Differential diagnoses for atopic dermatitis, psoriasis, and contact dermatitis

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

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).

Health Promotion and Prevention Strategies

Health education is key to identify risk factors in patients' lives. Stress reduction is one of the key elements to help manage outbreaks. Also, Vitamin D supplements are useful for long-term prevention methods. It is important to stress patient education about changing lifestyle choices to reduce to risk of triggers (Dunphy et al., 2011).

Contact Dermatitis

Symptom Evaluation

This condition is a rash resulting from contact with some form of allergen or irritant. Essentially, "the cardinal symptom of contact dermatitis is a pruritic erythematous rash" (Dunphy et al., 2011). This rash often comes on quite quickly after the stimulus is introduced to the skin, with inflammation occurring within 6 to 12 hours of exposure. There are clear formation of papules and scaling skin as well as "clear fluid vesicles or bullae" (Dunphy et al., 2011). This matches with the patient's rash within this current case study. Skin reactions to environmental allergens and substances typically include reactions to antihistamines, anesthetics, hair dyes, latex, and other elements. Also naturally occurring elements like pollen, ragweed, and pet dander can cause condition symptoms.

Those with higher levels of allergens are most vulnerable. Still, "contact dermatitis accounts for 4 to 7% of all dermatology consultants" (Dunphy et al., 2011). White Americans seem to be the most vulnerable population. Moreover, females have higher rates over males, which make this a lesser chance for the current patient, who is a male. Apparently, 20% of females will experience this at one point or another in their lives, especially on the hands (Dunphy et al., 2011). Thus, "women are twice as men to develop dermatitis and are at highest risk after childbirth" (Dunphy et al., 2011). Risks include the fact that some patients may not have recognized previous outbreaks before. Thus, "often, the patient is not ware of a previous history, but there may have been periodic episodes of pruritic rash that resolved spontaneously" (Dunphy et al., 2011). Moreover, exposure to cosmetics and other chemicals can also increase risk.

Pharmaceutical Preparations

Over the counter creams are often most widely used because of the short duration of symptoms. This often includes Calamine lotion. Prescription of topical steroids is also common. Systemic treatments include oral steroids that will help relieve symptoms in 12 to 14 hours (Dunphy et al., 2011).

Health Promotion and Prevention Strategies

Allergy testing and patient awareness of their skins' reaction to certain chemicals or substances is key for prevention. Patients need to be aware of what chemicals and substances they use in order to detect what possibly might be causing the reaction.