A 19-year-old woman comes to the office due to a bothersome rash on her shoulders and upper arms for the last 5 years that is associated with significant itching during cold, dry weather. The patient says, "I had eczema when I was a baby that got better when I got older. I kept thinking this would go away too, but it just gets worse." Medical history is otherwise unremarkable, and she takes no medications. Skin examination findings are shown in the exhibit. Which of the following is the most appropriate next step in management of this patient's skin condition?

Question

A 19-year-old woman comes to the office due to a bothersome rash on her shoulders and upper arms for the last 5 years that is associated with significant itching during cold, dry weather.  The patient says, "I had eczema when I was a baby that got better when I got older.  I kept thinking this would go away too, but it just gets worse."  Medical history is otherwise unremarkable, and she takes no medications.  Skin examination findings are shown in the exhibit.  Which of the following is the most appropriate next step in management of this patient's skin condition?

Quizplus · Accepted Answer

Explanation: This patient has a papular rash consistent with keratosis pilaris (KP). KP ("chicken skin") is a benign condition characterized by retained keratin plugs in the hair follicles. It presents with small, painless papules, a roughened skin texture, and mottled perifollicular erythema. KP can occur anywhere but is most common on the posterior surface of the upper arm. It is usually asymptomatic but can become pruritic in cold, dry weather and can occasionally form small pustules. KP can occur alone or in association with atopic disorders (eg, atopic dermatitis, asthma). The diagnosis is typically obvious based on appearance; biopsy can reveal keratin plugs, dilated hair follicles, and a sterile lymphocytic infiltrate but is rarely needed for diagnosis (Choice D). Treatment, when necessary, includes emollients and topical keratolytics (eg, salicylic acid, urea), which can help soften the papules. (Choice A) Dermatitis herpetiformis is a skin disorder associated with celiac disease that generally improves with a gluten-free diet. It presents with intensely pruritic papules, vesicles, and bullae on the elbows, back, knees, and buttocks. (Choice B) HIV increases the risk for infectious skin diseases, such as molluscum contagiosum. Patients with HIV can develop numerous molluscum lesions, but these papules are smooth, firm, and umbilicated; would not be limited to the shoulders and arms; and usually resolve spontaneously. (Choice C) Oral minocycline is used for treatment of inflammatory acne, which presents with inflamed papules and pustules. Although the shoulders and upper arms can be affected, the central face is usually also involved. Educational objective: Keratosis pilaris is characterized by retained keratin plugs in the hair follicles. It presents with small papules; a roughened skin texture; and mottled, perifollicular erythema, most commonly on the posterior surface of the upper arm. Treatment includes emollients and topical keratolytics (eg, salicylic acid, urea).

A 19-Year-Old Woman Comes to the Office Due to a Bothersome