akele7 Posted July 17, 2011 I cannot figure this out... My patient is a 27 year old female. Has a rash on her left forearm, left thigh and medial and later parts of her heels. It's red, papular shaped, and does not itch. She is not on any medications and NKA. She was using a new soap, but has stopped, and the rash is still appearing in new spots now up her left arm and near her left knee (See attached pictures). No ticks were found, and she is not sexually active. Diagnosis? Thoughts? She has tried triamcinolone with some results.
SocialMedicine Posted July 17, 2011 possibly viral exanthem and if responsive to steroid thats ok .... maybe a lower potency would be better for facial and light exposed areas. if she has no other symptoms i would attribute it to that and monitor for return of rash or other symptoms. If you are concerned about a tick borne illness people often have no recollection of bite. Also, the bite would probably of been few weeks ago. In terms of sexual activity this rash is atypical for a secondary syphilis and acute HIV but if risk factors present i would screen for both.
SocialMedicine Posted July 17, 2011 possibly viral exanthem and if responsive to steroid thats ok .... maybe a lower potency would be better for facial and light exposed areas. if she has no other symptoms i would attribute it to that and monitor for return of rash or other symptoms. If you are concerned about a tick borne illness people often have no recollection of bite. Also, the bite would probably of been few weeks ago. In terms of sexual activity this rash is atypical for a secondary syphilis and acute HIV but if risk factors present i would screen for both.
Just Steve Posted July 17, 2011 First thought, urishol oil exposure. Poison oak, ivy, sumac...and a variety of other things such as the rinds of Mangos to a lesser extent. The different areas of skin react at different times which will give you the idea that it is "spreading" when in reality, it's just developing at a later time frame. The lack of itch could be due to her own reaction to the allergen, or the itch is subtle enough not to be bothersome or noticable. Personally, I react like a fiend and have to suppress the urge to surgically remove large portions of my own flesh. Has she been out of doors, or does she have animals that have been out of doors that could have contacted the plant? The oil is persistant and will transfer from animal. My second thought is that rash on the ankle looks a bit like a fungal intrusion. Have you pointed a woods lamp at it yet to see if it reacts? Typically steroids will make fungals worse, but you didn't mention a time frame. I am only in my 8th day of PA school so I am just WAGing it (wild a** guess). Good luck
Just Steve Posted July 17, 2011 First thought, urishol oil exposure. Poison oak, ivy, sumac...and a variety of other things such as the rinds of Mangos to a lesser extent. The different areas of skin react at different times which will give you the idea that it is "spreading" when in reality, it's just developing at a later time frame. The lack of itch could be due to her own reaction to the allergen, or the itch is subtle enough not to be bothersome or noticable. Personally, I react like a fiend and have to suppress the urge to surgically remove large portions of my own flesh. Has she been out of doors, or does she have animals that have been out of doors that could have contacted the plant? The oil is persistant and will transfer from animal. My second thought is that rash on the ankle looks a bit like a fungal intrusion. Have you pointed a woods lamp at it yet to see if it reacts? Typically steroids will make fungals worse, but you didn't mention a time frame. I am only in my 8th day of PA school so I am just WAGing it (wild a** guess). Good luck
deborah212 Posted July 17, 2011 How long has shes had the rash for? Where did it first begin? Is there dermatographism? Any flushing, nausea, lightheadedness, or headache (mast cell release)? Does she live in an endemic lyme, rickettsial, or a babesial area? Any dogs or cats?
deborah212 Posted July 17, 2011 How long has shes had the rash for? Where did it first begin? Is there dermatographism? Any flushing, nausea, lightheadedness, or headache (mast cell release)? Does she live in an endemic lyme, rickettsial, or a babesial area? Any dogs or cats?
akele7 Posted July 17, 2011 Author The rash first appeared that she noticed on the saturday of 4th of July weekend. Just steve--would the rash last that long if she had been exposed to urishol oils? She has no recollection of being in any areas with poison ivy etc. She has no Pets. I have also thought on the lines of fungal. She has mentioned a window that has been leaking her her apt for over 2 months. She lives in florida so I am wondering if mold is growing in the crack of the ceiling and she has gotta a rash from that? She has touched the dry wall where the crack was several times. Deborah-no other symptoms are present. No dermatographism She does live in florida but there are no areas of a target lesion seen. Which is etiology for lyme disease. No dogs or cats. Rcdavis- Mites was also one of my first ddx's but it doesnt itch, and a lot of times mites end up in the creases of your bodies i.e. the folds of your hands.
akele7 Posted July 17, 2011 Author The rash first appeared that she noticed on the saturday of 4th of July weekend. Just steve--would the rash last that long if she had been exposed to urishol oils? She has no recollection of being in any areas with poison ivy etc. She has no Pets. I have also thought on the lines of fungal. She has mentioned a window that has been leaking her her apt for over 2 months. She lives in florida so I am wondering if mold is growing in the crack of the ceiling and she has gotta a rash from that? She has touched the dry wall where the crack was several times. Deborah-no other symptoms are present. No dermatographism She does live in florida but there are no areas of a target lesion seen. Which is etiology for lyme disease. No dogs or cats. Rcdavis- Mites was also one of my first ddx's but it doesnt itch, and a lot of times mites end up in the creases of your bodies i.e. the folds of your hands.
