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Simple cases
Case 5
35-year-old woman presents with an acute rash
History
How long have you had these skin changes?
They just started a few hours ago.
Good question. A more detailed inquiry should be made. It could be a contact allergy.
Do the lesions itch or burn?
Yes, they burn like crazy. Some fluid is running from my scalp down on my face.
Good question. The reaction is very acute with weeping blisters. Such reactions usually appear in a time frame of 24-72 hours.
Do you have any allergies?
Yes, I think I am allergic to nickel in costume jewelry and maybe on jeans buttons.
Worthwhile question. A pre-existing allergy, either Type I or Type IV, is not a requirement for such a severe reaction. Neither is an atopic diathesis.
Does anyone else in the family have similar problems?
No, no one else.
This question doesn't help. Any possible answer could be given, without advancing the diagnostic process.
Did you often have sunburns as a child?
Yes, as a kid I was outdoors a lot and had quite a few sunburns.
Poor question. This information is irrelevant.
Do you connect anything with this scalp problem?
I actually haven't done anything unusual. I did dye my hair black again, but I do that often and never had problems.
Good question. The history with allergic contact dermatitis is often a challenge, as the patients cannot imagine they are allergic to something they have been using for a long time.
Lesion
Choose the right efflorescences:
Correct. Papules are seen typically in this disease.
Correct. Small vesicles with fluid are seen on scalp and face.
False. No pustules are seen here, but they can rarely develop.
Correct. This disorder starts with an erythema.
Diagnosis
Choose the right diagnosis:
False, but a major differential diagnostic consideration. Toxic contact dermatitis is usually sharply circumscribed without distant spread, more painful and more likely to have blisters than allergic contact dermatitis but overlaps occur.
False. Atopic scalp dermatitis can occasionally be severe but it is rarely so acute, and the history points in a different direction.
False. This is part of differential diagnostic considerations but is more localized and not so acute.
Correct. After multiple uses, the patient became sensitized to a chemical in her black hair dye.
Therapy
Choose the right therapy(ies):
Correct. Will help in acute stage.
Correct. A short course is indicated in such a severe allergic reaction.
Correct. This simple measure will help remove debris and disinfecty.
Correct. May be needed to control secondary infection if topical measures fail.
Correct. This is the most practical way to try to control the itch.
