Dermatology issues and clinical applications

Dermatology Differential Diagnoses

Dermatology Differential Diagnosis

Skin conditions can be notoriously difficult to diagnose. It is crucial to understand the epidemiology and pathology of common conditions in order to make a thorough diagnosis of the current case. Here, the research states that "key questions for the patient include the time of onset, duration, location, evolution, and symptoms of the rash or lesion. Additional information on family history, occupational exposures, comorbidities, medications, and social or psychological factors may be helpful" (Goldstein et al., 2012). All of this knowledge provided by the patient can ultimately help lead to differential diagnoses that can then prepare treatment.

In this current case study, there is a 33-year-old male suffering from a rash. The patient has a rash of 2-weeks duration located behind the knees and elbows bilaterally. It is itchy, red, somewhat raised, and dry. At times it has had clear drainage. Thus, the "papules are palpable, discrete lesions measuring ?5 mm diameter" (Goldstein et al., 2012). The primary lesions here are the most irritating. However, there is also redness and irritation as a secondary lesion. There has been no fever or chills, weight loss, and no CV/Resp/GI/GU symptoms. Based on these symptoms, the three differential diagnoses are atopic dermatitis, psoriasis, and contact dermatitis.

Atopic Dermatitis

This term actually covers a group of skin disorders that all share elements of the same symptoms. Thus, eczema is not technically a diagnosis in itself. In such cases, "the inflammatory process in eczema causes erythema of the skin as a result of dilated blood vessels that are surrounded by inflammatory cells that migrate into the epidermis, resulting in edema both inside and in between the epidermal cells" (Dunphy et al., 2011). What results are clear irritation, redness, and scaly skin that can last or quite some time. It is a result of "a superficial pathological process of the skin" (Dunphy et al., 2011). Even worse, it can be connected with the fact that the patients' rash is oozing. Here, the research explains that "early in its presentation, it is erythematous, with papulvesicular lesions that ooze and crust" (Dunphy et al., 2011). More acute cases show clear inflammation and are excoriated and macupapular. As it progresses, it becomes much more of a purple-red color "and develops scaling and lichenification" (Dunphy et al., 2011). All of these signs match with the redness of the patient's rash.

Atopic dermatitis begins to show up early on in life and then keeps coming back. It is actually quite common and "about 10% of the U.S. population will have atopic dermatitis at some point in their lifetimes" (Dunphy et al., 2011). According to the research, 5% of children have the skin condition, with about 40% of those individuals showing signs of the condition clearing up before they reach adulthood (Dunphy et al., 2011). The condition occurs equally in both genders. There is, however, evidence that family genetic history has a component. About two-thirds of all cases have some sort of family ties to the condition (Dunphy et al., 2011).

There are several known risks of exacerbating the condition. Stress is one of the biggest risks that can cause intense onsets of acute symptoms. Here, the textbook suggests that "Atopic patients are known to itch in seconds after experiencing a stressful event. Thus type of reaction is thought to be caused by a nueropeptide-induced vasodilatation, which produces a rise in skin temperature and erythema" (Dunphy et al., 2011). Clearly, stress is a major component that can lead to outbreaks and reoccurrences. Other lifestyle factors may include behaviors like excessive bathing, hand washing, licking of the lips, intense sweating and swimming (Dunphy et al., 2011). Moreover, there are also environmental factors that can contribute to outbreaks, including the presence of dust mites, animal dander, and pollen, various microbes, and also climate changes. Thus, "excessively hot or cold climates or excessively dry or moist environments are particularly suitable for setting the stage for the atrophic process" (Dunphy et al., 2011).

Several self-treatment methods can be recommended to help with the condition. Daily moisturizing is a huge factor that can help lead to the reduction of symptoms over time. Moreover, the use of petroleum jelly to prevent water loss from the skin has also proven effective (Dunphy et al., 2011). Cetaphil, Eucerinm and Unibase soaps are gentle enough not to cause further irritation. Finally, humidifiers can help dramatically in very dry, arid environments.

Pharmaceutical Preparations

There are a number of over the counter and prescription treatments for the condition. Topical solutions of Burow's solution, saline, and silver nitrate are often very successful in reducing symptoms (Dunphy et al., 2011). Moreover, systemic antihistamines and corticosteroids are a widely used treatment method for long-term prevention of future outbreaks as well. There is also Cyclosporine A, which is "an immunomodulatory drug" (Dunphy et al., 2011). Montelukast sodium is also suggested by the text. Finally, Omalizumab, "an anti-IgE antibody that has been developed as an immunotherapeutic has shown benefit in reducing atopy in highly allergic individuals and is available through referral to a specialist such as an allergist or pulmonologist" (Dunphy et al., 2011).

Health Promotion and Prevention Strategies

Patient education on the triggers of the condition is necessary for prevention. Stopping excessive bathing is one activity that is actually not often understood by patients. Moreover, "minimizing contacts with cosmetics, deodorants, detergents, and solvents should be stressed" along with the use of daily moisturizers (Dunphy et al., 2011).

