Four appropriate differential diagnoses for the 9-year-old boy with widespread itching and redness are

QUESTION

A 9-year-old boy complains of widespread itching and redness across his popliteal and antecubital fossae, limbs, and belly. Since he was 4 years old, he has suffered from this type of rash. He has tried diphenhydramine 25 mg q8h prn, hydrocortisone 2% QID, Zyrtec 10 mg QD, and Aquaphor QID. The patient has had a chronic cough and episodes of bronchial asthma since he was 6 years old. He has Atopic Dermatitis

list four appropriate differential diagnoses and rationales with references. For each differential diagnosis, explain why this is an appropriate differential and how it was/would be ruled in or out. Support your answers with references.

Pick one differential

Plans must include Pharmacology, Non-Pharmacology, Labs/Diagnostics, Referrals/Interprofessional Communications, Patient Education (10-15 individual items minimum) and follow up.

Make sure to pick one health maintenance item for this patient (primary or secondary) and explain to the patient why this is important.

Address one social determinant of the health this patient may face during your visit. How will you help the patient overcome this obstacle to health care?

ANSWER

Four appropriate differential diagnoses for the 9-year-old boy with widespread itching and redness are

Contact Dermatitis: Contact dermatitis is a common differential diagnosis for patients with chronic rash and itching. It can be caused by an allergic or irritant reaction to substances that come into direct contact with the skin, such as soaps, detergents, or clothing materials. To rule in or out contact dermatitis, a detailed history should be obtained to identify any potential triggers, and patch testing may be performed to confirm the diagnosis (Jacob & Hsu, 2020).

Scabies: Scabies is a contagious skin infestation caused by the Sarcoptes scabiei mite. It commonly presents with intense itching, especially in the flexor surfaces and between the fingers. A skin scraping or biopsy can be performed to identify the mite or its eggs, confirming the diagnosis of scabies (Strong et al., 2018).

Psoriasis: Psoriasis is a chronic inflammatory skin condition characterized by red, scaly plaques. It commonly affects the extensor surfaces, including the knees and elbows, but can also involve other areas of the body. The diagnosis of psoriasis is typically made based on clinical appearance and can be confirmed by skin biopsy if necessary (Menter et al., 2019).

Urticaria: Urticaria, or hives, presents as raised, itchy wheals that can occur anywhere on the body. It is often caused by an allergic reaction but can also be triggered by other factors such as infections or medications. The diagnosis of urticaria is based on the characteristic appearance of the lesions and a thorough history to identify potential triggers (Powell & Leech, 2021).

One selected differential diagnosis: Atopic Dermatitis

Rationale: Atopic dermatitis, also known as eczema, is a chronic inflammatory skin condition characterized by itching, redness, and a typical distribution pattern. It commonly affects the flexural areas of the body, such as the popliteal and antecubital fossae. Atopic dermatitis is a fitting differential diagnosis in this case because the patient has a history of chronic rash and itching, which are typical symptoms of the condition.

To confirm the diagnosis of atopic dermatitis, the patient’s medical history and physical examination findings should be consistent with the characteristic features of the condition. No specific diagnostic test exists for atopic dermatitis, but additional investigations may be performed to rule out other differential diagnoses or identify triggers that exacerbate the symptoms, such as allergy testing or skin biopsy (Eichenfield et al., 2014).

Plan

Pharmacology

Topical Corticosteroids: Prescribe a higher-potency topical corticosteroid, such as mometasone furoate, to be applied twice daily to affected areas for acute flares (Eichenfield et al., 2014).
Topical Calcineurin Inhibitors: Consider prescribing a non-steroidal immunomodulatory agent, such as tacrolimus ointment, for maintenance therapy in sensitive areas (Eichenfield et al., 2014).

Non-Pharmacology

Emollients: Recommend regular use of fragrance-free moisturizers, such as petroleum jelly or ceramide-containing creams, to restore and maintain skin barrier function (Eichenfield et al., 2014).
Wet Wrap Therapy: Educate the patient and family on the application of wet wraps using dampened cotton garments over emollients to enhance hydration and relieve itching (Eichenfield et al., 2014).

Labs/Diagnostics

Allergy Testing: Consider referral to an allergist for allergy testing if specific triggers are suspected (Eichenfield et al., 2014).

Referrals/Interprofessional Communications

Dermatology Consultation: Consider referring the patient to a dermatologist for further evaluation and management, particularly in complex cases (Eichenfield et al., 2014).

Patient Education

Trigger Identification and Avoidance: Educate the patient and family on identifying and avoiding triggers, such as irritants, allergens, and excessive dryness (Eichenfield et al., 2014).
Importance of Skin Care: Emphasize the significance of proper skin care, including regular moisturization and gentle cleansing practices (Eichenfield et al., 2014).

Follow-up:
Schedule a follow-up appointment in 4-6 weeks to assess treatment response, adjust medications if necessary, and address any concerns or questions (Eichenfield et al., 2014).

Health Maintenance

Primary: Regular Skin Checks
Explain to the patient and family the importance of routine skin checks to monitor for any signs of infection, worsening symptoms, or new lesions. Encourage them to report any changes promptly to ensure early intervention and optimal management of the condition.

Social Determinant of Health

Transportation Barrier
If transportation is identified as a barrier to healthcare access, explore potential solutions such as public transportation options, community resources for transportation assistance, or telehealth services to facilitate the patient’s access to necessary healthcare appointments and follow-up care.