A patient who received a kidney transplant admitted to the hospital for worsening renal function

steroid-induced acne

Educational Objective:

Review the differential diagnosis of an acneiform eruption in a patient with a suppressed immune system.

Key Point:

It is important to perform cultures of pustular rash in an immunocompromised patient to rule out an infectious etiology. Steroid-induced acne is diagnosed once infection is excluded.

Explanation:

This patient has multiple erythematous papules and pustules over the chest and arms without comedones (blackheads and whiteheads). Any pustular eruption in an immunosuppressed patient should trigger appropriate bacterial, candidal, and fungal cultures to be performed. Steroid-induced acne cultures are sterile.

Disseminated Candida albicans infection resulting in sepsis can lead to small pustular lesions similar in appearance to those shown in the Figure. A candidal infection is less likely in this case because this patient does not have any signs of sepsis.

Rash associated with staphylococcal sepsis is typically described as erythematous and maculopapular. The patient’s rash does not have that appearance.

Varicella is characterized by several days of fever, pharyngitis, and malaise followed by a pruritic, vesicular rash that presents in crops over several days. This patient’s history and rash are inconsistent with this diagnosis.

Acne vulgaris is characterized by the presence of comedones in the setting of erythematous papules and pustules. There are no comedones present in this patient, making acne vulgaris less likely.

References:

Albrecht MA. Clinical features of varicella zoster virus infection: chickenpox. Revised February 8, 2016. Accessed June 7, 2017.

Graber E. Treatment of acne vulgaris. Revised March 24, 2017. Accessed June 7, 2017.

Kauffman CA. Overview of Candida infections. Revised January 5, 2016. Accessed June 7, 2017.

Lopez FA, Sanders CV. Fever and rash in the immunocompetent patient. Revised September 13, 2016. Accessed June 7, 2017.