Skin rash - generalised
Overview
Several STIs may be associated with generalised dermatological problems.
Possible causes
Clinical presentation
| Symptoms | Comments/Considerations |
|---|---|
| Rash - chlamydia | Hypertrophic rash on soles, circinate balanitis, psoriatic rash (associated with chlamydia as part of reactive arthritis and eye signs). Erythema over grossly swollen inguinal lymph nodes (bubo = lymphogranuloma venereum (LGV). |
| Rash - gonorrhoea |
Macular rash that may include necrotic pustules |
| Rash - syphilis |
|
| Oral lesions | Mucous patches (secondary syphilis) and transient vesicles/erosions (chlamydia) |
Diagnosis
| Diagnosis in males | ||
|---|---|---|
| Infection | Site/Specimen | Test |
| Chlamydia | FPU Eye swab if symptomatic |
NAAT |
| Gonorrhoea | FPU Eye swab if symptomatic |
NAAT If NAAT test result is positive, take swab at relevant site(s) for culture, before treatment. |
| Syphilis | Blood | Syphilis serology |
| Lymphogranuloma venereum (LGV) | Rectal swab | NAAT. Write on request form “NAAT. If chlamydia positive please send for LGV testing.” |
| FPU – First pass urine NAAT – Nucleic Acid Amplification Test |
||
| Diagnosis in females | ||
|---|---|---|
| Test | Site/Specimen | Consideration |
| Chlamydia |
Endocervical swab Self-collection of samples for NAAT testingVaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. OR FPU Eye swab if symptomatic. |
NAAT |
| Gonorrhoea |
Endocervical swab Self-collection of samples for NAAT testingVaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. OR FPU Eye swab if symptomatic. |
NAAT If NAAT test result is positive, take swab at relevant site(s) for culture, before treatment. |
| Syphilis | Blood | Syphilis serology |
| Lymphogranuloma venereum (LGV) | Rectal swab |
NAAT. Write on request form “NAAT. If chlamydia positive please send for LGV testing.” |
| FPU - First pass urine NAAT - Nucleic Acid Amplication Test |
||
Investigations
Always check for ano-genital infection if chlamydia or gonorrhoea is found in conjunctival swabs.
Specimen collection
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
Special considerations
- Gummata are a very rare presentation of tertiary syphilis in current times, but may involve skin as an indurated nodule or an ulcerated nodule.
- Syphilis has been described as the great mimic and should be considered in unusual presentations including rashes. Higher rates of syphilis occur in populations such as men having sex with men (MSM), Aboriginal and Torres Strait Islander people and travellers who have sex overseas.
Management
| Principal Treatment Options | ||
|---|---|---|
| Situation | Recommended | Alternative |
| Chlamydia |
Doxycycline 100mg PO, BD 7 days OR Azithromycin 1g PO, stat |
|
| Gonorrhoea | Seek specialist advice for disseminated gonorrhoea. | |
| Syphilis# |
Benzathine penicillin 1.8g IMI, stat |
Procaine penicillin 1.5g IMI, daily for 10 days |
| Lymphogranuloma venereum (LGV) |
Doxycycline 100mg PO, BD for 21 days |
Alternative regimens are not recommended due to lack of efficacy data. If alternative regimen required, seek specialist advice. |
Treatment advice
- # Seek specialist advice for all patients who are pregnant, hypersensitive to penicillin or who are HIV positive
- Treat the underlying infection which will usually lead to resolution of symptoms and signs of skin disease.
- Provide symptomatic relief of itch with topical emollients and antihistamines if needed. Moderate skin irritation may require low strength topical steroid ointment.
- Ocular involvement requires review by an ophthalmologist.
Other immediate management
- Advise no sexual contact for 7 days after treatment is administered.
- Advise no sex with partners from the last 6 months until the partners are tested and treated if necessary.
Contact Tracing
Contact tracing for chlamydia, gonorrhoea and lymphogranuloma venereum (LGV) is a high priority and should be performed in all patients with confirmed infection.
See Australasian Contract Tracing Manual for more information.
Follow up
If STI confirmed, follow up provides an opportunity to:
- Confirm patient adherence with treatment and assess for symptom resolution.
- Confirm contact tracing has been undertaken or offer more contact tracing support.
- Provide further sexual health education and prevention counselling.
For test of cure (TOC) and retesting advice see:
Auditable outcomes
Refer to the relevant STI:
References
British Association for Sexual Health and HIV (BASHH) 2014. Available from: http://www.bashh.org/BASHH/Guidelines/Guidelines/BASHH/Guidelines/Guidelines.aspx