A 35-year-old woman comes to the physician for evaluation of a rash on her hands. She noted the onset of periungual swelling around all her fingers 2 weeks ago. She subsequently developed a rash with stinging pain and burning on some of her fingertips. The patient has worked as a manicurist for the past 10 years and has worn artificial nails intermittently for the past 2 years. She has a history of hypothyroidism and gastroesophageal reflux disease. Her medications include omeprazole and levothyroxine. She has no history of tobacco or alcohol use.
Vital signs are within normal limits. Skin examination of the fingers reveals mild warmth, edema, and tenderness to palpation. There are also fissures at the distal fingers. Neurological examination shows decreased sensation at the patient's fingertips. The remainder of her physical examination is normal.
Which of the following is the most likely diagnosis?

Question

A 35-year-old woman comes to the physician for evaluation of a rash on her hands.  She noted the onset of periungual swelling around all her fingers 2 weeks ago.  She subsequently developed a rash with stinging pain and burning on some of her fingertips.  The patient has worked as a manicurist for the past 10 years and has worn artificial nails intermittently for the past 2 years.  She has a history of hypothyroidism and gastroesophageal reflux disease.  Her medications include omeprazole and levothyroxine.  She has no history of tobacco or alcohol use.
Vital signs are within normal limits.  Skin examination of the fingers reveals mild warmth, edema, and tenderness to palpation.  There are also fissures at the distal fingers.  Neurological examination shows decreased sensation at the patient's fingertips.  The remainder of her physical examination is normal.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's presentation is consistent with allergic contact dermatitis (ACD), most likely due to artificial nails. ACD is a delayed hypersensitivity response to exogenous agents such as latex, nickel, soaps/cleaning agents, cosmetic products, rubber, and formaldehyde. Artificial nails often contain formaldehyde and acrylates. ACD to artificial nails can occur in both manicurists applying the nails and customers receiving them. Clinical findings can include periungual edema or eczema, nail dystrophy, periungual hyperkeratosis, fingertip dermatitis, and paresthesias. Diagnosis is usually based on clinical findings, but some cases may require skin biopsy and/or patch testing for confirmation. Symptoms usually improve with removal of the artificial nails. (Choice A) Acute paronychia is a bacterial infection (most commonly Staphylococcus aureus) of the nail fold and surrounding tissues. Clinical findings include swollen and tender nail folds (posterior or lateral), often with a purulent fluid collection. Paronychia would not cause symmetric involvement of multiple nails. Acute paronychia (Choice C) Distal subungual onychomycosis typically presents with nail discoloration (white, yellow, or brown), thickening, and deformity. However, it is not usually associated with paresthesias or fissures as seen in this patient. (Choice D) Herpetic whitlow is due to inoculation of the herpes virus into broken skin. Patients typically develop tingling and burning of the hand associated with a vesicular rash. The absence of the typical vesicular rash in this patient makes herpetic whitlow unlikely. Herpetic whitlow (Choice E) Psoriasis of the nail can present with nail plate pitting, nail bed salmon patches, and onycholysis (distal separation of the nail plate from the inflamed underlying nail bed). Psoriasis of the nail Educational objective: Allergic contact dermatitis is a delayed hypersensitivity response to an exogenous agent. Clinical findings in contact dermatitis due to artificial nails can include periungual edema or eczema, nail dystrophy, periungual hyperkeratosis, fingertip dermatitis, and paresthesias. __________ References: Allergic contact dermatitis from acrylates in artificial nails. (http://www.ncbi.nlm.nih.gov/pubmed/15573650) Contact and primary irritant dermatitis of the nail unit diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/17403259)

A 35-Year-Old Woman Comes to the Physician for Evaluation of a Rash