Butterfly rash
Related Terms
Acne, allergen, allergic reaction, antibodies, antibody, autoimmune disorder, atopic dermatitis, bacteria, bacterial infection, butterfly-shaped rash, discoid rash, fungal infection, fungus, Ig, IgE, immunoglobulin, immunoglobulin E, KOH preparation, macules, papular, papules, pimples, poison ivy, poison oak, poison plants, poison sumac, potassium and hydroxide preparation, psoriasis, rash, scarlet fever, scarletina, skin biopsy, skin condition, skin disease, skin disorder, skin rash, skin test, tzanck test, virus, viral infection, wood lamp.
Background
Rash is a general term that describes a change in color and texture in the skin. A rash generally causes temporary red patches or bumps in the skin, and may be itchy and/or tender. The affected skin is often swollen.
A rash is a symptom of an underlying medical condition. There are hundreds of conditions that are known to cause rashes. Among the most common causes are allergies, autoimmune disorders (like lupus), infections, irritants (like sun exposure), poisonous plants (like poison ivy), and skin disorders (like eczema).
There are many forms of rashes, which differ depending on the cause. Rashes vary in appearance, location, severity, and duration. Some rashes may contain blisters, flat or raised bumps, pimples, or dry or flaky skin. The amount of skin affected may be limited to an isolated area, or it may affect multiple areas of the body.
While the duration of a skin rash varies depending on the cause, most rashes resolve either on their own or with treatment within one to 14 days. Some rashes, including those caused by conditions like lupus and rosacea, are long-term but they can be managed with medications. Once the underlying cause is treated, symptoms will begin to subside.
Author information
This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).
Bibliography
American Academy of Allergy Asthma & Immunology. .
American Academy of Dermatology (AAD). .
American Dermatological Association. .
DermNet NZ. Dermatitis. .
Guin JD. Treatment of toxicodendron dermatitis (poison ivy and poison oak). Skin Therapy Lett. 2001 Apr;6(7):3-5. .
Leung DY, Bieber T. Atopic Dermatitis. Lancet. 2003 Jan 11;361(9352):151-60. .
Lupus Foundation of America. .
Mantle D, Gok MA, Lennard TW. Adverse and beneficial effects of plant extracts on skin and skin disorders. Adverse Drug React Toxicol Rev. 2001 Jun;20(2):89-103. .
Natural Standard: The Authority on Integrative Medicine. .
Causes
There are hundreds of conditions that have been shown to causes rashes. Some of the most common causes include allergies, autoimmune disorders, infections, irritants, poisonous plants, and skin disorders.
Allergies: An allergic reaction, which occurs when the body's immune system overreacts to a harmless substance (like pollen or dust mites), may cause a skin rash. Common triggers of allergic reactions include insect stings (bees, wasps, etc.), medications (like antibiotics and seizure medications), foods (especially peanuts, seafood, and eggs), and latex (like rubber gloves and condoms).
Autoimmune disorders: Autoimmune disorders, which occur when the immune system mistakenly identifies the body's own cells as foreign invaders (like bacteria), may also cause skin rashes. Rashes are a common feature of autoimmune disorders such as rheumatoid arthritis and lupus..
Infections: Many infections caused by bacteria, fungi, or viruses may cause skin rashes. Infections such as chickenpox, Lyme disease (bacterial infection), ringworm (parasitic infection), shingles (chickenpox in adults), measles, fifth disease (flu-like illness that causes reddening of the cheeks), and herpes (viral infection) are among the most common causes of rashes.
Irritants: Rashes may develop if the skin becomes irritated. For instance, some patients develop rashes after exposure to heat or sun. Some babies develop diaper rash if the diaper rubs against the skin or is not changed frequently enough.
Poisonous plants: Exposure to poison ivy, poison oak, and poison sumac plants may lead to an itchy skin rash. These plants produce oil called urushiol, which may trigger an allergic reaction. Patients who are allergic to these plants may experience a rash that consists of swollen, itchy, red bumps and blisters that appear wherever the oil has touched the skin.
Skin disorders: Other potential causes include skin disorders like acne (pimples), psoriasis, rosacea, and atopic dermatitis (eczema).
Symptoms
General: While the duration of a skin rash varies depending on the cause, most rashes resolve either on their own or with treatment within one to 14 days. Some rashes, including those caused by conditions like lupus and rosacea, are long-term but they can be managed with medications. There are many different forms of rashes that vary in their appearance, location, severity, and duration. The skin may be red and/or itchy. If the skin itches, it is called pruritus. If a butterfly-shaped, red rash develops on the cheek and nose, it is called a malar rash.
Dermatologists classify rashes based on their physical appearance. The main types of rashes include discoid rashes, macular rash, macularpapular rash, papular rash, papulosquamous rash, and vesicular rash.
Discoid rash: A discoid rash is characterized by red and scaly patches of skin on the face and scalp that can lead to scarring and temporary hair loss
Macular rash: When the skin has areas of flat, red spots, it is called a macular rash.
Macularpapular rash: A macularpapular rash occurs when a patient has areas of flat, red spots combined with areas of small, raised, solid bumps on the skin.
Papularrash: A papular rash causes small, raised, solid bumps on the skin.
Papulosquamous rash: A papulosquamous rash occurs when the patient has a combination of pimples and dry, flaky skin.
Vesicular rash: A vesicular rash occurs when a patient has small, raised, fluid-filled blisters.
Other symptoms: A rash is usually just one symptom of an underlying medical condition. Some of the most common symptoms associated with rashes include fever and enlarged lymph nodes.
Diagnosis
General: A rash is easily identified during a physical examination. However, because it is a symptom of an underlying medical condition, the cause must be identified in order to treat it. During a physical examination, a healthcare provider will take a careful medical history to determine the underlying cause. Medical tests may be necessary.
