Treatment for Scaly Rash on Palms/Soles with Papular Rash on Neck/Face

Critical First Step: Rule Out Life-Threatening and Infectious Causes

The American Academy of Dermatology and the Centers for Disease Control and Prevention recommend obtaining VDRL/RPR testing to rule out secondary syphilis, which classically presents with scaly palmoplantar lesions plus papular rash on face/neck 1, 2
A complete blood count is necessary to evaluate for Rocky Mountain Spotted Fever (RMSF), which presents with rash on palms/soles spreading to face/neck, with thrombocytopenia being a key finding 1
The Centers for Disease Control and Prevention recommend obtaining a tick exposure history, as RMSF has 5-10% mortality if untreated and requires immediate doxycycline 1
Bacterial/viral/fungal cultures are necessary if any signs of superinfection are present, as recommended by the Annals of Oncology 3, 4

The combination of palmoplantar AND facial/neck involvement narrows the differential significantly, with secondary syphilis (Treponema pallidum) being a possible cause, as recommended by the American Academy of Dermatology 2
RMSF is another possible cause, presenting with maculopapular rash starting on wrists/ankles spreading to palms/soles and trunk, can involve face, as recommended by the Centers for Disease Control and Prevention 1
Hand, foot, and mouth disease (in toddlers) is also a possible cause, presenting with vesicular lesions on palms/soles with oral involvement, as recommended by the American Academy of Pediatrics 2
Meningococcal infection can present with palmoplantar rash, as recommended by the Centers for Disease Control and Prevention 2
Psoriasis vulgaris can involve palms, soles, and face simultaneously, as recommended by the American Academy of Dermatology 5, 6, 7
Drug-induced hypersensitivity reaction can cause palmoplantar involvement with facial rash, as recommended by the Annals of Oncology 2
Papulopustular exanthema from EGFR inhibitors/MEK inhibitors (if on cancer therapy) can cause papules on face/neck with palmoplantar involvement, as recommended by the Annals of Oncology 3, 4

For palmoplantar psoriasis with facial involvement, systemic therapy is justified regardless of body surface area involved, as quality of life impact is disproportionate to BSA, as recommended by the American Academy of Dermatology 6, 7, 8
First-line systemic treatment is acitretin 25 mg daily, with substantial improvement typically seen within 2 months, as recommended by the American Academy of Dermatology 6, 7
Topical adjunctive therapy includes clobetasol propionate solution for scalp/face and high-potency topical corticosteroids under occlusion for palms/soles, as recommended by the American Academy of Dermatology 6, 7
Alternative systemic options if acitretin fails include methotrexate or cyclosporine, as recommended by the American Academy of Dermatology 6, 7
Biologics (adalimumab, infliximab, ustekinumab) are recommended for refractory cases, as recommended by the American Academy of Dermatology 6, 7, 9
Phototherapy options include soak PUVA, as recommended by the American Academy of Dermatology 6, 7

For Grade 1-2 papulopustular rash (10-30% BSA), continue causative drug at current dose and add oral doxycycline 100 mg twice daily OR minocycline 50 mg twice daily for 6 weeks, as recommended by the Annals of Oncology 3, 4
Topical low/moderate potency steroid to face and affected areas twice daily is also recommended, as recommended by the Annals of Oncology 3, 4
For Grade ≥3 or intolerable Grade 2, interrupt causative drug until Grade 0-1 and add systemic corticosteroids (prednisone 0.5-1 mg/kg for 7 days), as recommended by the Annals of Oncology 3, 4

Never start treatment without ruling out secondary syphilis, as recommended by the American Academy of Dermatology and the Centers for Disease Control and Prevention 2
Do not delay doxycycline if RMSF is suspected, as mortality is 5-10% and increases with delayed treatment, as recommended by the Centers for Disease Control and Prevention 1
Avoid systemic corticosteroids as monotherapy in psoriasis, as recommended by the American Academy of Dermatology 9