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Simple cases
Case 16
19-year-old military recruit is referred by troop physician because of pruritic rash on back for 5 days.
History
Do you have diabetes?
No.
Patients with diabetes mellitus have an increased risk for this disorder.
Have you have anything like this before?
No.
This disorder tends to be recurrent. Here we have an acute case.
Tell me what you have been doing in the past week?
Nothing special. We had several long marches with full battle gear, and only had one chance to shower. I am not crazy about sleeping in the same room with 30 people.
The life circumstances of the patient often give clues to the cause of the illness.
Do any of the other recruits have the same problem?
No.
Military training is an ideal place for epidemics.
Do you take any medications?
No.
The history of medications is important to exclude a drug reaction, to alert the physician to other illnesses and to plan therapy.
Do you smoke?
No, but what does that have to do with my back.
The patient is righta silly question.
Lesion
Choose the right efflorescences:
False. Hives are transient dermal swellings that can be red or pale. They are not present here.
Good. Pustules are pus-filled spaces, as we see here.
False. Vesicles are fluid-filled spaces; they may evolve into pustules.
False. Papules are small elevated lesions, not fluid- or pus- filled.
False. Nodules are similar to papules but >5mm in diameter.
Diagnosis
Choose the right diagnosis:
False but a good differential diagnostic consideration. Scabies usually involves the interdigital spaces, nipple, penis, axillae. The itching is worse at night.
False. Psoriasis can be pustular (von Zumbusch form) but these patients are seriously ill and have widespread pustules.
One rare type of drug reaction is acute generalized exanthematous pustulosis, but the drug exposure history is missing here. The reaction is also widespread, not confined to the back.
Folliculitis is an infection of the hair follicle. The most common cause is Staphylococcus aureus (as was the case here) but also other bacteria, yeasts or rarely herpes viruses.
Acne always starts with comedones, which are not found here.
Therapy
Choose the right therapy(ies):
Disinfection and drying are both helpful.
Systemic therapy is usually not needed for folliculitis in immunocompetent patients.
This is the treatment for severe acne.
The mechanical pressure and sweating undoubtedly triggered the folliculitis. Disinfection is essential, as is good hygiene.