Medical history: The healthcare provider will ask whether the patient has a history of allergies, infections, skin diseases, or has been exposed to chemicals or irritants. A healthcare provider will also ask about the patient's daily activities. For instance, individuals who spend time in wooded areas have an increased risk of developing rashes from exposure to poisonous plants.
Physical examination: The healthcare provider will ask when the rash first developed. It is important to know if it started after the patient ate a new food, tried a new skin product, or took a new drug, herb, or supplement.
The location and pattern of the rash is also important. For instance, a heat rash will only be present on areas of the skin that were exposed to the sun. Certain patterns are associated with specific diseases. For instance, patients who have lupus often develop a butterfly-shaped rash on their cheeks and nose. Reactions to poisonous plants often have a streaky pattern where the plant brushed against the skin.
Depending on the underlying cause, certain rashes typically last longer than others. For instance, a rash caused by a viral infection called roseola usually only lasts a couple of days, whereas fifth disease (flu-like illness) may cause a rash for a week. Patients with lupus will have symptoms that persist until they receive treatment.
The healthcare provider will also take into account other symptoms (if any) that accompany the rash. For instance, if patients also have a fever and enlarged lymph nodes, an infection may be suspected.
Allergen-specific immunoglobulin (IgE) test: An allergen-specific immunoglobulin E (IgE) test, commonly referred to as radioallergosorbent test (RAST?), may also be used to determine whether the patient is allergic to particular substances. This test is less accurate than a skin test. It is usually performed in patients who have coexisting severe skin diseases (like eczema or psoriasis) that make it difficult to interpret a skin test. During the procedure, a sample of the patient's blood is sent to a laboratory for testing. The allergen is combined with the blood to determine whether the patient has immunoglobulin E (IgE) antibodies to the allergen. Antibodies are substances that identify and bind to foreign invaders in the body. If the patient has IgE antibodies, an allergy is diagnosed.
Blood test: A blood tests may be performed to determine whether the patient has a bacterial or viral infection. A blood test may also be performed if an autoimmune disorder (like lupus) is suspected. A sample of the patient's blood is analyzed for the presence of autoantibodies. These autoantibodies in the blood mistakenly destroy the patient's own body cells if they have the disorder.
KOH (potassium and hydroxide) preparation: A KOH (potassium and hydroxide) preparation test is used to determine whether a fungal infection is causing the rash. During this test, a healthcare provider will gently scrape the skin with a blunt edge (like the edge of a microscope slide). The sample of scraped skin is then combined with a substance called potassium hydroxide (KOH). This solution allows the healthcare provider to see the fungus (if it is present) under a microscope.
This procedure is not painful because only a tiny amount of skin is needed. Patients may feel a slight pressure sensation when the skin is scraped.
Skin biopsy: A skin biopsy may also be performed. During the procedure, a healthcare provider will inject an anesthetic into the skin, which numbs the area. Then a small sample of skin is removed and analyzed under a microscope to determine whether the patient has a skin disorder, such as psoriasis.
Skin test: A skin test may be used to determine whether the rash is caused by an allergic reaction. During the test, the skin is exposed to the suspected allergens (substances that may be triggering an allergic reaction) and observed for an allergic reaction. If the allergen triggers an allergic reaction, the patient will develop reddening, swelling, or a raised, itchy red wheal (bump) that looks similar to a mosquito bite. The healthcare provider will measure the size of the wheal and record the results. The larger the wheal, the more severe the allergy.
Tzanck test: A tzanck test is used to determine whether a viral infection called herpes is causing a rash. The virus may be suspected if the patient has a rash that contains blisters. During the procedure, a small area of the skin is numbed and a blister is opened. The healthcare provider will scrape a small sample of the fluid and skin from the blister, and it will be analyzed under a microscope for the virus. If the virus is present, a positive diagnosis for herpes is made.
Wood lamp: A wood lamp test may be performed if a healthcare provider suspects the patient has a bacterial or fungal infection of the skin. The procedure is performed in a dark room, at a doctor's office. The healthcare provider shines an ultraviolet light onto the patient's rash. The rash is then observed for color changes when it comes into contact with the light. If a bacterial or fungal infection is present, the skin will appear to glow under the light.
Before undergoing this test, patients should not wash their skin because it may alter test results. Skin products, such as soap, deodorant, makeup, or lotion, should not be applied to the skin prior to testing. These products may glow under the light and cause false-positive results. Also, if the room is not dark enough, a patient may receive false-negative results. This means the patient has the infection, even though he/she tests negative.
Treatment
General: Treatment depends on the cause of the rash. If an allergic reaction causes a rash, oral antihistamines may be taken or hydrocortisone may be applied to the skin. Anaphylaxis, the most severe allergic reaction, must be treated with an injection of epinephrine as soon as possible. Antimicrobials are used to treat infections that cause rashes. Autoimmune disorders are treated with corticosteroids and other medications. Rashes caused by poisonous plants may be treated with antihistamines, calamine lotion, hydrocortisone, and/or baking soda solutions. Diaper rash may be treated with zinc oxide ointments. Skin disorders like atopic dermatitis may be treated with topical corticosteroids. If a patient develops Stevens-Johnson syndrome (SJS) in response to medication, the patient should stop taking the offending drug immediately. No specific drug treatment exists for SJS. Recovery may take two to six weeks. Severe cases may require hospitalization in an intensive care unit (ICU) or burn unit where the patient will receive intravenous fluids and nutritional supplements.
Antihistamines: Oral antihistamines like diphenhydramine (Benadryl?) have been used to treat skin rashes cause by an allergic reaction. Antihistamines decrease redness and itchiness associated with the rash.
