From the Guidelines
When evaluating a rash, a thorough physical examination and review of systems is crucial to rule out other etiologies and guide further workup, as recommended by the American Society of Clinical Oncology guideline update in 2021 1. The evaluation should include a thorough review of systems, assessing for symptoms such as skin pain, fevers, malaise, myalgias, arthralgias, abdominal pain, ocular discomfort or photophobia, and sores or discomfort in the nares, oropharynx, genitals, and perianal area. A physical examination should include vital signs and a full skin examination, evaluating all skin surfaces and mucous membranes, and assessing for lymphadenopathy, facial or distal-extremity swelling, pustules, blisters, erosions, and areas of dusky erythema. Consideration of a dermatology consultation for skin biopsy and direct immunofluorescence, as well as further serologic workup, may be necessary to determine the underlying cause of the rash, as outlined in the guideline update 1. Key aspects of the evaluation include:
- A thorough physical examination to assess the distribution, pattern, color, and morphology of the lesions
- A review of systems to identify associated symptoms such as fever or joint pain
- Consideration of common conditions like contact dermatitis, atopic dermatitis, psoriasis, drug eruptions, or infections based on the clinical presentation
- Potential referral to a dermatologist for specialized evaluation and management, particularly for severe or widespread rashes, those with systemic symptoms, or those not responding to initial treatment.
From the FDA Drug Label
Directions for itching of skin irritation, inflammation, and rashes: adults and children 2 years of age and older: apply to affected area not more than 3 to 4 times daily children under 2 years of age: ask a doctor for external anal and genital itching, adults: when practical, clean the affected area with mild soap and warm water and rinse thoroughly gently dry by patting or blotting with toilet tissue or a soft cloth before applying apply to affected area not more than 3 to 4 times daily children under 12 years of age: ask a doctor
The hydrocortisone (TOP) drug label provides directions for use in cases of itching of skin irritation, inflammation, and rashes.
- For adults and children 2 years of age and older, apply to the affected area not more than 3 to 4 times daily.
- For children under 2 years of age and children under 12 years of age, it is recommended to ask a doctor before use. 2
From the Research
Rash Evaluation
- Skin problems are common, affecting up to one-third of the population during their lifetime, and they are frequently encountered by advanced clinical practitioners (ACPs) in both primary and secondary care settings 3.
- A thorough dermatological history and examination are essential for accurate diagnosis and treatment of skin problems, but ACPs often feel unprepared to conduct these assessments 3.
- For cellulitis without purulent drainage, β-hemolytic streptococci are presumed to be the predominant pathogens, and antimicrobial regimens possessing in vitro MRSA activity may not provide improved outcomes compared with treatments lacking MRSA activity 4.
- Topical corticosteroids are an essential tool for treating inflammatory skin conditions such as psoriasis and atopic dermatitis, and their choice and application depend on the strength, potency, and formulation of the corticosteroid, as well as the patient's age, skin location, and total surface area treated 5.
- The combination of clotrimazole and hydrocortisone (Canesten HC) has been shown to be effective in treating various skin conditions, with the best efficacy observed in a double-blind study comparing the combination product with its components 6.
Treatment Options
- Cephalexin and cefadroxil are first-generation oral cephalosporins that have traditionally been considered second-line treatment options for uncomplicated lower urinary tract infections (uLUTIs), but may be reconsidered as fluoroquinolone-sparing alternatives in the era of "bad bugs, few drugs" 7.
- Cephalexin plus trimethoprim-sulfamethoxazole may not result in higher rates of clinical resolution of cellulitis compared with cephalexin alone, but further research may be needed to determine the optimal treatment regimen 4.
- Topical corticosteroids can be applied once or twice per day for up to three weeks for super-high-potency corticosteroids or up to 12 weeks for high- or medium-potency corticosteroids, with correct patient application critical to successful use 5.