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Suggest Treatment For Painless, Nonpruritic Rashes In Right Axilla
Question: I am an Emergency Dept physician. Last week I saw a 19 y/o wrestler with a painless, non-pruritic rash in the R axilla. Exam revealed a cluster of papular lesions. Several, but not all, had a prurulent cap. There were no lesions anywhere else. The area was non-tender and was not associated with adenopathy. I thought that it may have been a folliculitis and gave him bactroban and hibiclens. His mother wanted a second opinion and took him to an urgent care center where he was diagnosed with shingles and given Valtrex and a medrol dosepac. He took those as well as stayed on bactroban. He returns today for re-eval. I have attached a picture. The lesions continue to be asymptomatic (no pain, no pruritis). I still think that this is (now) a resolving folliculitis but I am troubled by its being asymptomatic and without associated adenopathy. I continued the bactroban (he completed the valtrex and dosepac).
Brief Answer:
I would like to know more from you.
Detailed Answer:
Hello. Thank you for writing to us
I have gone through the query and I have also reviewed the Image.
Right now this looks like a healing lesion with some crusting. Could be shingles and also the way you describe it. Cluster of papular lesions.
Another possibility I would like to keep is of Herpes gladiatorum, which is also common in wrestlers.
I wonder why was he given medrol dosepac? It is a steroid and is neither indicated in folliculitis Or in shingles.
Must be having some sort of symptoms for him to start on steroids?
I want to know how have the lesions changed after a week?
Though steroids being antiinflammatory would mask pain and other signs of inflammation.
Regards
I would like to know more from you.
Detailed Answer:
Hello. Thank you for writing to us
I have gone through the query and I have also reviewed the Image.
Right now this looks like a healing lesion with some crusting. Could be shingles and also the way you describe it. Cluster of papular lesions.
Another possibility I would like to keep is of Herpes gladiatorum, which is also common in wrestlers.
I wonder why was he given medrol dosepac? It is a steroid and is neither indicated in folliculitis Or in shingles.
Must be having some sort of symptoms for him to start on steroids?
I want to know how have the lesions changed after a week?
Though steroids being antiinflammatory would mask pain and other signs of inflammation.
Regards
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I am not certain that you understood my question.
This is part I: The patient's presentation:
Last week I saw a 19 y/o wrestler with a painless, non-pruritic rash in the R axilla. Exam revealed a cluster of papular lesions. Several, but not all, had a prurulent cap. There were no lesions anywhere else. The area was non-tender and was not associated with adenopathy. I thought that it may have been a folliculitis and gave him bactroban and hibiclens.
The lesions were NOT PAINFUL (unlikely to be shingles).
The lesions were discrete, papular, and a few had prurlent caps. There were NO blisters. The lesions were present in the axilla only. Also unlike shingles.
There were no systemic sx, unlike H. Gladitorium.
Part two: His mother wanted a second opinion and took him to an urgent care center where he was diagnosed with shingles and given Valtrex and a medrol dosepac. He took those as well as stayed on bactroban.
Another physician felt it to be shingles and treated as indicated.
Part III: recheck today: He returns today for re-eval. I have attached a picture. The lesions continue to be asymptomatic (no pain, no pruritis). I still think that this is (now) a resolving folliculitis but I am troubled by its being asymptomatic and without associated adenopathy.
MY QUESTION: What skin lesion produces a folliculitis picture but has no pain and no lymphadenopathy?
I DO NOT BELIEVE that the answer set includes a herpetic etiology.
This is part I: The patient's presentation:
Last week I saw a 19 y/o wrestler with a painless, non-pruritic rash in the R axilla. Exam revealed a cluster of papular lesions. Several, but not all, had a prurulent cap. There were no lesions anywhere else. The area was non-tender and was not associated with adenopathy. I thought that it may have been a folliculitis and gave him bactroban and hibiclens.
The lesions were NOT PAINFUL (unlikely to be shingles).
The lesions were discrete, papular, and a few had prurlent caps. There were NO blisters. The lesions were present in the axilla only. Also unlike shingles.
There were no systemic sx, unlike H. Gladitorium.
Part two: His mother wanted a second opinion and took him to an urgent care center where he was diagnosed with shingles and given Valtrex and a medrol dosepac. He took those as well as stayed on bactroban.
Another physician felt it to be shingles and treated as indicated.
Part III: recheck today: He returns today for re-eval. I have attached a picture. The lesions continue to be asymptomatic (no pain, no pruritis). I still think that this is (now) a resolving folliculitis but I am troubled by its being asymptomatic and without associated adenopathy.
MY QUESTION: What skin lesion produces a folliculitis picture but has no pain and no lymphadenopathy?
I DO NOT BELIEVE that the answer set includes a herpetic etiology.
Brief Answer:
Signs and symptoms are subjective.
Detailed Answer:
Hi.
I did get your point. I was trying to extract more information from you.
Deeper folliculitis is usually painful and there is surrounding swelling/ tenderness and lymph nodes too. However, a superficial folliculitis may not be very symptomatic.
Moreover symptoms are subjective and vary from patients to patients. Some patients may be in lot of discomfort and others are totally fine.
Also the fact that soon after he was given systemic steroids by another physician, which would have suppressed whatever little discomfort that he might have or was going to develop subsequently.
Yes, shingles is usually symptomatic/ painful but again there are patients who have minimal or no symptoms at all, specially young patients, more so if it is a very limited eruption such as this, rather than a florid/ widespread eruption.
Similarly Herpes gladiatorum may be associated with just mild tingling sensation and may not be very symptomatic. Not all patients have floird manifestations.
However, I am not convinced as to the reason for giving Oral steroids in this case?
Whatever symptoms that he was going to show whether pain or burning or lymphadenopathy, they must have been cut short by steroids.
Otherwise I can't think of any other condition in a young healthy 19 year old wrestler.
Regards
Signs and symptoms are subjective.
Detailed Answer:
Hi.
I did get your point. I was trying to extract more information from you.
Deeper folliculitis is usually painful and there is surrounding swelling/ tenderness and lymph nodes too. However, a superficial folliculitis may not be very symptomatic.
Moreover symptoms are subjective and vary from patients to patients. Some patients may be in lot of discomfort and others are totally fine.
Also the fact that soon after he was given systemic steroids by another physician, which would have suppressed whatever little discomfort that he might have or was going to develop subsequently.
Yes, shingles is usually symptomatic/ painful but again there are patients who have minimal or no symptoms at all, specially young patients, more so if it is a very limited eruption such as this, rather than a florid/ widespread eruption.
Similarly Herpes gladiatorum may be associated with just mild tingling sensation and may not be very symptomatic. Not all patients have floird manifestations.
However, I am not convinced as to the reason for giving Oral steroids in this case?
Whatever symptoms that he was going to show whether pain or burning or lymphadenopathy, they must have been cut short by steroids.
Otherwise I can't think of any other condition in a young healthy 19 year old wrestler.
Regards
Note: Hope the answers resolves your concerns, however for further guidance of skin related queries consult our Dermatologist.Click here to book a consultation
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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