What's Your Assessment?

Rhonda Goodman

Disclosures

Dermatology Nursing 

In This Article

Differential Diagnosis

  1. Tinea corporis

  2. Folliculitis

  3. Darier's disease

  4. Grover's disease

  1. Tinea corporis. Tinea is one of the most common fungal infections and usually involves the trunk and extremities. Dermatophytes are the cause of tinea and the lesions usually present as circular lesions on an erythematous base. The borders of the lesions are raised and erythemic while the center is pale, scaley, and dry (Goldsmith, Lazarus, & Thorp, 1997). Usually, the lesions are pruritic. This condition is common in hot and humid climates and is exacerbated by moist or occlusive clothing. Diagnosis is made by visual inspection or by microscopic examination of a scraping of the lesions with KOH added to the slide (Popovich & McAlhany, 2008). Treatment includes topical antifungal agents, such as clotrimazole, miconazole, or ketoconazole. Topical steroids should be avoided as the steroid will alter the appearance of the initial lesion, and perhaps cause an increase in pain and pruritus. If the lesions do not resolve with the topical treatment, it may be necessary to treat with oral griseofulvin. The patient should avoid wet or damp clothing.

  2. Folliculitis. While the patient with folliculitis usually presents with papular lesions which are erythemic and pruritic, the lesions almost always evolve into vesicles, and sometimes pustules with secondary crusts. Folliculitis involves an inflammation of the hair follicle and may be the result of injury, infection, or chemical irritation. The offending agent is often staphylococcus aureus, candida, dermatophytes, or pseudomonas (Habif, 2004). The lesions may be grouped, clustered, or scattered and may be found on various areas of the body, but are particularly common on the face, groin, chest, and thighs. Common irritants are of the mechanical type, such as shaving, plucking, or waxing hairy areas or from occlusion in the intertriginous areas. Diagnosis is usually obtained by a thorough history and assessment of exposure, along with a visual inspection. Treatment includes daily cleansing with an antibacterial cleanser, topical antibiotics, or oral antibiotics for severe or persistent infections. Topical steroids may be used to control pruritus (Graham, 2003).

  3. Darier's disease. Darier's disease, also called keratosis follicularis, is an autosomal dominant inherited disease (Graham-Brown & Bourke, 1998). The patient presents with multiple and discrete papules, which are pruritic, painful, and may exhibit scales and crusts. An unpleasant odor may accompany the lesions, which may be located on the chest, back, ears, face, scalp, groin, nails, and mucous membranes. The lesions may have the appearance and texture of warts. Both males and females may inherit this disease in the first few decades of life. Factors which exacerbate the development of lesions are heat, humidity, trauma, and infections. Diagnosis is made based upon family history of disease, histopathology, and the appearance of the lesions. Treatment includes topical and systemic antibiotics, topical and systemic retinoids, and sunscreen (Goldsmith et al., 1997).

  4. Grover disease. This patient was diagnosed with Grover disease, or transient acantholytic dermatosis, which is most common among older White males (Wolff, Johnson, & Suurmond, 2005). The lesions are papulovesicular and are generally located on the upper trunk. The onset of the rash is rapid, beginning with small papules which evolve into vesicles with crusting and sometimes erosion. The lesions are erythemic and pruritic with a discrete distribution across the chest. The disease was named for Dr. Ralph Grover after he reported the condition in 1970 (Weaver, 2009). Although the disease is called transient, the lesions may persist for weeks, even months, in some cases. Irritating factors include heat, humidity, heavy perspiration, exposure to sunlight, and bed confinement. Diagnosis was made by visual inspection along with a punch biopsy and histopathologic examination. The unique feature of Grover disease is the presence of lymphocytes and eosinophils in the dermal layer. Treatment includes the application of topical glucocorticoids with occlusion with plastic wrap, and may also include oral glucocorticoids. Systemic antibiotics may be necessary if there is accompanying infection of the secondary lesions. Phototherapy and topical vitamin D analogs have also been used for persistent lesions. Topical moisturizers and systemic nonsedating antihistamines may be useful in alleviating pruritus (Mainier, 2009).

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