Antimicrobials: Medications called antimicrobials are used to treat skin rashes caused by infection. Antibiotics are used for bacterial infections (like Lyme disease), antifungals are used to treat fungal infections (like yeast infections), and antivirals are used to treat viral infections (like herpes). Depending on the type and severity of the condition, these agents may be administered in topical, oral, or injectable forms. Treatment duration and doses also depend on the type and severity of the infection. Many viral infections will resolve on their own and do not require medications.
Aloe vera gel: Aloe vera gel has been applied to affected areas of the skin to relieve itching and help rashes heal. Aloe vera is used most often to treat rashes from sunburn, heat rash, or poisonous plants. Aloe vera gel should not be applied to open cuts, blisters, or sores on the skin.
Baking soda: A solution of baking soda and water may help treat allergic skin reactions caused by poisonous plants. Three teaspoons of baking soda has been mixed with one teaspoon of water and applied to affected areas of the skin.
Calamine lotion: Calamine lotion (Calamox?) can be applied to the skin to reduce itching and blistering caused by poisonous plant exposure.
Cool compress: Applying a cool compress to affected areas of the skin may help relieve itching and swelling associated with rashes.
Epinephrine: A medication called epinephrine is used to treat anaphylaxis. Epinephrine is injected into the skin at a hospital. Patients with a history of anaphylaxis should carry an auto-injectable epinephrine (EpiPen?) with them at all times. If symptoms of anaphylaxis appear after exposure to an allergen, the patient uses the device to inject the epinephrine into his/her thigh. Epinephrine acts as a bronchodilator because it opens the patient's airway. It also constricts the blood vessels, which increases blood pressure. Patients who experience anaphylaxis may also be admitted to the hospital to have their blood pressure monitored and possibly to receive breathing support.
Hydrocortisone: Hydrocortisone cream has been applied to the affected area to temporarily relieve itching associated with allergic reactions and exposure to poisonous plants. Hydrocortisone 1% cream, which is available over-the-counter, has anti-inflammatory effects and relieves swelling and redness in addition to itching. Prescription hydrocortisone has been used to relieve itching, redness, dryness, crusting, scaling, inflammation, and discomfort associated with the reaction.
Sunscreen: Patients who are sensitive to sun exposure should wear ultraviolet-blocking sunscreens to prevent or reduce the development of a skin rash.
Oral corticosteroids: Autoimmune disorders are often treated with oral corticosteroids like methylprednisolone (Adlone?, Medrol?, Solu-Medrol? or Depopred?) and prednisone (Deltasone?, Orasone? or Meticorten?) to suppress the body's immune system and decrease skin inflammation. These medications may also be used short-term to treat severe rashes caused by poisonous plants. Patients should slowly taper off medication to avoid serious side effects.
Topical anesthetics: Topical anesthetics like lidocaine (Lidoderm?) have been applied to the skin to relieve pain associated with SJS lesions.
Topical corticosteroids: Topical (applied to the skin) corticosteroids (like hydrocortisone, betamethasone, or fluticasone propionate) are the most common and effective treatments rashes caused by atopic dermatitis. They are used until the rash clears up. Low-strength topical corticosteroids should be used on the face. Over-the-counter hydrocortisone (like Bactine?, Cortaid?, Dermolate?, or Aveeno Anti-Itch cream?) is a low-strength corticosteroid cream that has been used to treat young children.
Zinc oxide creams: Ointments that contain zinc oxide (like Desitin? or Diaparene?) may help relieve diaper rash in babies. The ointment is applied to affected areas of the skin each time the baby's diaper is changed.
Integrative therapies
Strong scientific evidence:
Probiotics: Probiotics show promise for preventing atopic dermatitis (eczema) in children. Infants benefit when their mothers take probiotics during pregnancy and breastfeeding. Direct supplementation of infants may reduce the incidence of atopic eczema by as much as half. It may also reduce cow's milk allergy and other allergic reactions during weaning. Probiotics may stabilize intestinal barrier functioning and decrease gastrointestinal symptoms in children with atopic dermatitis. Children do differ, however, in their responsiveness to specific probiotics. The effectiveness of probiotics for the treatment of eczema is still under investigation.
Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.
Vitamin D: A number of different approaches are used to treat psoriasis. Mild approaches include light therapy, stress reduction, moisturizers, or salicylic acid to remove scaly skin areas. For more severe cases, treatments may include ultraviolet A (UVA) light, psoralen plus UVA light (PUVA), retinoids like isotretinoin (Accutane?), corticosteroids, or cyclosporine (Neoral?, Sandimmune?). The man-made vitamin D3 analog calcipotriene (Dovonex?) appears to control skin cell growth and it is used for moderately severe skin plaques, particularly for skin lesions resistant to other therapies or located on the face. Vitamin D3 (tacalcitol) ointment has been reported as being safe and well tolerated. High doses of becocalcidiol (a vitamin D analog) used on the skin may be beneficial in the treatment of psoriasis.
Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well tolerated in recommended doses. Doses higher than recommended may cause toxic effects. Individuals with overactive thyroid, kidney disease, sarcoidosis, tuberculosis, or histoplasmosis are at a higher risk of experiencing toxic effects. Vitamin D is generally considered safe for pregnant women. It may be necessary to give infants vitamin D supplements along with breast milk. The recommended intake of vitamin D for normal infants, children, and adolescents is 200 IU daily.
Good scientific evidence:
Aloe vera: Early evidence suggests that extracts from aloe in a cream or lotion may be an effective treatment for psoriasis vulgaris and seborrheic dermatitis when applied to the skin. Further study is needed in this area before a conclusion can be made.
Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, tulips). Do not inject aloe into the skin. Do not apply to open surgical wounds or pressure ulcers. Patients should not take aloe by mouth if they have diarrhea, bowel blockage, intestinal diseases, bloody stools, hepatitis, a history of irregular heartbeat (arrhythmia), electrolyte imbalances, diabetes, heart disease, or kidney disease. Avoid taking by mouth if pregnant or breastfeeding.
Evening primrose oil: Several small human studies of atopic dermatitis suggest benefits of taking evening primrose oil by mouth. Large well-designed studies are needed before a strong recommendation can be made. Evening primrose oil is approved for atopic dermatitis in several countries outside of the United States.
Individuals who are allergic to plants in the Onagraceae family, gamma-linolenic acid or other ingredients in evening primrose oil should avoid the substance. Individuals with seizure disorders and pregnant or breastfeeding women should also avoid evening primrose oil.
Unclear or conflicting scientific evidence:
Acupuncture: Acupuncture plus point-injection has been found beneficial for obstinate urticaria (rash), although more research is needed to confirm these findings. Further research is also needed to determine whether acupuncture can effectively treat skin disorders such as hives (itchy, red welts that form on the skin).
Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
Agrimony: It remains unclear whether agrimony can effectively treat cutaneous disorders and rashes. Further research is needed to determine if agrimony is safe and effective.
Avoid if allergic or hypersensitive to agrimony or its related species. When used as recommended, agrimony is considered to be safe. Avoid with bleeding disorders, kidney or liver disease, or diabetes. Use cautiously with drugs that lower blood pressure.
Aromatherapy: Aromatherapy is a loosely applied term that refers to several modalities that deliver essential oils to the body. It is unclear whether aromatherapy may be of benefit in pediatric atopic eczema.
Essential oils should be administered in a carrier oil to avoid toxicity. Avoid if history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
Avocado: Early scientific research showed promising results using avocado in a cream for psoriasis. Additional studies are needed in this area before a firm recommendation can be made.
Avoid if allergic or hypersensitive to avocado, banana, chestnut, or natural rubber latex. Use cautiously with anticoagulants (like warfarin). Avoid with monoamine oxidase inhibitors (MAOIs). Doses greater than found in a normal diet are not recommended if pregnant or breastfeeding. Some types of avocado may be unsafe when breastfeeding.
Bishop's weed: Clinical study has used 8-methoxypsoralen (8-MOP), a compound from Bishop's weed that has been identified as a treatment for psoriasis. High quality clinical studies are needed before any strong recommendation can be made.
Use cautiously in patients with photosensitivity. Use cautiously in patients with bleeding disorders or taking anticoagulants, NSAIDs/anti-platelet agents, or herbs/supplements that increase risk of bleeding. Use cautiously in patients taking drugs or herbs/supplements metabolized by cytochrome P450. Use cautiously in patients with eye disorders. Avoid in patients with known allergy/hypersensitivity to bishop's weed, its constituents, or members of the Apiaceae family.
Borage seed oil: The evidence for borage oil in the treatment of atopic dermatitis is mixed. Additional study is needed in this area. Seborrheic dermatitis is a type of inflammatory skin rash. Currently, there is insufficient evidence to support borage in the treatment of seborrheic dermatitis.
Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously in patients with bleeding disorders or taking warfarin or other anticoagulant or antiplatelet (blood thinning) agents. Use cautiously in patients with epilepsy or taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid in pregnant patients as borage oil may be contraindicated in pregnancy given the teratogenic and labor-inducing effects of prostaglandin E agonists, such as borage oil's GLA. Avoid if breastfeeding.
Bromelain: Bromelain has been shown to decrease inflammation, regulate the immune system, and have antiviral effects and may help treat skin rash.
Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or members of the Bromeliaceaefamily. Use cautiously with a history of bleeding disorders, stomach ulcers, or heart, liver, or kidney disease. Use caution before dental or surgical procedures or while driving or operating machinery. Avoid if pregnant or breastfeeding.
Butterbur: Preliminary research suggests that butterbur may not suppress allergic skin disease reactions when compared to the prescription drug fexofenadine (Allegra?), which does suppress these reactions. Additional study is needed. Use caution if allergic or sensitive to
Petasites hybridus or other plants from the Asteraceae/Compositae family (like ragweed, marigolds, daisies and chrysanthemums). Raw, unprocessed butterbur plant should not be eaten due to the risk of liver or kidney damage or cancer. Avoid if pregnant or breastfeeding.
Calendula: Limited early research suggests that calendula extracts may reduce skin inflammation. Human studies are lacking in this area.
Avoid if allergic to plants in the Aster/Compositae family such as ragweed, chrysanthemums, marigolds, and daisies. Use cautiously in patients taking sedatives, blood pressure medications, cholesterol medications, blood sugar-altering agents, and immunomodulators. Use cautiously with diabetes and in children. Avoid if pregnant or breastfeeding.
Chamomile: The German Commission E authorizes the use of topical chamomile for diseases of the skin. However, little research has been done on topical chamomile for eczema. Topical chamomile preparations have traditionally been used to soothe skin inflammation. The existing human evidence shows that chamomile may be of little, if any, benefit while animal studies support its anti-inflammatory action. Additional human research is needed in this area.
Avoid if allergic to chamomile. Anaphylaxis, throat swelling, skin allergic reactions and shortness of breath have been reported. Chamomile eyewash may cause allergic conjunctivitis (pinkeye). Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.
Chondroitin sulfate: Early research suggests that chondroitin may help treat psoriasis. Well-designed clinical trials are needed to confirm these results.
Use cautiously if allergic or hypersensitive to chondroitin sulfate products. Use cautiously with bleeding disorders and with blood-thinners like warfarin (like Coumadin?). Avoid if pregnant or breastfeeding.
