Patching the Gaps in Our Diagnostic Knowledge. By Tyler Hooton MS3 UWSOM
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1 Patching the Gaps in Our Diagnostic Knowledge By Tyler Hooton MS3 UWSOM
2 Disclosures The author has no financial disclosures or conflicts of interest The following patient has given permission for this presentation
3 Patient Presentation 74 year old woman presents to dermatology clinic for multiple complaints: Rash on eyelids bilaterally Scaling on fingertips of right hand Occasional truncal rash
4 Patient Presentation Rashes have been on/off for years 6 months prior was given triamcinolone 0.1% 1:1 Vanicream for hands Has been self treating with vaseline on eyelids
5 Potential Contributing Factors Acrylic paint user Rash is worse in winter
6 Pertinent Negatives Denies scaling on palms No history of childhood dermatitis ROS negative No systemic symptoms including muscle aches/weakness
7 Past Medical History Former Smoker Increased BMI Hyperlipidemia Hypertension Osteoarthritis
8 Physical Exam Well appearing female Red eczematous patches on upper eyelids Mild scaling on tips of fingers on right hand No truncal rash present on exam
9 Pictures
10 Pictures
11 Physical Exam Negatives Heliotrope Rash
12 Physical Exam Negatives Gottron s sign Gottron s papules and /RHEUM/50909/Gottrons_sign_DM_II.jpg
13 Physical Exam Negatives Mechanics hands
14 Differential Diagnosis Dermatitis Atopic Dermatitis Contact Dermatitis Allergic Irritant Dermatomyositis
15 Pathology Punch biopsy of upper eyelid The biopsy shows subacute spongiotic dermatitis, and eosinophils are present in the inflammatory infiltrate. The differential diagnosis includes allergic contact dermatitis versus eczematous dermatitis. Features of connective tissue disease are not identified.
16 Differential Diagnosis Dermatitis Atopic Dermatitis Contact Dermatitis Allergic Irritant Dermatomyositis
17 Suspected Contact Dermatitis Characterized by subacute spongiotic dermatitis, and eosinophils Reactants the patient has been exposed to for years that they are only now reacting to Type IV hypersensitivity reactions
18 Identifying Triggers Patch Testing can be performed to identify reactants TRUE panels (36) versus NACDG panels (66) plus patient s home products
19
20 Patch Testing Schedule Day 1 Patient brings in all of their self-care products, test panels are applied Interval No showering, heavy sweating, steroids, or tanning Day 3 Panels outlined and then removed Day 4-5 Final reading, product elimination Follow-up Update on symptoms, maintenance plan
21 Day 5
22 Pictures
23 Strongly Positive Reaction
24 Patient s Patch Testing Results 1+ morphology for propylene glycol which is a preservative found in skin care products and perfumes PG is also used as a softening agent in foods and other products Many prescription contain PG (acetaminophen, cyclosporine, clarithromycin)
25 Patient s Patch Testing Results Weak reaction to lyral which is a component of most perfumes Eyelid rash makes a lyral reaction more likely
26 Product Investigation No products contained propylene glycol or lyral Only partial ingredient list obtained for MaryKay products Patient had homework to find full ingredient list Called back and MaryKay products did have propylene glycol on full list along with fragrance
27 Summary Patch Testing done by dermatologists can aid in identifying exposures Not all ingredient lists are complete Avoidance of allergen is the only definitive treatment Patch testing can be used to distinguish allergic from irritant contact dermatitis TRUE patch testing has a limited spectrum of reactants
28 Questions? Thanks to Dr. Spenny!
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