Author: V. Dimov, M.D., Fellow, Creighton University Division of Allergy & Immunology
Reviewer: S. Randhawa, M.D., Fellow, LSU (Shreveport) Department of Allergy & Immunology
A 27-year-old female is self-referred to our clinic for evaluation of skin rash, maculopapular and pruritic which affects both hands, forearms, and the lower portion of her neck. She has had the rash for four months.
She works as a manual laborer at a parcel courier service, moving boxes. Apart from the rash, she does not report any other symptoms. The skin rash started 4 months ago. She is not on any medications and does not have any significant past medical history.
She wants to have "skin prick testing done for allergies."
The physical examination is positive for maculopapular rash and xerosis affecting both hands, forearms, and the lower portion of the neck.
What is the most likely diagnosis?
This is a patient with contact dermatitis which is most likely of irritant etiology. It is likely that her hands are in contact with the irritant substance and then she gets lesions wherever she scratches her skin with the contaminated hands, mostly on the forearms and lower portion of the neck.
What treatment would you suggest?
We prescribed prednisone 40 mg po daily for 5 days and hydrocortisone 1% ointment daily for 7 days and also we advised her to use skin moisturizers twice a day.
What did we learn from this case?
The occurrence of a rash on the neck and forearms does not mean that the rash originated there. Often, in the case of irritant allergic dermatitis, the irritant substance on the person's fingers and nails can cause a rash wherever they touch their skin or scratch.
One example is a patient who complains of rash affecting the eyelids which is actually caused by the nail polish applied to the fingernails. Many of these patients have lengthy evaluations for periorbital rashs while the correct diagnosis is irritant contacts dermatitis of the hands with a secondary spread to the periorbital area.