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Diseases » Diaper rash » Diagnosis
 

Diagnosis of Diaper rash

Diaper rash Diagnosis: Book Excerpts

Diagnostic Tests for Diaper rash: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Diaper rash.


RASH--DISTRIBUTION: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is it focal or diffuse? Focal rashes suggest the dermatophytoses, scabies, actinic dermatitis, herpes zoster, warts, contact dermatitis, erythema nodosum, actinic dermatosis, dyshidrosis, skin tumors, nummular eczema, stasis dermatitis, pyoderma, acne vulgaris, herpes simplex, impetigo, and tuberous sclerosis. Diffuse rashes suggest xanthoma, erythema multiforme, psoriasis, lichen planus, eczema, drug eruptions, dermatitis herpetiformis, secondary syphilis, exfoliative dermatitis, and pemphigus. A diffuse rash also may be due to pityriasis rosea and tinea versicolor.
  2. If diffuse, is it primarily the extremities that are involved? A diffuse rash that involves primarily the extremities would suggest smallpox and erythema multiforme, eczema, milium, lichen planus, and psoriasis.
  3. If diffuse, does it involve primarily the face and trunk? A diffuse rash that involves primarily the face and trunk suggests chickenpox, typhoid fever, German measles, pityriasis rosea, tinea versicolor, and pemphigus.
  4. If focal, does it primarily involve the extremities? A focal rash that involves primarily the extremities suggests dermatophytosis, erythema nodosum, contact dermatitis, warts, discoid lupus, actinic dermatosis, scabies, dyshidrosis, skin tumors, nummular eczema, stasis dermatitis, and pyoderma.
  5. If focal, is it primarily involving the face and head? A rash that involves primarily the face and head should suggest acne vulgaris, acne rosacea, seborrheic dermatitis, herpes simplex, actinic dermatosis, carcinoma, impetigo, contact dermatitis, Sturge-Weber syndrome, tuberous sclerosis, and tinea capitis.
  6. Is it equally distributed to the trunk and extremities? A rash that is equally distributed to the trunk and extremities would suggest herpes zoster, neurofibromatosis, scarlet fever, drug eruptions, dermatitis herpetiformis, secondary syphilis, measles, and exfoliative dermatitis.

DIAGNOSTIC WORKUP

If there are any exudates, a smear and culture for fungi and routine bacteria should be done. Skin scrapings may be examined microscopically with a saline or potassium hydroxide preparation to rule out scabies and fungi. A Wood's lamp examination is very useful in diagnosing various fungi. All isolated lesions should be biopsied.

Diffuse rashes require routine CBC, sedimentation rate, urinalysis, chemistry panel, ANA test, and VDRL test. If there is fever, blood cultures should probably be done. Skin biopsies in consultation with a dermatologist should be done in a timely fashion. Patch testing and intradermal skin testing should be done when appropriate. A dark field examination may be necessary. GI series and barium enemas may be necessary to look for GI neoplasms, Crohn's disease, and ulcerative colitis.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

RASH--MORPHOLOGY: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is the rash macular or papular? A macular or papular rash would suggest scarlet fever, measles, erythema multiforme, exfoliative dermatitis, pityriasis rosea, eczema, contact dermatitis, secondary syphilis, drug eruption, and actinic dermatoses.
  2. Is the rash pustular? A pustular rash suggests staphylococcus, scabies, secondary syphilis, acne, folliculitis, and dermatophytosis.
  3. Is the rash vesicular or bullous? A bullous or vesicular rash would suggest chickenpox, smallpox, dermatitis herpetiformis, contact dermatitis, pemphigus, herpes zoster, bullous impetigo, herpes simplex, dyshidrosis, and nummular eczema.
  4. Is the rash scaly? A scaly rash suggests ichthyosis, psoriasis, lichen planus, neurodermatitis, dermatophytosis, exfoliative dermatitis, and drug eruptions.
  5. Are there ulcers? The presence of ulcers in the lesions would suggest basal cell carcinoma, syphilis, lupus erythematosus, diabetic ulcers, ischemic ulcers, pyoderma gangrenosum, and ecthyma.
  6. Is there fever? The presence of fever suggests scarlet fever, measles, erythema multiforme, exfoliative dermatitis, serum sickness, chickenpox, and smallpox.

