mystery of a rash
TRANSCRIPT
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Daniel Tawfik, MD, PGY-3
6 November 2013
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8yo boy with 4 weeks of rash 4 weeks ago:
Erythematous, pruritic rash began over right shin.
One day later, also noted similar rash on left shin.
Slowly worsening pruritis.
2 weeks ago: Noted rash spreading to trunk, extremities, groin, and
buttocks. Saw PCP, started on Triamcinolone cream and Cetirizine. Mild
benefit noted, but stopped after 2 days.
Continued worsening pruritis and spread of rash.
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PMH: Epidural hematoma 4 years ago afterfalling down stairs
Meds: none FHx: Brother with eczema SHx: Lives with parents and 3 siblings Imms: up to date except influenza Allergies: NKDA
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VITALS: Temperature 36.5, HR 92, RR 16, weight of 23.1 kg. GENERAL: awake, alert, attentive, well-appearing. HEENT: Tympanic membranes normal. Oropharynx normal. No lesions noted
in the mouth, nares, or the conjunctival region. No conjunctival injection. NECK: No lymphadenopathy of the neck. CARDIOVASCULAR: S1 and S2 are normal without murmur, gallop, click, or rub. RESPIRATORY: Lungs are clear to auscultation throughout without rhonchi,
wheezes, grunting, retractions, or nasal flaring. GASTROINTESTINAL: Abdomen is soft and nontender without rebound,
guarding, or masses. Bowel sounds are normal. There is no organomegaly. EXTREMITIES: Warm and well perfused. DERM: Well-demarcated erythematous scaly plaques on the bilateral shins
with overlying yellow-colored crusting. Numerous pink scaly papules and
plaques scattered on the neck, chest, abdomen, back, and bilateral upper andlower extremities, many with overlying hemorrhagic crusts.
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Derm Allergic contact
dermatitis
Irritant contact dermatitis Atopic dermatitis Nummular dermatitis Bullous pemphigoid Photosensitivity
Stasis dermatitis Linear IgA Dermatosis Dermatitis Herpetiformis Granuloma annulare
ID Mycosis fungoides Scabies
Cutaneous tuberculosis Viral exanthem Gianotti-Crosti Syndrome
Heme/Onc Cutaneous T-cell
Lymphoma Other
Drug eruption
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Overview Response to an exogenous agent
Nickel, ammonium, gold, thimerosal, p-toluenediamine (hair
dyes), poison ivy, poison oak, poison sumac T-cell mediated delayed-type hypersensitivity
reaction Common association with atopic dermatitis
Erythematous plaques and pruritis most prominent Also edema, vesiculation, bullae
Usually confined to area of contact with allergen May spread by secondary transfer
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Acute, pruritic dermatitis Distant from initial focus
Pathogenesis not fully understood May be due to cytokine effect
May be due to dissemination of antigen
Treatment similar to ACD
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Avoidance of offending agent! Topical corticosteroids
First line treatment
Treat similar to atopic dermatitis
Example: Triamcinolone 0.1% ointment BID Topical calcineurin inhibitors
For failure of topical steroids or if on face/intertriginous areas
Slower onset than steroids, and may cause burning/stinging
Example: Tacrolimus 0.1% ointment BID Topical symptomatic relief
May reduce itching and discomfort
Examples: calamine lotion, oatmeal compresses, oatmeal baths Topical emollients
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Systemic corticosteroids If involving >20% of body surface area If quick relief is needed (face/hands/feet/genitalia involvement)
Systemic antibiotics If evidence of secondary bacterial infection
Systemic symptomatic relief Primarily target pruritis Examples: Cetirizine, Diphenhydramine
Systemic immunosuppression Rarely needed May be needed if allergen avoidance is impossible (aeroallergens or
photodermatitis) Examples: Azathioprine, Mycophenolate mofetil, Cyclosporine
Phototherapy Psoralen+UVA (PUVA) or narrow-band UVB If chronic dermatitis unresponsive to topical/oral steroids
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Acute treatment Avoid shin guards responsible for rash Triamcinolone 0.1% ointment BID to trunk and
extremities Cetirizine 5mg PO daily Diphenhydramine 25mg PO qHS Cephalexin 30 mg/kg/day PO divided TID for 10 days
Bathe in lukewarm water, pat skin dry, andimmediately moisturize with Eucerin cream, 1-2 timesper day
Bleach baths 2x/week (1/4 cup to half bath or 1/2 cupto a full bath)
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1 week later Had not taken full course of topical steroid or
antibiotics
Still with diffuse rash
Started Prednisolone 24mg PO daily x 7 days
Restarted Cephalexin x 10 days
Restarted Triamcinolone ointment Continued Cetirizine
Continued Diphenhydramine