Dermatology

Week 2 Dermatology Assignment

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Week 2 Dermatology Assignment

Figure 1

Week 2 Assignment Nur602 Image 1

To obtain an adequate history of present illness for this type of skin condition, I would begin my diagnosis with the following questions.

1. When did the lesions appear initially? Where did they appear first?
2. What were the symptoms that preceded the formation of the lesions? Any fever or general weaknesses?

• Are the lesions symptomatic? Itchy, tingly or burning?

1. Are the lesions confined to a particular location, or do they appear elsewhere?
2. Any past incidence of chickenpox (varicella) or psoriasis? If no, was there any recent exposure to a patient(s) with the sicknesses?
3. Any known allergies? If yes, was there any recent exposure to allergy initiating conditions?

• Is the patient under any medical prescription? If yes, which medication?

The examination questions, in this case, will be aimed at ascertaining the location and historical and distribution patterns of the lesions. The patient’s face will also be evaluated to ascertain if any lesions are present as vesiculations may also present around the trigeminal nerve, on the tip of the nose, or in the patient’s eye.  Questions concerning existing allergies and ongoing treatment will be aimed at eliminating some possible rudimentary causes, such as contact dermatitis or allergic eczema.

To describe the area, I would document the affected area as being erythematous with ill-defined plaque papules manifesting as overlying scales and erosions. The lesions appear to have a Zosteriform distribution mimicking a dermatomal dispersal that originates from the patient’s back at the top of the thoracic spine and wraps around the underside of the left axilla to the left chest.

The first diagnosis to consider is herpes zoster (HZ).  HZ is commonly referred to as shingles and is characterized by a distinctive syndrome “belt” caused by the reactivation of the varicella-zoster virus (Kaye, 2019). The history of HZ is usually used to guide the diagnosis to a specific isotopic pathway. As patients age, their risk of HZ increases, with almost half of all cases of HZ occur in those that are older than 60 years of age (Kaye, 2019). The condition is also common and severe among immunocompromised patients. One of the most common and enervating symptoms of HZ is postherpetic neuralgia, which denotes protracted pains that may extend for more than three months after the rash has healed (Kaye, 2019).

If the condition presents without accompanying nerve pain and there are more concomitant lesions where the “belt appearance” is lost, atopic dermatitis could be considered as a possible diagnosis for this patient (Janniger, 2019).  According to Nutten (2015) and Janniger (2019), atopic dermatitis entails a typical chronic inflammatory skin disease that is defined by a wide variety of clinical manifestations and combinations of symptoms.  With an ever-increasing prevalence rate, atopic dermatitis currently affects up to three per cent of adults (Nutten, 2015).

Figure 2

Week 2 Assignment Nur602 image 2

For picture two, it would be necessary to obtain relevant information concerning the history of illness and location of this injury site by employing the following questions.

1. When did the lesions appear initially? Where did they appear first?
2. Are the lesions confined to a particular area, or do they manifest elsewhere?

• If confined to a particular location, was it caused by an injury or trauma?

1. Are the lesions symptomatic? Tender, painful or accompanied by a discharge (colour if present)?
2. Any history of similar conditions among family members? If no, was there any recent exposure to a patient(s) with similar conditions?
3. Any conditions that alleviate or increase symptoms?

• Any known allergies? If yes, was there any recent exposure to allergic conditions?
• Is the patient under any medical treatment? If yes, which medication?

It is also PARTICULAR to determine the evolution of the lesion since the patient has become aware of it.  Depending on the patient’s age and location of lesions, it may also be important to inquire about their sexual activity history.

The condition may be documented as a well-circumscribed ulcerated erythematous lesion suggesting minimal inflammatory infiltration of the upper dermis.  The lesion’s measurement (diameter) should also be documented and used to ascertain whether it falls in the category of bullae or vesicle. While both manifest as clear fluid-filled blisters, the two differ in that bullae diameter is > 10mm while vesicle diameter is < 10mm.  Location(s) and discharge characteristics must also be documented.

Possible diagnoses for this patient include bullous impetigo and herpes simplex virus (HSV).  Bullous impetigo is a PARTICULARLY contagious bacterial infection that is common among children – it resembles pemphigus foliaceus. Bullous impetigo affects the superficial layers of the epidermis and is primarily caused by Streptococcus pyogenes or Staphylococcus aureus (Lewis, 2018).  HSV is comprised of two distinct types of DNA viruses:  HSV-1 and HSV-2 (Kohn, 2019).  Typically, HSV-1 causes oral lesions but has been found to also cause genital lesions in a few cases (Kohn, 2019).  HSV-2 is exactly the opposite of HSV-1.  That is, most of the lesions associated with HSV-2 occur in the genital regions, with only a few incidences of oral lesions (Kohn, 2019).

