A 26-year-old woman comes to the office due to an intensely pruritic rash on her back that has been present for the past 24 hours. The rash developed shortly after the patient awoke from a nap and has been spreading. Other than the rash, she has no symptoms. The patient reports no changes in cosmetic products or detergents. She has not been ill recently and has never had a similar rash. The patient has no known chronic medical conditions and takes no medications or supplements. She is not sexually active, and her last menstrual period was 2 weeks ago. Vital signs are normal. Appearance of the skin on examination is shown in the exhibit. Oropharyngeal and cardiopulmonary examinations reveal no abnormalities. Heart and lung sounds are normal. Which of the following is the most appropriate next step in management?

Question

A 26-year-old woman comes to the office due to an intensely pruritic rash on her back that has been present for the past 24 hours.  The rash developed shortly after the patient awoke from a nap and has been spreading.  Other than the rash, she has no symptoms.  The patient reports no changes in cosmetic products or detergents.  She has not been ill recently and has never had a similar rash.  The patient has no known chronic medical conditions and takes no medications or supplements.  She is not sexually active, and her last menstrual period was 2 weeks ago.  Vital signs are normal.  Appearance of the skin on examination is shown in the exhibit.  Oropharyngeal and cardiopulmonary examinations reveal no abnormalities.  Heart and lung sounds are normal.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d218_7da5_bc81_4dc9974c88f1_MD0003_00 This patient has acute urticaria, intensely pruritic, well-circumscribed erythematous plaques (ie, wheals) caused by mast cell activation in the superficial dermis. Acute urticaria usually represents an IgE-mediated allergic reaction (eg, medication, insect bite, food); additional etiologies include infection (eg, bacterial, viral) and systemic illness (eg, rheumatologic disorder, mastocytosis). However, many cases are idiopathic. Initial management includes a second-generation H₁ blocker (eg, cetirizine). A single episode, such as this patient's presentation, typically requires no additional evaluation. Laboratory evaluation and biopsy are recommended when urticaria is unresponsive to therapy, exhibits atypical features (eg, purpura), or is accompanied by systemic symptoms (eg, arthritis, weight loss) (Choice C). (Choice A) Intramuscular epinephrine is indicated for treatment of anaphylaxis, a severe, multisystem hypersensitivity reaction. Although patients with anaphylaxis may have urticaria, they typically have abnormal vital signs (eg, hypotension) and extradermal (eg, respiratory, gastrointestinal) manifestations. Treatment for isolated urticaria does not require epinephrine. (Choice B) Serum IgE level is typically elevated in atopic dermatitis, which presents acutely with erythematous papules and vesicles, not wheals. Although acute urticaria is IgE mediated, the serum IgE level is not typically elevated. erythematous papules (Choice D) High-potency topical corticosteroids are used to treat plaque psoriasis, which presents with pruritic, erythematous plaques with silvery scales, which are absent in this patient. Lesions typically develop over time on the extensor extremities rather than abruptly throughout the back. erythematous plaques Educational objective: Initial management of acute urticaria includes a second-generation H₁ blocker (eg, cetirizine). No additional evaluation is needed for a single episode of urticaria, although laboratory evaluation and biopsy are recommended for episodes that are unresponsive to therapy, that exhibit atypical features, or that are accompanied by systemic symptoms. References: Acute and chronic urticaria: evaluation and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28671445)

A 26-Year-Old Woman Comes to the Office Due to an Intensely