Patient information: L.D., a 15-year-old Caucasian male.
- Chief Complaint: Rash on the elbow folds, wrists, under the knees that itch throughout the day and night
- History of present illness: The patient, 15-year-old Caucasian male, came with his mother with a chief complaint of an itching rash. It started spreading and influencing the patient’s life quality for the last 7 days. The patients cannot connect the rash worsening with any issues; however, the mother notices an elevated level of the stress connected with schoolwork. The mother also stated the patient has had atopic dermatitis from 5 years old with periodical aggravations once per year.
- Location: wrists, elbow bends, and under the knees
- Onset – 7 days ago
- Character: itching throughout the day
- Associated signs and symptoms: lichenification of the lower lid (Dennie-Morgan fold), excoriations predominantly on elbow bends, bloody crusts on wrists
- Timing: rash got worse after stress connected with a school assignment
- Exacerbating/relieving factors: tablets of Loratadine 10 mg decreases itching but does not last through all night
- Severity: 5/10
- Current medication: 1 pill of Loratadine (10 mg) per os. No other current or permanent medication intake.
- Allergies: Plant pollen, tree pollen, animal dander, citrus fruits: sneezing, redness of sclerae, hayfever.
- Past Medical History: Vaccines: HepB (2007), DTaP, Tdap (2013), Hib (September 2020), IPV, PCV, MMR (2011). PMI: tonsilitis (October 2020). Appendectomy 2018.
- Social & Substance History: Studies in 9th grade, good performance at school. Relationship with family and peers: well. Plays volleyball, likes mathematics and history. Denies smoking or alcohol intake. Lives in an apartment with his mother.
- Family History: His younger sister has allergies to animal dander and dust. Grandmother from mother’s side has bronchial asthma.
- Mental History: No history of depression or anxiety. Lately struggles with sleep and stress.
- Violence History: Not known
- Reproductive History: Not sexually active.
Review of Systems:
- General: Weight is stable, no temperature deviations, weakness, or fatigue.
- Heent: Eyes: Vision functions are symmetrical, no blurred vision, double vision, sclerae are clear. Ears, nose, throat: Hearing is bilateral, no runny nose, sore throat, sneezing, or congestion.
- Skin: Red and Rose rash on the elbow bends, wrists, and under knees that itches throughout the day and night. Dennie-Morgan folds on the lower lids. Skin is generally pale and dry.
- Cardiovascular: No chest pain, pressure, or discomfort. No visual palpitations, extremities have no signs of edema.
- Respiratory: Breathing is calm, not shortened, with no sounds, no cough, or sputum.
- Gastrointestinal: No signs of weight loss, vomiting, or diarrhea. No abdominal pain before or after food, no heartburn, no blood in the stool.
- Genitourinary: Urination is painless, 3-4 times per day. Genitals with no visual signs of anomalies. Not sexually active.
- Neurological: No headache, no history of trauma, dizziness, syncope, paralysis, ataxia, aphasia, dyslexia, numbness in the extremities.
- Musculoskeletal: Muscle contraction is symmetrical, no cramping, no muscle pain, no back or joint pain.
- Hematologic: No dizziness, anemia, no bleeding, no bruising.
- Lymphatics: Lymphatic nodes are not enlarged
- Psychiatric: No history of depression or anxiety. Psychological issues: Sleep distribution, stress.
- Endocrinologic: No signs of heat intolerance. No known history of polyuria or polydipsia. No growth and development issues.
- Reproductive: Not sexually active.
- Allergies: No signs of asthma, has Season-dependent episodes of hayfever; Food allergies, allergies on animal dander.
- General: Vital signs height 66.14 in, weight 132.5 lbs, BMI 21.3 (Healthy weight), BP 123/63 mmhg, temperature 97.80 f, pulse 61 beats/Min.
- Heent: Eyes: Perrl, conjunctivae, sclera clear. Tms normal bilaterally. Tonsils & pharynx: Clear.
- Skin: Red and Rose round macules, papules, and plaques, excoriations, crusts of red-brown color, regions of lichenification, dennie-Morgan folds on the lower lids, elbow bends, wrists, under knees. White dermographism. The skin out of the rash locations is generally dry and pale.
- Cardiovascular: Heart sounds S1, S2 normal; No S3, no S4, no murmurs.
