What is the next step in management for a 33-year-old male with a recurrent viral exanthem, previously treated with Benadryl (diphenhydramine) and prednisone, now worsening with a generalized rash?

From the Guidelines

The patient's current treatment with Benadryl and prednisone should be reassessed, and considering the worsening of symptoms, a more comprehensive approach including a possible change in antibiotic therapy and adjunctive treatments should be considered. Given the patient's diagnosis of viral exanthem, it is crucial to rule out any secondary bacterial infections, especially since the rash has worsened despite initial treatment. The guidelines for skin and soft-tissue infections 1 suggest that therapy for typical cases of erysipelas or cellulitis should include an antibiotic active against streptococci, and many clinicians choose an agent that is also effective against S. aureus.

Key Considerations

• The patient's symptoms have worsened despite initial treatment with Benadryl and prednisone, indicating a need for reassessment and possible adjustment of the treatment plan.
• The guidelines recommend antibiotic therapy active against streptococci, with options including dicloxacillin, cephalexin, clindamycin, or erythromycin, unless resistance is common in the community 1.
• Adjunctive treatments such as systemic corticosteroids may be considered to hasten resolution and attenuate the inflammatory reaction, as suggested by a randomized, double-blind, placebo-controlled trial 1.
• Elevation of the affected area and appropriate therapy for any underlying conditions are also crucial for promoting recovery and preventing complications.

Recommendations

• Reassess the patient's current medication regimen and consider changing the antibiotic therapy to one that is effective against streptococci and S. aureus, such as cephalexin or clindamycin, based on the guidelines for skin and soft-tissue infections 1.
• Consider adding adjunctive treatments such as systemic corticosteroids, as they may help to hasten resolution and attenuate the inflammatory reaction, as suggested by the study 1.
• Emphasize the importance of elevation of the affected area and appropriate therapy for any underlying conditions to promote recovery and prevent complications.
• If the patient's symptoms continue to worsen or if they develop fever, mucosal involvement, or systemic symptoms, immediate hospitalization should be considered to rule out severe drug reactions or other serious conditions.

From the Research

Patient Assessment

The patient is a 33-year-old male who was previously diagnosed with a viral exanthem and discharged with Benadryl and prednisone. However, the patient's condition has worsened, and the rash has spread over his body.

Possible Causes

• The patient's symptoms could be due to an infectious or non-infectious etiology, as fever can result from the body's natural response to a pyrogen 2.
• The patient's condition may not be directly related to fever, but rather to an allergic reaction or other causes of agitation, which can have a broad differential diagnosis including metabolic, neurologic, infectious, toxicologic, and psychiatric etiologies 3.

Diagnostic Approach

• A complete blood count (CBC) with differential can provide information about the production of all blood cells and identify the patient's oxygen-carrying capacity, as well as provide information about the immune system 4, 5.
• However, the patient's current symptoms do not seem to be directly related to the complete blood count or differential.
• The patient's condition may require a focused history and physical examination to determine the underlying cause of the worsening symptoms.

Management

• The patient's current treatment with Benadryl and prednisone may need to be reassessed, and additional testing or management strategies may be required to address the patient's worsening condition.
• Verbal de-escalation techniques and pharmacologic interventions may be necessary to manage the patient's agitation or discomfort 3.