26 Sep CASE STUDY 1 A 46-year-old male presents to the of
CASE STUDY 1 A 46-year-old male presents to the office complaining of a pruritic skin rash that has been present for a few weeks. He initially noted the rash on his feet, but it then spread to between the fingers, his wrist, and waist. He notes that it does not seem to be on his face or trunk. He recently came home from a trip to Florida where he had stayed in multiple hotels. He takes occasional ibuprofen for knee pain but denies taking other medications or having other health problems. He has no known drug allergies. The physical examination reveals a male with several tiny vesicles and scales in between the fingers, on the feet and ankles, around the patient’s wrist and around the belt line. Introduction Nurse practitioners will see many patients seeking treatment for a variety of skin conditions. Physical examination and a health history provide pertinent information to help formulate and conclude an accurate diagnosis. Focusing on the size, location, and shape of the lesions plus gathering patient’s symptoms such as urticaria, helps narrow the differential diagnoses. This 46-year-old presents with a typical case of scabies. Diagnosis The patient history is noteworthy as it provides valuable information regarding patient exposure to a warm climate, multiple hotel bed sheets, and rash symptoms have been present for a few weeks. Physical exam reveals pruritic skin with tiny vesicles in an acral distribution pattern. Further examination may reveal intraepidermal burrow lines which result from the infesting female mite (Buttaro, 2017). Diagnosis is typically made based on patient history and clinical presentation. Dermatoscopy can be used to identify the characteristic delta sign and the burrow trail (Hardy, 2017). Scabies Human scabies is a “highly contagious skin parasitosis caused by Sarcoptes scabiei var. hominis and characterized by generalized pruritus” (Micali, 2016, p. 1). Scabies impacts approximately 300 million people every year and is most often found in hospitals, nursing homes, prisons, retirement homes and long-term care facilities (Micali, 2016). Scabies is more common in hot and humid climates and in poor overcrowded communities (Buttaro, 2017). Transmission is “by close personal contact, sexual or otherwise, or, less frequently, indirectly via fomite transmission such as on clothing or bed sheets” (Micali, 2016, p. 1). Patients typically present with intense, generalized pruritus that is more uncomfortable at night (Gunning, 2019). The “primary skin lesions are erythematous, pruritic papules, pustules, vesicles and nodules” (Gunning, 2019, p. 640). Lesions are more commonly found on the fingers, wrists, elbows, waistline, axillae, genitalia and breasts (Gunning, 2019). Differential Diagnosis It is important to consider alternate diagnoses such as atopic dermatitis, psoriasis, and syphilis. Atopic dermatitis is chronic, long lasting illness with acute flares. Patient history suggests no prior history of dermatitis or complaints of itching. Psoriasis is “an inflammatory papulosquamous eruption characterized by well-circumscribed erythematous macular and popular lesion with loosely adherent silvery white scale” (Buttaro, 2017, p. 301). Typical onset is young adulthood rather than a 46-year-old. Finally, red plaques have a sharply defined border indicative of psoriasis, unlike the rash described in the case study. Secondary syphilis presents as a blotchy red rash on the hands and soles of the feet a few weeks after a chancre goes untreated. This rash is not itchy, again unlike the presentation in the case study. Treatment First line treatment for scabies is topical permethrin 5% cream. The cream should be applied to the entire body, excluding the head and neck, and then washed off after 8-12 hours (Hardy, 2017). Patient education would include washing clothing and bedding in hot water and for non-washable items they should be placed in a plastic bag for one week (Buttaro, 2017). Patient should return in two weeks for follow up assessment. Reference Buttaro, T.M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier. Gunning, K., Kiraly, B., & Pippitt, K. (2019). Lice and Scabies: Treatment Update. American Family Physician, 99(10), 635–642. Hardy, M., Engleman, D., Steer, A. (2017). Scabies: a clinical update. Australian Family Physician, 46 (5), 264-268. Micali, G., Lacarrubba, F, Verzi, A. E., Chosidown, O., & Schwartz, R. A. (2016). Scabies: Advances in noninvasive diagnosis. PLoS neglected tropical diseases, 10 (6), e0004691. https://doi.org/10.1371/journal.pntd.0004691
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