How to manage skin lesions in patients with dengue?

Management of Skin Lesions in Dengue Fever

Skin lesions in dengue fever should be managed symptomatically with supportive care while monitoring for complications, as they typically resolve spontaneously with the resolution of the infection. 1

Types of Skin Lesions in Dengue

Dengue fever commonly presents with characteristic skin manifestations:

• Generalized macular blanchable erythema (65% of cases): Primarily affecting trunk and limbs 2
• Petechial lesions (35% of cases): Discrete hemorrhagic spots on various body areas 2
• Palmar erythema (30% of cases): Redness of the palms 2
• Morbilliform rash: Measles-like eruptions 3
• Pruritus (23% of cases): Generalized itching, with some patients experiencing isolated itching of palms and soles (30%) 2

Management Algorithm

1. Initial Assessment

• Determine the type of skin lesion (macular, petechial, morbilliform)
• Assess for warning signs of severe dengue:
  • Abdominal pain or tenderness
  • Persistent vomiting
  • Clinical fluid accumulation
  • Mucosal bleeding
  • Lethargy or restlessness
  • Liver enlargement >2 cm
  • Laboratory: Increase in hematocrit concurrent with rapid decrease in platelet count 1

2. Symptomatic Management of Skin Lesions

• For pruritus (itching):

  • Topical calamine lotion or other soothing lotions
  • Oral antihistamines for moderate to severe itching
  • Avoid scratching to prevent secondary infections 2, 3

• For petechial/hemorrhagic lesions:

  • Monitor for progression or extension
  • Avoid unnecessary pressure on affected areas
  • Do not administer prophylactic platelet transfusions based solely on skin manifestations 4

3. Supportive Care

• Maintain adequate hydration with oral fluids
• Administer antipyretics as needed (acetaminophen/paracetamol)
• Avoid aspirin, NSAIDs, and steroids as they may worsen bleeding tendencies 1
• Monitor complete blood count daily, especially platelet count and hematocrit 1

4. Monitoring for Complications

• Patients with skin rash should be monitored for:

  • Progression to severe dengue
  • Development of plasma leakage syndrome
  • Worsening of coagulopathy
  • Organ impairment 5

• Important note: Patients without skin rash may have higher risk of complications, including:

  • Higher platelet transfusion rates
  • Lower hemoglobin and hematocrit levels
  • Greater genital mucosa involvement 3

Special Considerations

Differential Diagnosis

• Consider other causes of similar skin manifestations:
  • Drug reactions
  • Other viral exanthems
  • Bacterial infections 6

When to Escalate Care

• Immediate hospitalization for patients with:
  • Extensive petechial lesions with active bleeding
  • Signs of shock or plasma leakage
  • Altered mental status
  • Severe organ involvement 1, 4

Clinical Pearls and Pitfalls

• Pearl: Skin lesions can provide early diagnostic clues for dengue fever 2
• Pearl: Patients with morbilliform lesions tend to have better outcomes with lower rates of complications compared to those with maculopapular or petechial lesions 3
• Pitfall: Do not focus solely on skin manifestations while overlooking systemic complications of dengue
• Pitfall: Avoid unnecessary platelet transfusions based solely on low platelet count without bleeding manifestations 4

Skin lesions in dengue are generally self-limiting and resolve with the resolution of the infection. The primary focus should be on monitoring for progression to severe dengue and providing appropriate supportive care to prevent complications and mortality.