Figure 3

Week 2 Assignment Nur602 image 3

To develop an appropriate history of the illness profile, the following questions must be presented to the patient.

1. When did the lesions appear initially? Where did they appear first?
2. Are the lesions confined to a particular area, or do they manifest elsewhere? If confined to a particular location, was it caused by an injury or trauma?

• Are the lesions symptomatic? Tender, painful or accompanied by a discharge (colour if present)?

1. Any conditions that alleviate or increase symptoms?
2. Any known allergies? If yes, was there any recent exposure to allergic conditions?
3. Is the patient under any medical treatment? If yes, which medication?

It is also NECESSARY to document the development of the lesion from the time it was initially noticed.

The lesions may be reported as being erythematous lichenified plaques with overlying scales and crusts positioned bilaterally on the posterior of the knees.  The borders are not well defined.

The differential diagnosis for this patient includes atopic dermatitis (eczema) and psoriatic erythroderma dermatitis. Atopic dermatitis entails a chronic inflammatory dermatologic condition characterized by complex pathogenesis involving immunologic and epidermal barrier dysfunction, genetic predisposition and environmental factors. Patients with a history of atopic dermatitis HAVE BEEN FOUND TO BE AT A greater risk of developing allergic contact dermatitis (“Erythroderma,” n.d.). Psoriatic erythroderma, on the other hand, presents with diverse histopathologic and clinical findings, such as generalized inflammatory erythema. The VARIOUS causes OF psoriatic erythroderma INCLUDE beta-blockers, non-steroidal anti-inflammatories, infections, pregnancy and emotional stress (“Erythroderma,” n.d.).

Figure 4

Week 2 Assignment Nur602 image 4

For this particular patient, the following questions may be used to generate the relevant history of illness profile.

1. When did the lesions appear initially? Where did they appear first?
2. Are the lesions confined to a particular area, or do they manifest elsewhere? Did the condition develop as a result of an injury, trauma, or other causes?

• Are the lesions symptomatic? Tender, painful or accompanied by a discharge (colour if present)?

1. Any conditions that alleviate or increase symptoms?
2. Any known allergies? If yes, was there any recent exposure to allergic conditions?
3. Is the patient under any medical treatment? If yes, which medication?

It is also ESSENTIAL to determine the evolution pattern of the lesion from the time it was first noticed.

Documentation of the condition would be that the patient has well-demarcated erythematous plaques with overlying silvery scales on the extensor surface of the knees.

Differential diagnosis of plaque psoriasis and nummular eczema should be considered in this case. Psoriatic plaques entail chronic, inflammatory, autoimmune skin conditions, whose manifestations include raised lesions that are easily palpable (Tuzun, 2016; Cole & Shiel, 2020). The lesion can be irregular or oval in shape that ranges from one to several centimetres in size.  Nummular eczema lesions are generally well-defined with sharply demarcated boundaries.  The lesions are rounded, circular desquamative erythematous lesions covered with vesicles, crusts, scales and are very itchy (Tuzun, 2016).

References

Basic dermatology curriculum: Erythrodema. (n.d.). Retrieved from http://olc.aad.org/diweb/catalog/launch/package/3/guid/h8WdsNyFTqEMQsrKG5U2j0mZZNef*2Fl1oQhfCQIyLrqh7snhJJHIGQg*3D*3D/eid/2132286.

Cole, G. W. & Shiel, W. S. (2020). Psoriasis. Retrieved from https://www.medicinenet.com/psoriasis/article.htm#what_is_apremilast_and_how_does_it_work_mechanism_of_action.

Janniger, C. K. (2019). Herpes zoster differential diagnoses. Retrieved from https://emedicine.medscape.com/article/1132465-differential.

Kaye, K. M. (2019). Herpes Zoster. MSD Manual. Retrieved from https://www.msdmanuals.com/professional/infectious-diseases/herpesviruses/herpes-zoster.

Kohn, M. (2019). Herpes Simplex Virus (HSV) in emergency medicine. Retrieved from https://emedicine.medscape.com/article/783113-overview.

Lewis, L. S. (2018). Impetigo. Retrieved from https://emedicine.medscape.com/article/965254-overview.

Nutten, S. (2015). Atopic dermatitis: global epidemiology and risk factors. Annals of Nutrition and Metabolism, 66, 8-16. https://doi.org/https://doi.org/10.1159/000370220.

Tuzun, B. (2016). The differential diagnosis of psoriasis vulgaris. Retrieved from https://www.omicsonline.org/open-access/the-differential-diagnosis-of-psoriasis-vulgaris-2376-0427-1000245.php?aid=81111.