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DERMATITIS Amimi Osayande, M.D DERMATITIS Amimi Osayande, M.D. Department of Family & Community Medicine History (Salient points): Duration? How did it look when it first appeared, and how is it now different? Location - Where did it first appear, and where is it now? Prior treatments and response? Associated symptoms, such as itching or pain? Are any other family members affected or have a similar history? History of similar rash in the past Is anything new or different, i.e. medications, personal care products, occupational or recreational exposures Any Chronic medical conditions? Current medications including over-the-counter and herbal therapies? What is the social history, including occupation, hobbies, travel, and new stressors? Does the patient have any underlying allergies? Physical exam to include: General Appearance - Healthy, Malnourished, acutely or chronically ill looking Complete skin exam describing: Type of lesion - (macules, papules, plaques, nodules, pustules, patches, vesicles, erosions, fissures, crust, excoriations, atrophy, petechiae, purpura, scars, ulcers, scales) Shape of individual lesions Arrangement of multiple lesions (e.g. scattered, grouped, linear, etc.), Distribution of lesions Color Texture Consistency or variations in lesions Diagnoses: Most Diagnoses can be made from a good history and thorough physical exam. Some common differential diagnoses based on type of lesions are listed below: - - Macules: drug eruptions, viral exanthem, syphilis, SLE, tinea versicolor, vitiligo, melasma, stasis dermatitis, Mongolian spots, Nevi, Post inflammatory, Cafe au lait spots. - Papules: actinic keratosis, basal cell carcinoma, acrochordon, keratoacanthoma, melanoma, warts, seborrheic keratosis, pyogenic granuloma, acne, drug eruptions, granuloma annulare, folliculitis, milaria, molluscum, scabies, syphilis, viral exanthem, lichen planus, pityriasis rosea. - Plaques: acanthosis, candidiasis, cellulitis, eczema dermatitis, lichen planus, lichen sclerosus, tinea, syphilis, lymes diseases, seborrheic dermatitis, Psoriasis. - Pustules: Acne, drug eruptions, pyoderma gangrenosum and most infectious disorders - furunculosis, folliculitis, disseminated gonorrhea, impetigo, pseudofolliculitis barbae, syphilis. - Vesicles/Bullae: burns, erythema multiforme, drug eruptions, contact dermatitis, impetigo, herpes zoster, staphylococcal scalded skin, toxic shock due to streptococcus, varicella, and toxic epidermal necrolysis. - Nodules: erythema nodosum, squamous or basal cell cancers, dermatofibroma, angioma, warts, pyogenic granuloma, melanoma, keloid, lipoma. - Other differentials could be based on location, or history. © 2010 The University of Texas Southwestern Medical Center at Dallas Dermatitis The University of Texas Southwestern Medical Center at Dallas Tests These are indicated when the cause of the skin lesion or disease is not obvious from history and physical exam alone. KOH exam for fungi, Skin scrapings, Woods light exam, Gram stain, Fungal and Bacterial cultures, Tzanck smear for Herpes, Blood tests (CBC, BMP, RPR, HIV, Hepatitis panel if immunosuppression is suspected), Diascopy – to differentiate vascular from avascular lesions (Microscope slide pressed against a lesion to assess for blanching) and Skin Biopsies. Approach to treatment: Directed at specified lesion(s). If diagnosis has not been established, medications should NOT be prescribed Infectious cause - antibiotics, antifungals, pediculocides and scabicides, Drug eruptions - Stop offending medication Other modalities – topical, intralesional or systemic steroids, soap free cleansers, lubricating agents, wet dressings, excision (with biopsy), immune modulators, protective barrier creams, and cryotherapy. Patient Education 1. Explanation of disease process 2. Emphasis on Compliance 3. Treatment goals and need for follow up 4. Lifestyle modifications to avoid triggers. 5. Proper hygiene 6. Control and treatment of other medical conditions contributing to the disease When to Refer If unable to establish a diagnosis Non response to treatment Skin disorders associated with major systemic involvement, or manifestations of internal disease Dermatologic emergencies – Toxic Epidermal Necrolysis, exfoliative dermatitis, urticarial angioedema, autoimmune bullous diseases When toxic medications are involved requiring close monitoring Lesions suspicious for neoplasia Lesions requiring allergy testing Follow up Generally within 1-2 weeks depending on severity of the condition References - UpToDate. Approach to dermatologic diagnosis. http://www.uptodate.com. - Merck Manual Professional. Diagnostic Tests. Approach to the dermatologic patient. http://www.merck.com. - Habif TP. Clinical dermatology. 4th ed. St Louis: Mosby; 2004. p.2, 23-30. Amimi Osayande, M.D. Assistant Professor, Family & Community Medicine Last Reviewed: February 2010 – 2 – .
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