Can a rash with sharply demarcated dark red centers on palms and soles be an adverse reaction to doxycycline (tetracycline antibiotic)?

Doxycycline-Associated Rash with Sharply Demarcated Dark Red Centers on Palms and Soles

Yes, a rash with sharply demarcated dark red centers on palms and soles can definitely be an adverse reaction to doxycycline, and this pattern is particularly concerning as it may represent a serious dermatological reaction that requires immediate discontinuation of the medication. 1

Types of Doxycycline-Associated Skin Reactions

Doxycycline can cause several types of cutaneous adverse reactions:

1. Common skin reactions:

   • Photosensitivity (most common) - exaggerated sunburn reaction 2
   • Maculopapular/erythematous rashes 1
   • Urticaria 1

2. Serious skin reactions:

   • Toxic epidermal necrolysis 1
   • Stevens-Johnson syndrome 1
   • Erythema multiforme 1
   • Exfoliative dermatitis (uncommon) 1

Palmar/Plantar Involvement and Concerning Features

The presentation of sharply demarcated dark red centers on palms and soles is particularly concerning because:

• This distribution pattern (palms and soles) with well-defined lesions can be seen in severe drug reactions
• It resembles patterns seen in certain serious conditions like:
  • Stevens-Johnson syndrome/Toxic epidermal necrolysis
  • Drug reaction with eosinophilia and systemic symptoms (DRESS)
  • Certain rickettsial diseases (which can mimic drug reactions) 2, 3

Management Algorithm

1. Immediate actions:

   • Discontinue doxycycline immediately 2
   • Document the reaction with photographs if possible
   • Assess for systemic symptoms (fever, malaise, lymphadenopathy, organ involvement)

2. Evaluation:

   • Check for mucosal involvement (eyes, mouth, genitals)
   • Assess body surface area affected
   • Monitor for signs of progression (blistering, skin sloughing, Nikolsky sign)
   • Consider laboratory evaluation: CBC, liver function, renal function

3. Treatment:

   • For mild reactions: Topical corticosteroids and oral antihistamines
   • For moderate-severe reactions: Systemic corticosteroids (e.g., prednisone 0.5-1 mg/kg) 2
   • For severe reactions with systemic symptoms: Hospital admission and dermatology consultation

Important Considerations

• Differential diagnosis: The rash pattern on palms/soles with dark red centers could also represent:

  • Rickettsial diseases (Rocky Mountain spotted fever) 2, 3
  • Other drug eruptions
  • Viral exanthems
  • Erythema multiforme

• Risk factors for severe reactions:

  • Previous drug allergies
  • Concurrent medications
  • Genetic predisposition
  • Immunocompromised status

• Documentation: Clearly document the reaction in the patient's medical record to prevent future re-exposure to doxycycline and consider cross-reactivity with other tetracyclines

Alternative Antibiotics

If antimicrobial therapy must be continued, alternatives to consider (depending on the original indication):

• Macrolides (erythromycin, azithromycin)
• Clindamycin
• Trimethoprim-sulfamethoxazole (though this also carries risk of severe cutaneous reactions) 2

Prevention of Future Reactions

• Avoid all tetracycline-class antibiotics in the future
• Consider allergy testing if appropriate (after complete resolution)
• Provide patient with documentation of the reaction

Remember that doxycycline-associated skin reactions can range from mild to life-threatening, and a rash with the characteristics described (sharply demarcated dark red centers on palms and soles) warrants immediate discontinuation and careful monitoring for progression to more severe manifestations.