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Itchy skin disease

Dermatitis case challenge 1

The 35-year old owner of a hairdressing salon presents with dermatitis on several fingertips present for some months. She reports mild intermittent dermatitis for many years. She has recently increased her hours at work as her youngest child has started at school.

Which terms best describe her fingertips? # Lichenified #! Fissured # Chronic dermatitis #! Acute dermatitis Explanation: A fissure is a a thin crack within epidermis or epithelium. Acute dermatitis is characterised by erythema, vesiculation and oozing, often with oedema. Which terms best describe her fingernails? # Subungual hyperkeratosis #! Transverse ridging #! Paronychia #Longitudinal ridging Explanation: Lifting of the nail fold off the nail plate is known as paronychia, a sign of nailfold dermatitis that may relate to secondary infection with bacteria and/or yeasts. She also has nail dystrophy with irregular transverse ridging of several nails.

For information about hand dermatitis, see DermNet

What are the most likely symptoms? #! Pruritus #! Painful fissures #! Throbbing at night # Palpitations Explanation: Common symptoms for hand dermatitis are pruritus, painful fissures and throbbing at night. What are possible causes of her hand dermatitis? Consider constitutional, occupational and nonoccupational factors. Short answer: Consider:
  • Atopy including infantile eczema, asthma or hay fever.
  • Exposure to occupational and household irritants including water, detergents, solvents, hair and various chemicals.
  • Delayed hypersensitivity (contact allergy) to paraphenylene diamine (permanent hair dye), ammonium peroxide (bleach), permanent solution, nickel (scissors), rubber antioxidants, preservatives.
  • Primary or secondary infection (Staphylococcus aureus, Streptococcus pyogenes, and/or Candida albicans).
What impact does her dermatitis have at work? Short answer: Unsightliness resulting in embarrassment. Pain and discomfort on contact with chemicals and typing (business management). Need to wear gloves to protect from contact with irritants. Expense of hiring additional staff and resultant loss of income. Potential end to business and career (stress). What impact does her dermatitis have at home? Short answer: Difficulty with household and personal activities such as caring for young children, dishwashing, washing clothes and hanging them up, cleaning the house, preparing vegetables, gardening, shampooing her hair. Relationship with partner and family may be strained.

She is given some advice regarding protection of her hands from irritants, and treated with topical steroids, thick emollients and oral antibiotics. These relieve discomfort and improve signs briefly. There is significant improvement after the salon has been closed for two weeks at Christmas, but the dermatitis relapses as soon as she returns to work.

What are the most approriate tests: #! Bacterial swabs for microscopy and culture # Viral swabs for culture #! Nail clippings for fungal microscopy and culture # Prick tests for immediate hypersensitivity #! Patch tests for delayed hypersensitivity # Dermoscopy (skin surface microscopy) # Histopathology of skin biopsy # Wood’s light examination (long wave ultraviolet) # Full blood count, renal and liver function tests Explanation: Tests for patients with severe acute dermatitis might include swabs for bacterial infection, nail clippings for fungal infection and patch tests for delayed hypersensitivity.

She is patch tested to the standard series and to a series of allergens specific to hairdressing. For information about patch testing see DermNet

She has strongly positive contact allergic reactions to Cl,Me- Isothiazolinone (Kathon-CG) and to ammonium persulfate, a bleaching agent.. Refer to DermNet for information about Cl,Me-Isothiazolinone (Kathon-CG).

What is Cl,Me-Isothiazolinone (Kathon-CG)? # Adhesive # Dye # Perming solution #! Preservative Explanation: Cl,Me- Isothiazolinone (Kathon-CG) is a preservative. It is found in cosmetics and skin care products, topical medications and household cleaning products.

The patient identifies a shampoo containing isothiazolinone and avoids contact with it. She is careful to wear new latex gloves when applying bleach. However, she reports very little improvement in her dermatitis. She is advised that dermatitis is likely to persist as long as she works in the salon.

On review a year later, she continues to use moisturising hand cream and intermittent potent topical steroids. She has had three courses of antibiotics for severe flare-ups of infected dermatitis in which she had oozing, swollen and very painful fingertips and scattered boils on her trunk and limbs. She continues to work full-time in her own salon. At home she is able to care for her children and manage the household. She maintains a positive outlook despite the severity of the dermatitis.