life threatening nature of RMSF, he was treated empirically with seven days of doxycycline without improvement; both tests were negative.

Over the next two weeks the rash spread diffusely, becoming mildly pruritic, and he presented to our institution for evaluation. His vital signs were within normal limits and he had no erythema of the oral mucosa or lymphadenopathy. Hundreds of pink papules with silvery scale measuring 2-3 mm in diameter were noted on his face, palms and dorsal hands, arms, trunk, legs, and feet (fig 1⇓). Linear lesions in areas of excoriation were seen in the right antecubital fossa. …