What is the Differential Diagnosis of an Infectious Rash on the Palms and Soles?

Patient Presentation
A 19 month-old female comes to clinic with a 24 hour history of mild runny nose, fever to 101 degrees F and general tiredness. Late last night she kept saying ‘owie’ but her mother didn’t know what was the problem. The child appeared to feel better after some acetaminophen and was okay over the night.
This morning her mother noticed a rash on her hands and feet. The rash has not spread since that time. She is otherwise healthy.
The review of systems shows her to be drinking less, not eating solid foods and she has no other rashes. She attends day care.
The pertinent physical exam shows her to have a fever of 100.5 degrees F. She appears tired and drooling slightly, but appears well hydrated. She has white/gray ulcers on her soft palate that appear punched-out and have a red halo around them. She has shoddy anterior cervical adenopathy.
On the palms and soles she has 2-4 mm dark pink macules that blanch. She has no other skin findings and the rest of her examination is normal.
The diagnosis of Hand-Foot-Mouth disease (most likely a Coxsackievirus) was made clinically. Her mother was instructed to give her acetaminophen or ibuprofen for pain and fever control. She is also to push fluids, especially cold fluids as these may feel better with the painful ulcers. She was instructed to watch for signs of dehydration and to call if she has any concerns.

Discussion
Enteroviral infections are RNA viruses including Coxsackieviruses A and B, Echoviruses and Enteroviruses. They are common and spread by respiratory secretions, fecal-oral contamination and fomites. They commonly occur in summer and fall in temperate climates but are less seasonally seen in the tropics. Hand hygiene is especially important to prevent infection.
The incubation period is usually 3-6 days. The viruses are best isolated from the throat, stool and rectal swab specimens but other infectious sites can also be used for viral isolation. Treatment is supportive but some anti-viral drugs are being developed.

Hand-Foot-Mouth disease is usually caused by Coxsackie A16 but also other Coxsackie viruses and Enterovirus 71. It is a self-limited disease with resultant acquired immunity.

Skin rashes are a common presenting problem for the clinician.
The distribution and pattern of skin rashes is especially important in identifying the etiology. The distribution refers to the location of the skin findings, while the patterns refers to the specific anatomic or physiologic arrangements. For example, the distribution may include the trunk, face, and upper arms, while the pattern could be sun-exposed, or flexural.
In addition to the distribution and pattern, the local organization of the lesions and their depth are important for diagnosis.

A differential diagnosis of some common skin rashes by distribution and pattern is presented below:

Distribution

  • Scalp

    • Contact Dermatitis
    • Hair loss
    • Folliculitis
    • Psoriasis
    • Seborrheic dermatitis
    • Pediculosis
  • Ears

    • Atopic dermatitis
    • Psoriasis
    • Seborrheic dermatitis
  • Face

    • Acne
    • Contact dermatitis
    • Dermatomyositis
    • Folliculitis
    • Herpes simplex
    • Impetigo
    • Lupus erythematosus
    • Measles
    • Parvovirus
    • Rubella
    • Seborrheic dermatitis
  • Eyelids

    • Atopic dermatitis
    • Contact dermatitis
    • Seborrheic dermatitis
  • Posterior neck

    • Acne
    • Contact dermatitis
    • Neurodermatitis (i.e. Lichen Simplex Chronicus)
    • Psoriasis
    • Measles
    • Rubella
    • Seborrheic dermatitis
  • Mouth

    • Aphthae
    • Geographic tongue
    • Herpes simplex
    • Lichen planus
  • Axillae

    • Acne
    • Acanthosis nigricans
    • Contact dermatitis
    • Erythrasma
    • Seborrheic Dermatitis
  • Chest and Back

    • Acne
    • Pityriasis rosea
    • Psoriasis
    • Tinea versicolor
    • Seborrheid dermatitis
    • Syphilis, secondary
  • Groin

    • Candidiasis
    • Granuloma inguinale
    • Intertrigo
    • Pediculosis
    • Scabies
    • Tinea
  • Penis

    • Candidiasis
    • Chancroid
    • Condyloma acuminata
    • Contact dermatitis
    • Drug eruption
    • Herpes simplex
    • Syphilis, primary and secondary
    • Tinea
  • Hands

    • Atopic dermatitis
    • Contact dermatitis
    • Erythema multiforme
    • ID reaction to fungus
    • Syphilis, secondary
    • Rocky Mountain Spotted Fever
    • Tinea
  • Cubital and Popiliteal Fossea

    • Atopic dermatitis
    • Contact dermatitis
    • Prickly heat
  • Elbows and Knees

    • Atopic dermatitis
    • Psoriasis
    • Deratomyositis
    • Granuloma annulare
  • Feet

    • Atopic eczema
    • Bacterial infections
    • Contact dermatitis
    • Erythema multiforme
    • Psoriasis
    • Rocky Mountain Spotted Fever
    • Syphilis, secondary
    • Tinea
    • Verrucea

Common Patterns

  • Flexural rashes – elbows, knees, neck, armpits, buttock/leg junction, groin, outline of breast

    • Atopic dermatitis, infantile
    • Candidiasis
    • Epidermolytic hyperkeratosis (i.e. Ichthyosis)
    • Intertrigo
    • Psoriasis, inverse
    • Seborrheic dermatitis, infantile
    • Tinea cruris
  • Sun exposed sites – legs, arms, neck, face, trunk, etc.

    • Lupus erythematosus
    • Photo-contact dermatitis
    • Porphyria
    • Sunburn
    • Viral exanthams
    • Xeroderma pigmentosum
  • Acrodermatitis – lower legs, arms, hands, feet from knees or elbows distally

    • Atopic dermatitis, infantile
    • Eczema, dishidrotic
    • Poststreptococcal desquamation
    • Tinea pedis with ID reaction
    • Viral exantham (i.e. papular acrodermatitis)
  • Pityriasis Rosea – along trunk in herringbone pattern (i.e. follows along ribs but also in similar pattern over entire trunk)

    • Pityriasis rosea
    • Atopic dermatitis
    • Drug reaction
    • Psoriasis, guttate
    • Syphilis, secondary
  • Clothing-covered sites – where clothing covers bodies

    • Contact dermatitis
    • Miliaria
    • Psoriasis
  • Acneiform rashes – face, shoulders, upper trunk

    • Acne vulgaris
    • Acne, drug-induced (i.e. prednisone, lithium isoniazid)
    • Cushing Syndrome
    • Chloracne

Learning Point

Although there are several causes of rashes that occur on the palms of hands and soles of feet, there are few which are caused by infectious agents.

Infectious causes of rashes on palms and soles

  • Enteroviral infections including Coxsackievirus and Echovirus
  • Rocky Mountain Spotted Fever
  • Scabies – atypical distribution
  • Syphilis, secondary

Other causes of rashes on palms and soles

  • Atopic dermatitis
  • Contact dermatitis
  • Drug eruption
  • Erythema multiforme
  • Palmar and Plantar Kertoderma
  • Psoriasis
  • Tinea

Questions for Further Discussion
1. What is the difference between primary and secondary skin lesions?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Hurwitz S. Clinical Pediatric Dermatology. 2nd Edit. W.B. Saunders Co. 1993.

Cohen BA. Pediatric Dermatology. Second Edit. Mosby, London, England. 2000:1-5.

Hall JC. Sauer’s Manual of Skin Diseases. 8th edit. Lippincott Williams& Wilkins. Philadelphia, PA 2000:17-24

American Academy of Pediatrics. Enterovirus (Nonpoliovirus) Infections, In Pickering LD, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2003;269-270.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
May 9, 2005