Value: Complete/Incomplete (100 points is Complete and 0 is Incomplete)
Due: Day 7
Gradebook Category: Other Assignments
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Differentials
1. Contact Dermatitis. There are two types of contact dermatitis- irritant and allergic (Dunphy et al., 2019). Allergic contact dermatitis is when the skin manifestations are immunologically mediated, and irritant contact dermatitis is due to repeated exposures to caustic, irritant, or detergent-type substances (Dunphy et al., 2019). Irritant contact dermatitis is a very pruritic and erythematous rash (Dunphy et al., 2019). The family stated having a new dog and using a new laundry detergent. Both of these new exposures, paired with the patient’s history of recurrent skin infections, and asthma could account for a contact dermatitis diagnosis. The locations of his rashes are what would deter me from making this diagnosis. His rash locations are more concurrent with atopic dermatitis, and there is a significant history.
2. Atopic dermatitis. This is the most likely diagnosis because of his age, and the common places where atopic dermatitis is found on children: antecubital fossae and popliteal fossae (Dunphy et al., 2019). Another physical manifestation common in atopic dermatitis in this patient is the Dennie-Morgan lines. These lines appear in the infraorbital folds and are caused by edema (Dunphy et al., 2019). He is likely in the “subacute” stage of atopic dermatitis as evidenced by scaly, excoriated rash areas that are intensely pruritic, with papules or plaques over reddened areas (Dunphy et al., 2019). This stage can result in secondary infection (Dunphy et al., 2019).
3. Impetigo. Impetigo can result in children with underlying eczema issues (Baddour, 2022). Impetigo usually occurs in warm, humid conditions, which could likely be the case with this patient since he is having a seasonal flare (Baddour, 2022). He has lesions on his left elbow. Staphylococcus aureus is the most common pathogen seen with impetigo, that are “crust-like” and oozing. Non-bullous impetigo appears as papules, vesicles, and pustules that break down to a golden crust and are typically on the face or extremities (Baddour, 2022). This can be diagnosed by the clinical manifestations and performing gram stain and culture of the pus or exudate (Baddour, 2022). First-line treatment for localized impetigo is a topical antibiotic ointment like mupirocin (Baddour, 2022). Apply 3 times per day for 5 days (Baddour, 2022).
4. Scabies. Scabies is a mite infestation that occurs a lot in children, and manifests as generalized intractable pruritus (Dunphy et al., 2019). Patients usually complain of intense itching that is worst at night (Dunphy et al., 2019). The patient’s parents said his itching is worst at night. However, scabies is highly contagious and both mothers have said they do not have anything like what he is experiencing and they do not know anyone close to him with similar symptoms. The areas he has rash are also not consistent with scabies, which are usually found on the web spaces, wrists, anterior axillary folds, periumbilical skin, pelvic girdle, penis, and ankles (Dunphy et al., 2019).
Final Diagnosis: Atopic dermatitis
Plan
Pharmacology:
• Petroleum jelly (no fragrance) applied liberally to affected areas 3-4 times daily (Spergel & Lio, 2022).
• Triamcinolone acetonide (Kenalog) 0.1% ointment diluted for wet wrap therapy. Apply 1-2 times daily for up to 10 days, you do not have to apply for an entire 10 days. Leave wet wrap on for up to 2 hours, or as long as tolerated, overnight if comfortable. If not tolerated well, apply wet wraps with corticosteroid for 15-30 minutes 2-3 times per day (Spergel & Lio, 2022). Once flare subsides, continue with just the topical ointment twice daily for 14 days, then use intermittently (2 days, then every other day) to prevent exacerbations during this time of year (Spergel & Lio, 2022).
Nonpharmacological:
• Limit baths to every other day
• Cetaphil for bathing
• Aveeno oatmeal baths
• Emollient (petroleum jelly) for prevention of flares (Dunphy et al., 2019).
Diagnostics:
• Patch testing to rule out possible allergens in current therapies (Spergel & Lio, 2022).
• Skin prick testing – to test for other possible food and environmental allergies causing flare during this seasonal occurrence (Spergel & Lio, 2022).
• Viral culture- this can be done to rule out a viral etiology contributing to the flare (Dunphy et al., 2019).
• RAST test- radioallergosorbent test, can be done to identify if there is allergen-specific mast cell activation or to quantify levels of IgE (Dunphy et al., 2019).
Referrals:
• Dermatology
• Allergist (Dunphy et al., 2019).
Patient education:
• Do not take showers/ baths daily. This can have the opposite effect of what is desired and dry the skin out more. Baths wash away the protective oils on our skin that hold onto moisture (Dunphy et al., 2019).
• Instead of using soap to clean when bathing, use an emollient-based substitute called Cetaphil (Dunphy et al., 2019). You can find this product OTC and in most grocery stores.
• When he does bathe, do soaking baths with water that is not too hot. Keep the bath short.
• Do not use soaps, detergents, or lotions/moisturizers with fragrance coloring agents, or perfumes (Dunphy et al., 2019). These can irritate healthy skin as well as the areas where lesions are present.
• Apply moisturizer as soon as he gets out of the bath. Only pat dry the skin partially drying. Leaving moisture on the skin and applying moisturizer while the skin is still damp will help increase absorption of the moisturizer (Dunphy et al., 2019).
• Apply the corticosteroid to the lesions after the moisturizer; this will help increase absorption and effectiveness of the steroid (Dunphy et al., 2019).
• Colloidal oatmeal baths (Aveeno) can help soothe the itching and inflammation (Dunphy et al., 2019).
• Limit antihistamine use to nighttime. This can help with sleep and will not make him drowsy throughout the day (Dunphy et al., 2019).
• Flare’s make him more susceptible to secondary bacterial infections, so he may need to be treated with erythromycin if he shows any signs of infection (purulent drainage, increasing redness, fever) (Dunphy et al., 2019).
• He should stop taking any Benadryl and Zyrtec two weeks prior to doing allergen skin testing because these will interfere with the result of the skin test (Dunphy et al., 2019).
• Do not go for allergy skin testing until this current flare is over (Dunphy et al., 2019).
Follow-up:
• Follow up in 10 days to ensure that flare is resolving (Dunphy et al., 2019). Follow-up in the clinic sooner if you notice any signs and symptoms of infection or the flare seems to be worsening.
Health maintenance item: Skin hydration is the most important prevention tool you have in preventing future flares. Be sure to use emollients, year-round, as these will help the kid lock in moisture and your body’s nature oils to keep the skin well hydrated (Dunphy et al., 2019).
Social determinant of Health: Sometimes going from household to household, a child can experience differences in parenting and therefore treatment may differ between his moms, and his dad. To avoid any issues with noncompliance with treatment regimen, it would be important for the provider to speak with all parents about the best way to care for their son’s skin issues and talk about the limitation of allergic and environmental exposures that could be contributing to flares.
References
Baddour, L. M. (2022). Impetigo. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/impetigo?search=impetigo&source=search_result&selectedTitle=1~142&usage_type=default&display_rank=1#H1111243
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care: The Art and Science of Advanced Practice Nursing-An Interprofessional Approach. (5th ed.). F. A. Davis.
Spergel, J. M., & Lio, P. A. (2022). Management of severe atopic dermatitis (eczema) in children. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/management-of-severe-atopic-dermatitis-eczema-in-children?search=atopic%20dermatitis%20treatment&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