DHEA: DHEA (dehydroepiandrosterone) is a hormone that is produced by the adrenal glands in the body. Overall, study results suggest that DHEA likely offers no benefit to individuals with psoriasis, but some disagree. Additional research is needed before a firm conclusion can be made.
Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or anticoagulants, or drugs, herbs, or supplements for diabetes, heart disease, seizure, or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
Euphorbia: Early research of
Euphorbia acaulis has demonstrated an effect on patients with eczema. More trials are needed to evaluate the effect of
Euphorbia acaulis for eczema.
Avoid if allergic or hypersensitive to pollen from Euphorbia fulgens. Use cautiously with history of Epstein Barr virus infection or stomach conditions. Avoid if pregnant or breastfeeding.
Gamma linolenic acid (GLA): Clinical studies have used GLA to treat atopic dermatitis in adults, children, and infants. Changes in linolenic acid metabolism have been related to eczema where conversion of linolenic acid to GLA is inhibited in persons with atopic dermatitis. However, studies in the past 20 years reveal minimal therapeutic improvements with GLA as therapy for atopic dermatitis, noted by only marginal to no improvement in inflammation and itching.
GLA is generally considered nontoxic and well tolerated for up to 18 months. Use cautiously with anticoagulants (blood-thinners), and avoid if pregnant or breastfeeding.
Gamma oryzanol: A few studies have used gamma oryzanol by mouth or applied on the skin to treat skin conditions. Although these studies seem to indicate that gamma oryzanol may be useful, additional research is needed to assess gamma oryzanol's effects.
Avoid if allergic/hypersensitive to gamma oryzanol, its components, or rice bran oil. Use cautiously if taking anticoagulants (blood thinners), central nervous system (CNS) suppressants, growth hormone, drugs that alter blood sugar levels, immunomodulators, luteinizing hormone or luteinizing hormone-releasing hormone, prolactin, cholesterol-lowering agents, thyroid drugs, and herbs or supplements with similar effects. Use cautiously with diabetes, hypothyroidism, hypoglycemia, hyperglycemia, or high cholesterol. Avoid if pregnant or breastfeeding.
Grapefruit: There is early but inconclusive evidence to support the use of grapefruit seed extract in the treatment of atopic eczema. Additional research is needed to confirm these findings.
Avoid
if allergic to grapefruit. Grapefruit may interact with prescription drugs, herbs, and supplements. Use cautiously if taking cytochrome P450 3A4 substrates such as anticoagulant/antiplatelets (agents that affect blood/clotting), antiarrhythmics (medications used to treat abnormal rhythms in the heart), seizure drugs, antidepressants, antihistamines, drugs that affect blood pressure, benzodiazepines (a class of psychotropic drugs that have a hypnotic and sedative action), calcium channel blockers, caffeine, corticosteroids (anti-inflammatories), erectile dysfunction drugs, estrogens, immune modulators, HMG-CoA reductase inhibitors, macrolide antibiotics, and protease inhibitors. Use cautiously if drinking red wine or tonic water. Use cautiously when smoking and with liver cirrhosis or at risk for kidney stones. Use cautiously in patients that have undergone gastric bypass surgery. Use cautiously if pregnant or breastfeeding.
Honey: The evidence supporting the use of honey in the treatment of dermatitis is limited. Further investigation is needed to make a firm recommendation.
Avoid if allergic or hypersensitive to honey, pollen, celery, or bees. Honey is generally considered safe in the recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously if taking antibiotics. Potentially harmful contaminants (e.g. C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously if pregnant or breastfeeding.
Hydrotherapy: There is insufficient evidence to determine whether hydrotherapy is an effective treatment for atopic dermatitis or psoriasis.
Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices such as pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.
Hypnotherapy: Further research is needed to determine whether hypnotherapy is an effective treatment for skin conditions (eczema, psoriasis, atopic dermatitis).
Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder, or dissociative disorders. Use cautiously with seizure disorders.
Jewelweed: Jewelweed has been used traditionally as a treatment for various types of contact dermatitis, including poison ivy/oak rashes and allergic dermatitis, however, human study indicates that it may not be effective for this use. Avoid if allergic or hypersensitive to jewelweed (
Impatiens biflora), its constituents, or members of the Balsaminaceae family. Use cautiously if taking calcium supplements and with kidney stone disorders. Avoid consuming excess amounts of jewelweed due to reports of high mineral content, particularly calcium oxalate. Avoid if pregnant or breastfeeding.
Khella: Preliminary evidence suggests that khellin taken by mouth may be an effective therapy for psoriasis. However, additional study is needed to confirm these results.
Avoid if allergic to members of the Apiaceae family. Khella may cause liver poisoning (hepatotoxicity) in high doses. Use cautiously with liver problems or asthma. Avoid prolonged exposure to sunlight or ultraviolet radiation. Avoid if pregnant.
Lavender: In limited clinical study, essential oils were used in combination with massage to treat childhood atopic eczema. It was found that there was deterioration in the patient's eczema, which may have been due to possible allergic contact dermatitis provoked by the essential oils themselves. More study on the effect of lavender essential oil alone is needed before any firm conclusions can be made.
Avoid if allergic or hypersensitive to lavender. Avoid with a history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.
Licorice:
Topical licorice extract gel has been shown to be effective in the treatment of atopic dermatitis in preliminary human study. Further research is needed to confirm these results.
Avoid with a known allergy to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid with congestive heart failure, coronary heart disease, kidney or liver disease, fluid retention, high blood pressure, hormonal abnormalities or if taking diuretics. Licorice may cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities.
Marshmallow:
Marshmallow extracts have traditionally been used to treat inflammatory skin conditions. Several laboratory experiments, mostly in the 1960s, reported marshmallow to have anti-inflammatory activity but limited human study is available. Safety, dosing, and effectiveness compared to other anti-inflammatory agents have not been examined.
