A 34-year-old forest service firefighter comes to the physician with an itchy rash on both arms. The rash began as small red papules 3 days ago and subsequently developed yellow blisters. The lesions appear to be spreading to the adjacent skin. He has no fever, chills, or malaise. The patient has no significant past medical history and takes no medications. He has been sexually active with a new partner over the last 6 months and uses condoms. He rents an apartment with 2 friends and they share a bathroom.
A photograph of his arm is shown below.

Which of the following is the best initial treatment for this patient's condition?

Question

A 34-year-old forest service firefighter comes to the physician with an itchy rash on both arms.  The rash began as small red papules 3 days ago and subsequently developed yellow blisters.  The lesions appear to be spreading to the adjacent skin.  He has no fever, chills, or malaise.  The patient has no significant past medical history and takes no medications.  He has been sexually active with a new partner over the last 6 months and uses condoms.  He rents an apartment with 2 friends and they share a bathroom.
A photograph of his arm is shown below.

Which of the following is the best initial treatment for this patient's condition?

Quizplus · Accepted Answer

11ec193a_9778_174c_853d_5b55284adb0e_MD0002_00 This patient - with an itchy, red, vesiculo-bullous rash involving exposed skin - has typical features of allergic contact dermatitis. Streak lesions (arrows) suggest that the allergen was brushed across the skin and are characteristic of Toxicodendron dermatitis (poison ivy/poison oak), one of the most common causes of allergic contact dermatitis. Initial skin lesions begin at the area of heaviest plant contact and may continue to appear at distant sites for up to 21 days. Repeated exposure from residue on clothing or pets may create additional lesions. poison ivy/poison oak Washing the skin with soap and water within 2 hours after the exposure reduces the severity of dermatitis. As this is a delayed hypersensitivity reaction, treatment consists of corticosteroids. Topical mid- to high-potency corticosteroids are most effective for treatment of early disease. Oral prednisone (given at 1 mg/kg/day) may be considered for severe dermatitis, facial/periocular involvement with significant edema, or widespread disease for which topical therapy is impractical. Treatment should be continued for 2-3 weeks as rebound dermatitis may occur with shorter corticosteroid regimens. (Choice A) Acute tinea pedis may present as pruritic vesicles or bullae involving the feet, sometimes with secondary involvement of distant sites (dermatophytid reaction). The most common sites of involvement include the soles, midfoot, palms, and interdigital areas. Streak lesions are not typical. Acute tinea pedis (Choice B) Herpes zoster typically presents with painful vesicular lesions in a dermatomal distribution. Streak lesions and bilateral outbreaks are not consistent with zoster. Herpes zoster (Choice D) Secondary skin infections with Staphylococcus or Streptococcus species are not uncommon and occur in conditions such as eczema and contact dermatitis. Pain, pyoderma, and folliculitis are frequent indicators of secondary infection. Suspected secondary bacterial infections are treated with appropriate systemic antibiotics. (Choice E) Typical scabies lesions are small, erythematous, nondescript papules. They do not appear as blisters. Lesions are common in the web spaces of the fingers although they can be seen in other areas of the body. scabies Educational objective: Toxicodendron dermatitis (poison ivy/poison oak) is one of the most common causes of allergic contact dermatitis. Treatment includes topical mid- to high-potency corticosteroids for limited disease or oral corticosteroids for severe or widespread disease. Treatment should be continued for 2-3 weeks. __________ References: Treatment of toxicodendron dermatitis (poison ivy and poison oak). (http://www.ncbi.nlm.nih.gov/pubmed/11376396) Poison ivy, oak, and sumac dermatitis identification, treatment, and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/20086717)

A 34-Year-Old Forest Service Firefighter Comes to the Physician with an Itchy