Just Steve Posted July 17, 2011 Urishol can last up to 14 days. Assuming the pics are recent, that rash doesn't look like it is in a waning stage so I have my doubts. For a reaction to mold, it's in a weird spot. From my understanding of mold complications, typically it is a systemic reaction due to inhaling it or aggressively handling it ie: remodeling the room. KOH makes a logical next step. After a bit of reading, it appears the Woods light does not fluoresce all types of fungus. again...newbie student...my thoughts are worth what you paid for them :-)
Just Steve Posted July 17, 2011 Urishol can last up to 14 days. Assuming the pics are recent, that rash doesn't look like it is in a waning stage so I have my doubts. For a reaction to mold, it's in a weird spot. From my understanding of mold complications, typically it is a systemic reaction due to inhaling it or aggressively handling it ie: remodeling the room. KOH makes a logical next step. After a bit of reading, it appears the Woods light does not fluoresce all types of fungus. again...newbie student...my thoughts are worth what you paid for them :-)
Joelseff Posted July 17, 2011 haha yes..I have. Still dx is unknown. Cool just makin sure! lol. I would do a trial of benadryl or topical steroid as has been suggested. If it's viral exanthem or allergic it should respond. At first glance it looks almost herpetic but does not follow dermatomal distribution. Point is you don't need to know what it is exactly to treat it sometimes. It doesnt really look like scabies either. My thought is allergic vs viral. What did your Preceptor say? BTW I SUCK at derm!!!! LOL
Joelseff Posted July 17, 2011 haha yes..I have. Still dx is unknown. Cool just makin sure! lol. I would do a trial of benadryl or topical steroid as has been suggested. If it's viral exanthem or allergic it should respond. At first glance it looks almost herpetic but does not follow dermatomal distribution. Point is you don't need to know what it is exactly to treat it sometimes. It doesnt really look like scabies either. My thought is allergic vs viral. What did your Preceptor say? BTW I SUCK at derm!!!! LOL
JFarnsworth Posted July 18, 2011 As I stated in your other post, do a KOH and a biopsy. I highly doubt that this is from mold, scabies, or a tick bite. It could be eczema. If it was viral then you'd expect it to be more widespread or in a dermotome distribution. As far as I know, poison oak reactions can take up to a month to manifest. She may have a delayed reaction. And it will itch like crazy. Does she have any other medical problems? Does she have seasonal or food allergies? Has she ever been patch tested? She could try Allegra or Zyrtec during the day as Benadryl can make her sleepy. TAC is a rather mild cream and if you rule out other things then I'd go with Lidex, 0.05% bid for 2 weeks and see how she does. You can also offer Kenalog 40 mg IM or a Pred taper. But since it doesn't itch, I don't know how effective any of it will be.
JFarnsworth Posted July 18, 2011 As I stated in your other post, do a KOH and a biopsy. I highly doubt that this is from mold, scabies, or a tick bite. It could be eczema. If it was viral then you'd expect it to be more widespread or in a dermotome distribution. As far as I know, poison oak reactions can take up to a month to manifest. She may have a delayed reaction. And it will itch like crazy. Does she have any other medical problems? Does she have seasonal or food allergies? Has she ever been patch tested? She could try Allegra or Zyrtec during the day as Benadryl can make her sleepy. TAC is a rather mild cream and if you rule out other things then I'd go with Lidex, 0.05% bid for 2 weeks and see how she does. You can also offer Kenalog 40 mg IM or a Pred taper. But since it doesn't itch, I don't know how effective any of it will be.
akele7 Posted July 18, 2011 Author We definitely think it is some type of contact dermatitis. We are having the patient wash all of her bed sheets and clothes since she went one time to a laundry mat to do her laundry. Also benadryl at night and hydrocortisone cream during the day. We will see where that takes us...
akele7 Posted July 18, 2011 Author We definitely think it is some type of contact dermatitis. We are having the patient wash all of her bed sheets and clothes since she went one time to a laundry mat to do her laundry. Also benadryl at night and hydrocortisone cream during the day. We will see where that takes us...
d2305 Posted July 19, 2011 May be neurodermatitis, the itch that rashes. The Pt may be scratching the lesion at night.
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