Historically, marshmallow is generally regarded as being safe in healthy individuals. However, since studies have not evaluated the safety of marshmallow, proper doses and duration in humans are not known. Allergic reactions may occur. There is not enough scientific evidence to support the safe use of marshmallow during pregnancy or breastfeeding.
Massage: Massage may be of benefit in pediatric atopic dermatitis. More studies are needed for a conclusion to be made.
Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin?). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously if history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the patient.
Meditation: Meditation has been suggested to improve healing of psoriasis, when used in combination with standard treatments. More studies are needed.
Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.
Neem: Limited human data on the effect of neem on psoriasis vulgaris is available. Further research is needed before a firm conclusion can be made.
Avoid if allergic or hypersensitive to neem (Azadirachta indica) or members of the Meliaceae family. Use cautiously with liver disease. Avoid in children and infants. Avoid if pregnant or breastfeeding.
Niacin: Niacin is a B complex vitamin found in a many foods such as liver, poultry, fish, nuts, and dried beans. Niacinamide has traditionally been used in topical products for skin conditions. Preliminary research suggests benefit of a niacinamide moisturizer on dry skin in patients with rosacea. Further research is warranted.
Avoid niacin/vitamin B3 if allergic to niacin or niacinamide. Avoid with a history of liver disease, irregular heartbeats, heart disease, blood clotting or bleeding disorders, asthma, anxiety, panic attacks, thyroid disorders, stomach ulcers, gout, or diabetes. Avoid if pregnant or breastfeeding.
Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single 6-ounce meal per week, and in young children to less than 2 ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat 7 ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).
Papain: Papain has shown some benefits in reducing scaling in dry skin conditions. More high quality studies are needed to confirm these results.
Use cautiously in patients sensitive to papain. Use cautiously in patients being treated for prostatitis. Use Wobenzym?, which contains papain, cautiously, especially in those with bleeding disorders or taking anticoagulants or antiplatelets. Use cautiously as an adjuvant to radiation therapy. Avoid in patients with gastroesophageal reflux disease. Avoid in patients using immunosuppressive therapy.
Para-aminobenzoic acid: Para-aminomethylbenzoic acid (PABA) may be useful in the treatment of lichen slerosus, a benign, progressive dermatologic condition characterized by inflammation, pruritus (itching), and pain, especially in the anogenital region (involving the anus and genitals). Additional investigations are needed regarding the use of PABA for inflammatory skin disorders.
Avoid with known hypersensitivity to PABA or its derivatives. Discontinue use if rash, nausea, or anorexia occurs. Avoid oral use in children and pregnant or nursing women. Use cautiously in patients with renal or liver disease. PABA should not be given concurrently with sulfonamides. Use cautiously in patients with bleeding disorders or taking anticoagulants. Use cautiously in patients with diabetes or hypoglycemia.
Peony: Peony root may have beneficial effects on immune function. These effects may help decrease inflammation associated with allergic skin reactions such as allergic dermatitis. There is currently not enough evidence to recommend for or against the use of peony in allergic skin conditions.
Avoid if allergic or sensitive to peony. Avoid with bleeding disorders or if taking drugs, herbs, or supplements that increase bleeding risk. Use cautiously with estrogen-sensitive cancers or if taking drugs, herbs, or supplements with hormonal activity. Avoid if pregnant or breastfeeding.
Polypodium: Laboratory and animal studies report that
Polypodium leucotomos extract (anapsos) may reduce inflammation. However, there is clinical little information about the effectiveness of anapsos taken by mouth in people with atopic dermatitis or psoriasis. Poor-quality human studies report that anapsos may improve skin appearance. More research is needed in this area before a recommendation can be made.
Avoid if allergic to ferns (family Polypodiaceae) or if pregnant or breastfeeding.
Psychotherapy:
Atopic dermatitis is a skin disease associated with an increased anxiety level. Psychotherapy may be helpful for atopic dermatitis patients with high levels of anxiety. However, more research is needed before recommendation can be made.
Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist.
Rose hip: Rose hips are reputed to have antibacterial and antifungal properties and have traditionally been used as an anti-inflammatory agent for dermatoses. In addition, rose hips contain several vitamins and minerals, including vitamin C, vitamin B1,vitamin E, calcium, zinc, and carotenoids that may have therapeutic effects when applied to the skin. High quality clinical trials are needed to establish the therapeutic efficacy of rose hips and rose oil preparations in the topical treatment of dermatological disorders.
Use cautiously in patients taking immune system stimulants, anticoagulant or anti-platelet aggregating agents, or laxatives. Avoid in patients who are allergic to rose hips, rose pollen, its constituents, or members of the Rosaceae family.
Rutin: In clinical study, O-(beta-hydroxyethyl)-rutoside (a form of rutin) offered benefit for skin irritation in individuals with breast cancer undergoing radiation treatment. More well-designed clinical trials are required to better determine the effectiveness of rutin for skin conditions.
Avoid if allergic/hypersensitive to O-(beta-hydroxyethyl)-rutosides or plants that rutin is commonly found in, such as rue, tobacco, or buckwheat. Use cautiously in elderly patients. Use cautiously with skin conditions. Use cautiously if taking medications for edema, diuretics, or anti-coagulation medications. Use cautiously if pregnant or breastfeeding.
Safflower: Preliminary evidence looks promising for the use of safflower oil in the treatment of phrynoderma, a rough, dry skin condition generally associated with a vitamin A deficiency. Additional study is warranted to better determine the effectiveness of safflower for skin conditions.
Avoid if allergic/hypersensitive to safflower, Carthamus tinctorius, safflower oil, daisies, ragweed, chrysanthemums, marigolds or any related constituents. Use parenteral safflower oil emulsions cautiously in newborns. Use cautiously with diabetes, hypotension, inadequate liver function, hypercoagulability, and skin pigmentation conditions. Use cautiously if pregnant or breastfeeding.