Psoriasis

Symptom Evaluation

Psoriasis is a skin condition that often occurs later in life. According to the text, it "is a chronic relapsing disorder of keratin synthesis that is characterized by well-circumcised, raised, erythematous papules and plaques, covered with silvery-white scales, usually involve extensor areas in adults such as the elbows and knees, the scalp," and elsewhere around the body (Dunphy et al., 2011). It includes ongoing outbreaks of scaly, dry skin. Unfortunately, "Psoriasis is a common chronic skin disorder typically characterized by erythematous papules and plaques with a silver scale, although other presentations occur" (Feldman et al., 2014). Most common are the plaques that are often raised. This matches with the symptoms of the patient's rash. In this case, "plaques are large (>5 mm) superficial flat lesions, often formed by a confluence of papules" (Goldstein et al., 2012). The condition is caused by abnormal skin functioning. The research suggests that "the typical clinical findings of erythema and scaling are the result of hyperproliferation and abnormal differentiation of the epidermis, plus inflammatory cell infiltrates and vascular changes" (Feldman et al., 2014). It is an immune-mediated condition, thus its links to stress and other environmental factors. Secondary lesions include scales, which "describes superficial epidermal cells that are dead and cast off from the skin" (Goldstein et al., 2012).

Psoriasis is often more common in adults than in younger patient populations. Here, the research suggests that "the prevalence of psoriasis in adults ranged from 0.91 to 8.5%, and the prevalence of the disease in children ranged from 0 to 2.1%" (Feldman et al., 2014). The condition is found in adults much more than in children. Moreover, there does not seem to be a correlation with gender, meaning that both male and females tend to have the condition at similar rates. Oddly enough, "geographic location appeared to influence the likelihood of having psoriasis; disease prevalence tended to increase with increasing distance from the equator" (Feldman et al., 2014). Thus, individuals further away from tropical areas tend to show higher incidences of the condition. Moreover, temperature is a factor as well. Therefore, "patients with psoriasis tend to show improvement in summer months, likely due to greater exposure to ultraviolet radiation from sunlight and perhaps to increased relative humidity" (Feldman et al., 2014).

The most common type is plaque psoriasis. This is found typically near where the patient's rash is. According to the research, "one population-based study found that plaque psoriasis accounted for approximately 80% of cases of psoriasis in adults and approximately 75% of cases of psoriasis in children" (Feldman et al., 2014). Patients typically see symptoms starting as teenagers or young adults and then symptoms grow in intensity as they age. Eventually, "patients with plaque type psoriasis usually present as young adults with symmetrically distributed plaques involving the scalp, extensor elbows, knees, and back" (Feldman et al., 2014). In this current analysis, the patient has a dry rash located behind the knees and elbows bilaterally. Thus, these symptoms are consistent with the symptoms seen in plaque psoriasis.

Risks

The primary risk for contracting the skin condition is genetics. Thus, "approximately 40% of patients with psoriasis or psoriatic arthritis have a family history of these disorders in first degree relatives" (Feldman et al., 2014). Genetics is thus the biggest risk. If there are direct family members with the condition, the rates of incidence go much higher. Still, there are also external environmental and lifestyle factors that can increase the risk of an individual experiencing the condition. According to the research, "Numerous potential "triggers" for psoriasis have been identified, such as infection, physical or psychological stress, and medications; however, they are not common to every patient" (Feldman et al., 2014). Smoking and excessive alcohol consumption is also typically considered as risk factors. Vitamin D deficiencies are also known to be related to the condition. This is one of the newest established risk factors. Here, the research suggests that "a case-control study that compared 43 patients with psoriasis and 43 matched controls with other non-photosensitive dermatologic diseases found that serum levels of 25-hydroxyvitamin D were significantly lower in the patients with psoriasis even after adjusting for factors such as Fitzpatrick skin phototype (table 1) and estimated sun exposure" (Feldman et al., 2014). Finally, certain drugs can worsen psoriasis symptoms. Bacterial and viral infections may also increase risk.

Self-Treatment Methods

For most patients with psoriasis, home treatments are preferred. Thus, outpatient treatment options are most common. According to the research, "an alternative to office-based phototherapy is the use of a home ultraviolet B (UVB) phototherapy unit prescribed by the treating clinician. This option may be preferred by patients who are not in close proximity to an office-based phototherapy center, whose schedules do not permit frequent office visits, or for whom the costs of in-office treatment exceed those of a home phototherapy unit" (Feldman et al., 2013). This may seem a bit excessive, but for long-term sufferers, it can help make life much easier.

Pharmaceutical Preparations

There are also a number of treatments associated with physicians as well. Essentially, "treatment modalities are chosen on the basis of disease severity, relevant comorbidities, patient preference (including cost and convenience), efficacy, and evaluation of individual patient response" (Feldman et al., 2013). There are over the counter methods like corticosteroid creams. Prescription NSAIDs are also commonly used to treat the condition (Dunphy et al., 2011). Additionally, "topical therapy may provide symptomatic relief, minimize required doses of systemic medications, and may even be psychologically cathartic for some patients" (Feldman et al., 2013). Topical corticosteroid creams and anthralin and other tars are also commonly used (Feldman et al., 2013). Physicians may insist on oocclusion therapy, where the skin is wrapped up after the topical creams are applied so that they can better soak into the deeper layers of the skin (Feldman et al., 2013). Ultra violet light therapies can also provide relief. Systemic methods are often only use din the most severe cases. Thus, "severe psoriasis requires phototherapy or systemic therapies such as retinoids, methotrexate, cyclosporine, or biologic immune modifying agents. Biologic agents used in the treatment of psoriasis include the anti-TNF agents adalimumab, etanercept, and infliximab and the anti-IL-12/23antibody ustekinumab. Improvement usually occurs within weeks" (Feldman et al., 2013).