- Respiratory: Chest exam reveals good air entry bilaterally. Clear to ippa with no adventitious sounds heard.
- Gastrointestinal: Abdominal exam reveals positive bowel sounds, soft, non-tender to palpation in all quadrants. Normal active bowel sounds.
- Genitourinary: Urination is painless, 3-4 times per day. Not sexually active.
- Neurological: Neurologic exam is unremarkable; The patient is alert and appropriate for age.
- Musculoskeletal: No deformities, full range of motion.
- Lymphatics: Peripheral nodes are not palpated, painless.
- Endocrinologic: Thyroid gland is not palpated.
The diagnosis of atopic dermatitis is usually based on several factors. The patient has a family history of atopy, comorbidities with environmental allergies, and food allergies (American Academy of Dermatology Association, 2021).
Priority diagnosis in this clinical case is atopic dermatitis (ICD-10 L20.0) as the patient has a previous history of the disorder and the worsening of the rash is connected with stress. According to the Hanifin and Rajka criteria, the patient has all the major signs of the disorder: pruritus, typical localization of the lesions, flexural lichenification, personal and family history of atopy, chronic relapsing (Medscape, 2021). Among minor criteria: Dennie-Morgan infraorbital folds, hand dermatitis, food intolerance, white dermographism, and xerosis (Medscape, 2021).
- Allergic contact dermatitis (ICD-10 L23.0). The pathology usually develops after some chemical agent contacts the skin that leads to a specific hypersensitivity of type IV (Nassau & Fonacier, 2020). The patient has no history of contact with any chemicals and possible allergic factors influencing the skin. Moreover, the charactered lesions for allergic dermatitis are vesicular, and the patient has no cavitary elements and no signs of oozing.
- Scabies (ICD-10 B86.0). A contagious skin disease caused by Sarcoptes scabiei that has multiple skin lesions and more intense itching at night (Thomas et al., 2019). The most frequent localizations are fingers, volar wrists, elbows, buttocks, and genitalia. The current case has no signs of increased itching at night, almost no typical localization of the lesions, and no history of similar symptoms of the patient’s family members.
- Psoriasis (ICD-10 L40.0). The chronic multisystem disorder with a complex pathogenesis may be initiated by stress factors or other environmental factors (Rousset & Halioua, 2018). The lesions are primarily papular with desquamation on the surface. The most common locations are the hairy part of the head (rash might go further the border of hair and forehead), elbows, knees, and places of most common trauma (Koebner symptom). The patient has different locations of the rash and no family history of psoriasis.
Treatment: non-pharmacological step 0 – diet and hypoallergenic environment. Base therapy: moisturizers La Roche Posay Lipikar AP + daily 4-5 times per day. To reduce itching, Cetirizine 10 mg 1 pill per day in the morning and 1 pill of Clemastime 1.34 mg before sleep until the pruritus disappears (1st and 2nd generation treatment). Cream with mometasone furoate 1% on all the lesions (except face) 1 per day for 14 days. Psychologist consultation to reduce the stress factor.
Due to this assignment, I have learned three various diagnoses that have different pathogenesis and clinical picture. During the patient’s examination, my “aha” moment was the facial signs of atopic dermatitis and the classical localization of lesions. The mother provided more specific information on HPI and a possible stress factor. This can be explained by the specialties of teenagers’ psychology and their different perceptions of their issues and condition. The patient seemed a responsible student having the stress factor because of the schoolwork. In a similar patient evaluation, I would be more accurate with examining teenagers as they are more sensitive to personal questions and doctor examinations.
American Academy of Dermatology Association. (2021). Atopic dermatitis clinical guideline.
Medscape. What are the Hanifin and Rajka diagnostic criteria for atopic dermatitis (AD)? (2021).
Nassau, S., & Fonacier, L. (2020). Allergic contact dermatitis. The Medical clinics of North America, 104(1), 61–76.
Rousset, L., & Halioua, B. (2018). Stress and psoriasis. International Journal of Dermatology, 57(10), 1165-1172.
Thomas, C., Coates, S. J., Engelman, D., Chosidow, O., & Chang, A. Y. (2019). Part I – Ectoparasites: Scabies. Journal of the American Academy of Dermatology, 82(3), 533-548.