Sanicle: Sanicle (
Sanicula europaea,
Sanicula europa) has been studied for use in atopic eczema. More studies are needed.
Avoid if allergic or sensitive to sanicle. Use cautiously with stomach problems. Use cautiously if taking blood pressure-lowering or diuretic drugs. Avoid if pregnant or breastfeeding.
Schisandra: There is a currently a lack of available sufficient evidence to determine if schisandra is an efficacious treatment for eczema. Results from limited study, which investigated the effect of schisandra in combination with other herbs, suggested a potential benefit. Further study is required before conclusions can be drawn.
Use cautiously during pregnancy or lactation due to insufficient available evidence. Use cautiously in patients with bleeding disorders, seizure disorders, high intracranial pressure, high blood pressure, gastoeseophageal reflux or peptic ulcer disease, neurological disorders, and diabetes. Avoid in patients allergic to schisandra, any of its constituents, or other members of the Schisandraceae family. Allergic skin rashes and urticaria has been reported in some patients.
Sea buckthorn: Study results on the effectiveness of sea buckthorn for atopic dermatitis are mixed. More study is needed in this area before a conclusion can be made.
Avoid if allergic or hypersensitive to sea buckthorn, its constituents, or members of the Elaeagnaceae family. Use cautiously if taking angiotensin converting enzyme (ACE) inhibitors, anticoagulants and antiplatelet agents (blood thinners), antineoplastics (anticancer agents), or cyclophosphamide or farmorubicin. Avoid higher doses than food amounts if pregnant or breastfeeding.
Selenium: Further research is necessary to determine whether selenium can be used to effectively treat psoriasis and other skin disorders. Studies report that selenium-containing shampoos may help improve dandruff, and selenium is included in some commercially available products.
Avoid if allergic or sensitive to products containing selenium. Avoid with history of non-melanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
Shark cartilage: Shark cartilage products have been tested by mouth or on the skin in people with psoriasis. However, no clear benefits have been shown. More research is needed before a conclusion can be drawn.
Avoid if allergic to shark cartilage or any of its ingredients (including chondroitin sulfate and glucosamine). Use cautiously with sulfur allergy. Avoid with history of heart attack, vascular disease, heart rhythm abnormalities, or heart disease. Use cautiously with history of liver or kidney disorders, tendency to form kidney stones, breast cancer, prostate cancer, multiple myeloma, breathing disorders (like asthma), cancers that raise calcium levels (like breast, prostate, multiple myeloma, or squamous cell lung cancer), or diabetes. Avoid if pregnant or breastfeeding.
Spiritual healing: There is limited research on the use of spiritual healing for eczema. Further research is needed.
Spiritual healing should not be used as the only treatment approach for medical or psychiatric conditions, and should not delay the time it takes to consider more proven therapies.
St. John's wort:
Early research of
Hypericum cream for the topical (applied to the skin) treatment of mild to moderate atopic dermatitis shows positive results. Further studies are needed before a firm conclusion can be made.
Avoid if allergic or hypersensitive to plants in the Hypericaceaefamily. Rare allergic skin reactions like itchy rash have been reported. Avoid with HIV/AIDS drugs (protease inhibitors) like indinavir (Crixivan?), or non-nucleoside reverse transcriptase inhibitors, like nevirapine (Viramune?). Avoid with immunosuppressant drugs (like cyclosporine, tacrolimus or myophenic acid). Avoid with organ transplants, suicidal symptoms, or before surgery. Use cautiously with history of thyroid disorders. Use cautiously with drugs that are broken down by the liver, with monoamine oxidase inhibitors (MAOI) or selective serotonin reuptake inhibitors (SSRIS), digoxin, or birth control pills. Use cautiously with diabetes or with history of mania, hypomania (as in Bipolar Disorder), or affective illness. Avoid if pregnant or breastfeeding.
Sweet marjoram: Limited available human study showed that massage with essential oils, including marjoram, was not more effective in alleviating childhood atopic eczema than massage without essential oils. More long term high-quality studies with sweet marjoram alone are needed.
Use cautiously in patients with bleeding disorders or in those taking anticoagulants, in patients with diabetes or in those taking antidiabetic agents, or in pregnant patients. Avoid in patients with known allergy/hypersensitivity to marjoram, its constituents, or to members of the Lamiaceae family.
Tea tree oil: Small studies show that tea tree oil applied to the skin may reduce allergic skin reactions caused by histamine-induced inflammation. Early research reports that the use of 5% tea tree oil shampoo on mild-to-moderate dandruff may be effective and well tolerated. Further research is needed to confirm these results.
Avoid allergic or hypersensitive to tea tree oil (Melaleuca alternifolia), any of its constituents, balsam of Peru, benzoin, colophony (rosin) tinctures, eucalyptol, or members of the Myrtle (Myrtaceae) family. Avoid taking tea tree oil by mouth. Avoid if taking antineoplastic agents. Use tea tree oil applied to the skin cautiously in patients with previous tea tree oil use. Avoid if pregnant or breastfeeding.
Thyme: Historically, thyme has been used topically for a number of inflammatory skin disorders. Results are mixed. Additional study is needed in this area.
Avoid with known allergy/hypersensitivity to members of the Lamiaceae (mint) family or to any component of thyme, or to rosemary (Rosmarinus officinalis). Avoid oral ingestion or non-diluted topical application of thyme oil due to potential toxicity. Avoid topical preparations in areas of skin breakdown or injury, or in atopic patients, due to multiple reports of contact dermatitis. Use cautiously in patients with gastrointestinal irritation or peptic ulcer disease due to anecdotal reports of gastrointestinal irritation. Use cautiously in patients with thyroid disorders due to observed anti-thyrotropic effects in animal research of the related species Thymus serpyllum. Avoid if pregnant or breastfeeding.
