What is the appropriate treatment for an adult rash with active lesions or pustules?

Treatment of Rash with Active Lesions or Pustules

Start with topical low-to-moderate potency corticosteroids (hydrocortisone 2.5% or alclometasone 0.05%) applied 3-4 times daily, combined with oral tetracycline antibiotics (doxycycline 100 mg twice daily or minocycline 50 mg twice daily) for at least 6 weeks if the rash is moderate or worsening. 1, 2

Initial Assessment: Rule Out Infection

Before initiating treatment, determine whether bacterial superinfection is present by looking for specific clinical signs: 1

• Failure to respond to initial topical therapy after 48-72 hours 1
• Painful skin lesions that worsen despite treatment 1
• Pustules extending to arms, legs, or trunk (beyond the initial site) 1
• Yellow crusts or purulent discharge from lesions 1

If any of these signs are present, obtain bacterial culture before starting antibiotics and administer targeted antibiotics for at least 14 days based on sensitivity results. 1

Treatment Algorithm by Severity

Mild Rash (Grade 1-2: Covering <30% Body Surface Area)

Topical therapy: 1

• Apply hydrocortisone 2.5% or alclometasone 0.05% twice daily to affected areas 1, 2
• Use alcohol-free moisturizers containing 5-10% urea twice daily to maintain skin barrier 1, 3

Oral antibiotics: 1

• Add doxycycline 100 mg twice daily OR minocycline 50 mg twice daily OR oxytetracycline 500 mg twice daily for at least 6 weeks 1
• These antibiotics target both bacterial overgrowth and have anti-inflammatory properties 1

Reassess after 2 weeks - if no improvement or worsening, escalate to next level 1

Severe Rash (Grade 3: Covering >30% Body Surface Area or Intolerable Grade 2)

All of the above PLUS: 1

• Systemic corticosteroids: Prednisone 0.5-1 mg/kg body weight for 7 days, then taper over 4-6 weeks 1
• Obtain cultures if infection suspected (bacterial, viral, fungal) 1
• Consider low-dose isotretinoin (20-30 mg/day) for refractory cases, but consult dermatology first 1

Supportive Care Measures (Critical for All Patients)

Skin hygiene: 1, 3

• Avoid frequent washing with hot water - this disrupts the skin barrier 1, 3
• Use gentle, non-irritating cleansers only 3
• Keep affected areas dry, especially in skin folds 3, 4

Avoid irritants: 1

• No over-the-counter anti-acne medications 1
• No solvents or disinfectants 1
• No alcohol-containing preparations on affected skin 4

Sun protection: 1

• Apply SPF 15 sunscreen to exposed areas every 2 hours when outside 1
• Avoid excessive sun exposure 1

Special Considerations for Location-Specific Rashes

Intertriginous Areas (Under Breasts, Axilla, Groin)

Consider fungal superinfection: 4, 5

• If satellite lesions present, add topical azoles (clotrimazole, miconazole, ketoconazole) 4, 5
• For resistant candidal cases, use oral fluconazole 100 mg daily for 7-14 days 4

Moisture control: 4

• Place clean cotton cloth or gauze between skin folds 4
• Never use high-potency steroids in skin folds - risk of skin atrophy 4

Critical Pitfalls to Avoid

Do not treat empirically without assessment: 1

• The presence of purulent exudate and pustules suggests bacterial infection over simple inflammation 1
• Crusting alone can occur in either infection or dermatitis - look for other signs 1

Do not use systemic antibiotics for non-infected dermatitis: 1

• Antibiotics are only indicated when clinical evidence of bacterial infection exists 1
• Routine antibiotic use for colonization (without infection) promotes resistance and provides no sustained benefit 1

Do not combine topical steroids with antifungals for >2 weeks without reassessment: 4

• Prolonged steroid use can mask fungal infections 4

When to Escalate or Refer

Refer to dermatology if: 1

• No improvement after 2 weeks of appropriate treatment 1
• Considering isotretinoin therapy 1
• Severe cases requiring systemic immunomodulation 1

Consider infectious disease consultation if: 6

• Signs of systemic infection develop 6
• Extensive involvement with unclear pathogen 6