INTRODUCTION
This teledermatology case of a red, itchy rash on the arms and trunk is evaluated using a standardized teledermatology template.1
CHIEF COMPLAINT
Rash on the arms and trunk.
HISTORY OF PRESENT ILLNESS
A 51-year-old man with a history of atopic dermatitis presents with a rash on his arms and trunk. On his bilateral arms, there are erythematous plaques with distinct overlapping edges directly under and extending beyond his medicinal transdermal patches. On his left chest are three circular plaques. He had a Holter monitor test 3 months ago. The patient was using triamcinolone 0.1% cream to the areas twice daily, with poor compliance. Therapy to the arms began 3 weeks ago, but the rash on his chest remains unresolved after 3 months of intermittent treatment. Primary symptom: pruritus. Other significant laboratory/study findings: none.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
One image was provided that showed multiple geometric erythematous plaques with increasing erythema in progression to the transdermal patch on the left arm. There are also three distinct, fine-scaled erythematous iris plaques with central sparing on the left chest (Figure 1).
INTERPRETATION OF IMAGES
Lesion A
The history and presentation are consistent with acute allergic contact dermatitis (ACD) on the left arm, potentially to the adhesive in the transdermal patch, and recall ACD on the left chest, potentially to the adhesive in the Holter monitor lead points.
RECOMMENDATIONS
Skin Care Recommendations
If possible, discontinue the medical transdermal patch. If medical necessity dictates continuance of the transdermal patch, then apply the patches on intact noninflammed skin (rotate the sites). Use triamcinolone 0.1% ointment twice daily to the affected areas up to 6 weeks. If the dermatitis continues, consider to pretreat the site where the transdermal patch will be applied with Kenalog Spray, as this will counter the immune response and not affect adhesion. Most transdermal patches contain a form of proprietary acrylate; it might be prudent to brand-switch the transdermal patch, so attempt utilization of a patch with a different acrylate.
Medication Recommendations
The patient may take oral antihistamines, as needed for pruritus and for maximal therapy. Consider fexofenadine in the morning and cetirizine in the evening (two antihistamines in different classes).
Recommended Follow-up
Return to the primary provider in 6 weeks to evaluate progress of therapy.
CLINICAL PEARL
ACD is a Type IV hypersensitivity reaction that occurs after initial exposure and sensitization to an agent. When the patient comes in recontact with the agent, a pruritic, erythematous dermatitis may ensue at the site of current and past exposures. Recall contact dermatitis refers to the phenomenon of ACD flare at a previously sensitized site due to either systemic exposure or sustained localized exposure at a different location (Jacob, Barland, & ElSaie, 2008). In this case, we believe the repeated exposure to the transdermal medication patch reactivated the prior adhesive reaction to the Holter leads.
ACD may present acutely or chronically. Acute ACD typically presents as pruritic and erythematous papules and plaques with overlying vesicles. Chronic ACD may present as lichenified and scaly plaques. Recall dermatitis may appear as acute or chronic ACD. Common allergens include poison ivy, sumac, oak, nickel, gold, adhesive resins, fragrance chemicals, and rubber additives (Elsevier, 2015).
REFERENCES