Thymus extract: It remains unclear whether thymus extract can effectively treat skin conditions such as psoriasis or eczema. Early research results are inconclusive. Further research is needed.
Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis (neuromuscular disorder), untreated hypothyroidism, or if taking hormonal therapy. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.
Witch hazel: Based on human study, witch hazel was less effective than hydrocortisone cream, and no more effective than placebo in relieving inflammation associated with atopic eczema. Although witch hazel has been commonly used to relieve minor skin irritations, there are few human studies evaluating its use for this purpose, especially in children. High quality clinical study is needed in this area.
Avoid if allergic or sensitive to witch hazel. Avoid if pregnant or breastfeeding. Use cautiously in patients with liver or kidney disorders, diabetes, and in children.
Zinc:
Preliminary research on the effectiveness of zinc to treat skin conditions, including diaper rash, psoriasis, and eczema are inconclusive. Further research is necessary before a firm conclusion can be made. Shampoo containing 1% of zinc pyrithione has been shown to reduce dandruff in some people.
Zinc is regarded as relatively safe and generally well tolerated when taken at recommended doses and few studies report side effects. Zinc should only be given to pregnant or breastfeeding women under the supervision of their qualified healthcare providers.
Fair negative scientific evidence:
Boron: Preliminary human research of a topical ointment containing boric acid does not report significant benefits in patients with psoriasis.
Avoid if allergic or sensitive to boron, boric acid, borax, citrate, aspartate, or glycinate. Avoid with history of diabetes, seizure disorder, kidney disease, liver disease, depression, anxiety, high blood pressure, skin rash, anemia, asthma, or chronic obstructive pulmonary disease (COPD). Avoid with hormone-sensitive conditions like breast cancer or prostate cancer. Avoid if pregnant or breastfeeding.
Evening primrose oil: Initial research does not show a benefit of evening primrose oil in the treatment of psoriasis.
Individuals who are allergic to plants in the Onagraceae family, gamma-linolenic acid, or other ingredients in evening primrose oil should avoid the substance. Individuals with seizure disorders and pregnant or breastfeeding women should also avoid evening primrose oil.
Prevention
Avoid exposure to known allergens (like pollen, dust mites, animal dander, mold, and certain foods and medications).
Individuals who have experienced anaphylactic reactions should avoid allergy-causing food, medications, or substances. Individuals with a history of anaphylaxis should carry an autoinjectable epinephrine device (known as an EpiPen?) with them at all times. A trained family member or friend may help the patient administer the epinephrine, if necessary.
Avoid unnecessary exposure to other environmental irritants such as insect sprays, tobacco smoke, air pollution, and fresh tar or paint.
Patients can take precautions to avoid contracting infections that may cause rashes. Patients should thoroughly wash their hands with soap and water. Patients should talk to their healthcare providers about recommended immunizations. Patients should minimize or avoid close contact with individuals who have contagious illnesses.
To help prevent diaper rash, regularly change diapers as soon as they become wet or dirty. Thoroughly dry the baby's bottom before putting a new diaper on.
Wear sunblock when outside to help prevent a skin rash. Patients should choose a sunblock with a sun protection factor (SPF) of 15 or higher. The sunblock should offer protection against both ultraviolet A (UVA) and ultraviolet B (UVB) rays. Also, patients should look for products that are "PABA-free." PABA is a chemical that is found in many sunblocks, and it is know to cause irritation in sensitive patients.
Individuals should learn what poison ivy, poison oak, and poison sumac look like in order to prevent contact with the plants. Individuals who are allergic to poisonous plants should wear long pants and long-sleeved shirts when they are in wooded areas.
Topical creams like bentoquatam (IvyBlock?), which are available over-the-counter, may help prevent or reduce allergic rashes caused by poison plants. The cream is applied to exposed areas of skin before possible exposure to poison ivy, poison oak, or poison sumac. The cream should not be applied to open cuts, sores, or wounds.
Complications
Anaphylaxis: A skin rash may be a symptom of a severe and potentially life-threatening reaction called anaphylaxis. The most serious symptoms of anaphylaxis include low blood pressure, breathing difficulties, shock, and loss of consciousness, all of which can be fatal. Patients should seek immediate medical treatment if these symptoms develop.
Psychological symptoms: Some patients who have long-term skin conditions like lupus, chronic acne, or rosacea may suffer from low self-esteem.
Secondary infections: Secondary infections may develop if the patient's rash has open sores or blisters. Patients should not scratch irritated skin because it may cause the skin to break. If bacteria or viruses enter the body through the open skin, an infection may develop. Antibiotics are used to treat bacterial infection, antifungals are used to treat fungal infections, and antivirals are used to treat viral infections. Specific treatment and duration depends on the type and severity of infection and overall health of the patient.
Stevens-Johnson syndrome (SJS): A severe skin rash called Stevens-Johnson syndrome (SJS) may develop as an allergic reaction to medication. SJS is potentially life threatening because in severe cases, the lesions can cause significant scarring of the involved organs, which often leads to loss of function of the organ systems. SJS typically starts with a nonspecific upper respiratory tract infection. The patient may experience flu-like symptoms including, fever, sore throat, chills, headache, and general feeling of discomfort for one to 14 days. Some individuals will also experience diarrhea and vomiting. As the disease progresses, skin lesions quickly develop. Patients may experience extensive shedding of the skin. Skin lesions may occur anywhere, but they are most common on the palms, soles of the feet, back of the hands, and extremities. Mucosal involvement may include reddening of the skin, edema (fluid in body tissues), blistering, open sores on the skin, and dead skin.