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Dermatitis


PICTURE QUIZ CLINICAL


Below are four types of dermatitis – diagnose each using the picture and case study 1 2


After presenting with subacute bowel obstruction, this man eventually had a laparotomy and ileostomy formation. He made a good recovery, but the incision was slow to heal and a large ulcer developed over his anterior abdominal wall. This was dressed regularly, but the adjacent skin became very red, with scale and pruritus.


3


This man, who was known to have advanced dementia, was referred with a longstanding ulcer on his scalp. He was resident in a nursing home and was otherwise well. He has a long history of male pattern baldness, but no history of any skin conditions in the past. The area had gradually increased in size over many months.


4


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After developing a red erythematous rash around her mouth, this 30-year-old lady visited her doctor and was diagnosed with infected eczema. She was treated with a combination of topical antibiotics and steroids. The rash became worse and so the strength of the steroid cream was increased and she was advised to use regular emollients. When it failed to improve she was referred to secondary care.


Answers


This man had had problems with dry scaly skin on his face and scalp since childhood. Although the rash cleared from time to time it always recurred and on this occasion was especially bad on his forehead. His father had also suffered with the condition and he reported a familial tendency to having greasy skin. His skin was usually better in the summer and worse in the winter.


Dr Nigel Stollery is a GPSI in dermatology in Kibworth, Leicestershire


Pulse February 2016 75


1 Contact dermatitis The perilesional eczema was the result of contact dermatitis from the dressings, which had been applied to the skin repeatedly over a prolonged period of time. He was referred for patch testing and this confirmed the diagnosis. Emollients and a topical steroid were prescribed and non- adhesive dressings used instead, and eventually the dermatitis and ulceration settled.


2 Dermatitis artefacta Initially this was thought to be a squamous cell carcinoma. A biopsy taken from the ulcer edge reassuringly showed no dysplasia or malignancy.


The diagnosis is dermatitis artefacta caused by repeated trauma from scratching and picking the skin. Treatment can be very challenging, especially in this location, when it is very difficult to keep the area protected with dressings.


3 Perioral dermatitis Perioral dermatitis is a common skin condition that mainly affects young women. It is often misdiagnosed as eczema and topical steroids prescribed in increasing strengths tend to make the condition worse. The affected area is usually itchy and patients often report a burning feeling. The treatment of choice is four to six weeks of an oral


antibiotic such as lymecycline, along with the avoidance of all steroid creams, emollients and make up. The condition often recurs.


4 Seborrhoeic dermatitis The cause of this isn’t completely understood. It is a chronic relapsing condition that affects the sebum-rich areas of the body such as the face, pre-sternal areas, groin and axillae. Treatment of choice is a combination of mild topical steroids and topical antifungal creams and shampoo to reduce the levels of malassezia on the skin. In more severe cases topical calcineurin inhibitors and keratolytics can be helpful.


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