What is the treatment for a morbilliform rash after sternotomy?

Treatment of Morbilliform Rash After Sternotomy

For a morbilliform rash following sternotomy, continue with topical corticosteroids (moderate-to-high potency on the body, low potency on the face) and oral antihistamines for symptomatic relief, while excluding infectious causes and drug reactions. 1

Initial Assessment and Exclusion of Serious Causes

The first priority is determining whether this represents a benign drug eruption versus a more serious condition:

• Exclude infection immediately by examining for crusting, weeping, yellow discharge, or painful lesions that would indicate bacterial superinfection requiring culture and antibiotics 1
• Rule out severe cutaneous adverse reactions (SCARs) including Stevens-Johnson syndrome, toxic epidermal necrolysis, or DRESS syndrome by assessing for skin sloughing, mucosal involvement, facial edema, lymphadenopathy, or systemic symptoms 2, 3
• Review all medications initiated perioperatively, as antibiotics are among the most common causes of morbilliform eruptions in hospitalized patients 4
• Consider viral etiologies if the patient has fever or systemic symptoms without clear drug exposure 2, 5

Grading and Treatment Algorithm

Grade 1 (Rash <10% Body Surface Area)

• Apply topical corticosteroids of mild-to-moderate potency once daily 1
• Add oral or topical antihistamines for pruritus management 1
• Continue observation without treatment interruption if asymptomatic and stable 1
• Use hydrocortisone 2.5% or alclometasone 0.05% on facial areas to avoid skin atrophy 1

Grade 2 (Rash 10-30% Body Surface Area)

• Escalate to moderate-potency topical steroids (e.g., triamcinolone) once daily or high-potency formulations twice daily 1
• Continue oral antihistamines (cetirizine, loratadine, or fexofenadina) for itch control 1, 6
• Monitor weekly for improvement or progression 1
• Consider dermatology consultation if not improving within 2 weeks 1

Grade 3 (Rash >30% Body Surface Area or Grade 2 with Substantial Symptoms)

• Initiate systemic corticosteroids: prednisone 0.5-1 mg/kg daily for mild-to-moderate cases, or IV methylprednisolone 0.5-1 mg/kg for severe cases 1
• Taper steroids over 1-4 weeks depending on severity and response 1
• Obtain dermatology consultation with consideration for punch biopsy and clinical photography 1
• Continue high-potency topical steroids to affected areas 1

Grade 4 (Skin Sloughing >30% Body Surface Area)

• Discontinue causative agent immediately and seek urgent dermatology review 1
• Administer IV methylprednisolone 1-2 mg/kg 1
• Admit to hospital for close monitoring and supportive care 1

Supportive Care Measures

Skin barrier protection is essential throughout treatment:

• Use alcohol-free moisturizers at least twice daily, preferably containing 5-10% urea 1, 6
• Avoid hot water for bathing and frequent washing that strips natural lipids 1, 6
• Apply emollients after bathing to provide a lipid film that reduces water loss 6
• Avoid skin irritants including over-the-counter anti-acne medications, solvents, and harsh soaps 1, 6
• Use sun protection (SPF 15 minimum) if sun exposure is anticipated 1

Critical Pitfalls to Avoid

• Do not assume all morbilliform rashes are benign – transient morbilliform rashes from drugs like pyrazinamide are usually self-limited and do not require drug discontinuation 1, but progression to SCAR requires immediate intervention 2, 3
• Avoid long-term topical corticosteroid use on the face due to risk of atrophy and telangiectasia 1, 6
• Do not overlook secondary bacterial infection, which presents with crusting, weeping, or purulent discharge and requires appropriate antibiotic therapy based on culture sensitivities 1, 6
• Recognize that hyperthermia in the immediate postoperative period (core temperature >37.9°C) is associated with increased infection risk and should be avoided 1

When to Consider Alternative Diagnoses

If the rash does not respond to standard treatment within 2 weeks or worsens despite therapy:

• Reassess for drug-induced hypersensitivity syndrome (DRESS) with eosinophilia, liver enzyme elevation, and lymphadenopathy 3
• Consider acute graft-versus-host disease if the patient has had any prior transplantation 1, 2
• Evaluate for unmasking of underlying dermatoses such as psoriasis, atopic dermatitis, or seborrheic dermatitis that may have been triggered by surgical stress 1, 6