Non-follicular milky globules-dermoscopy saves the day.

Acute generalized exanthematous pustulosis (AGEP) is a rare severe cutaneous adverse reaction caused mostly by medication. Early diagnosis is important as initiation of supportive treatment and avoidance of drug is of prime importance. A young male presented with an erythematous rash after taking diclofenac for pain. Polarized dermoscopy revealed milky globules on a uniform reddish background sparing the follicles, which confirmed the diagnosis of AGEP.

Case Report

A 29-year-old male presented with a two-day history of rash after taking the nonsteroidal anti-inflammatory drug, diclofenac, for pain. On examination there were multiple erythematous macules all over the trunk (Figure 1). Polarized dermoscopy revealed milky globules on a uniform reddish background sparing the follicles (Figure 2). A diagnosis of acute generalised exanthematous pustulosis (AGEP) was made.

Figure 1

Multiple erythematous macules all over the trunk. [Copyright: ©2017 Jha et al.]

Figure 2

Dermoscopy (polarized 10X) showing milky globules on a uniform reddish background sparing the follicles. [Copyright: ©2017 Jha et al.]

Discussion

Acute generalized exanthematous pustulosis (AGEP) is a rare severe cutaneous reaction pattern that in the majority of cases is related to medication administration [1-3]. Early diagnosis of AGEP is of paramount importance, as it necessitates a more aggressive therapeutic approach because it carries a worse prognosis [4,5]. The cutaneous manifestations of AGEP are usually associated with fever and leukocytosis, mostly due to blood neutrophil count above 7000/mcL. Mild eosinophilia may be present in about one-third of the patients [3]. Internal organ involvement is relatively rare and the mortality rate is approximately 5% [6]. In this patient, AGEP mainly showed small, milky, roundish globules, histologically corresponding to nonfollicular subcorneal pustules, a pinkish-reddish background, consistent with dermal inflammation [7]. No distinct vascular structure was evident. Dermoscopy may help in diagnosis at an early stage, as awaiting histopathology reports may prolong the treatment.