DIAGNOSTIC WORKUP

This can be found under Rash--Distribution.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Pruritis with Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Infectious causes
    –Fungal infections: Dermatophyte infections (tinea), candidiasis (beefy red color with satellite papules), seborrheic dermatitis (from Pityrosporum, common in hair-bearing areas, with scale)
    –Bacterial infections: Erythrasma (from Corynebacterium), frequently in axilla
    –Viral infections: Chicken pox (Varicella)
    –Insect vectors: Scabies, pediculosis or lice (also present on spouse and other family members), flea bites (typically on legs), mosquito bites (central punctum)
    –Mixed infections: Intertrigo (present at skin folds or area of friction)
  • Noninfectious causes
    –Contact dermatitis (e.g. rhus dermatitis): May be revealed in contact history, linear vesicular lesions with sharp margins
    –Atopic dermatitis: Erythematous rash in flexural areas, patient with seasonal allergies and/or asthma
    –Eczematous dermatitis: Stasis dermatitis (hyperpigmented legs of patients with vascular disease), lichen simplex chronicus (anxious patient who chronically scratches), dyshidrotic eczema (on hands and feet with scaling, erythema, and minute vesicles and painful fissures), nummular eczema (round scaly lesions on dry skin, common in the winter)
    –Pityriasis rosea: Mostly on trunk in “Christmas tree” pattern, begins as single, larger “herald” patch
    –Lichen planus: Koebner reaction (lesions occur with trauma, such as linear lesions from scratching), purple, polygonal, pruritic papules
    –Psoriasis: Koebner reaction, pink, silvery scaling plaques, extensor surfaces, nail pits
  • Less common etiologies (“zebras”) include mycoses fungoides (referred to as Sézary syndrome if erythroderma, lymphadenopathy, and atypical circulating white blood cells are present), dermatitis herpetiformis, miliaria (heat rash)

Workup and Diagnosis

  • History and physical examination
    –Past medical and family history (e.g., asthma, psoriasis) and exposure history (e.g., poison ivy, oak, or sumac) are important, including whether the lesions are occurring for the first time or are recurrent
    –Perform a total body skin exam to evaluate distribution of rash; evaluate especially for rashes on the extensor or flexor surfaces of skin folds, and interdigital spaces
    –Note the morphology of the lesion (e.g., macule, papule, pustule, plaque, crust, vesicle, bulla, wheal)
    –Note the configuration of the lesion [e.g., linear (Koebner reaction or contact), grouped, annular, geographic]
  • Scrape lesions and perform KOH test if fungal infection is suspected (hyphae visible in dermatophyte infections, and pseudohyphae visible in Candida infections)
  • Wood's lamp test: Erythrasma turns coral red
  • Scrape possible burrow site to identify a mite in scabies
  • Patch testing may be done if allergic contact dermatitis is suspected
  • Punch biopsy may be done to establish a histologic diagnosis (e.g., mycosis fungoides)
  • Anti-gliadin antibodies and/or anti-endomysial antibodies may be found in the serum of patients with dermatitis herpetiformis
  • Consider referral to a dermatologist if diagnosis remains unclear

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Pruritis without Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Hepatobiliary disorders
    –Cholestasis of pregnancy: Pruritus is most severe in third trimester, ceases after delivery
    –Primary biliary cirrhosis: Increased anti-mitochondrial antibodies
    –Biliary obstruction: Pruritus not a presenting symptom
  • Endocrine disorders
    –Hypo- and hyperthyroidism
  • Hematopoietic disorders
    –Polycythemia vera: Pruritus classic after emerging from bath, described as severe and prickling
    –Hodgkin's lymphoma: Pruritus may present 5 years before diagnosis; pruritus portends a poor prognosis
    –Iron deficiency anemia
  • Chronic renal failure: pruritus begins 6 months after start of dialysis, affects up to 75% of patients during or immediately after dialysis
  • Malignancies: Adenocarcinoma, squamous cell carcinomas
  • HIV: Increasing frequency with disease progression
  • Psychogenic states: May have underlying personality disorder such as OCD
  • Senescence: Elderly pruritus very common
  • Drug reactions
  • Less common etiologies (“zebras”) include multiple myeloma, carcinoid syndrome, Waldenström's macroglobulinemia, parasitic infections (e.g., hookworm, onchocerciasis, ascariasis, trichinosis), hepatitis B and C, diabetes mellitus (results in perianal pruritus)

Workup and Diagnosis

  • History and physical examination
    –A focused history including past medical history, social history, family history, and sexual history is important
    –A complete review of systems may identify underlying disease (e.g., change in bowel habits with colon cancer, cold intolerance with hypothyroidism, right upper quadrant pain with hepatic disease)
    –Complete physical examination is necessary including stool exam for occult blood, and Pap smear and pelvic examination
    –Include a full body skin exam to confirm that there are no cutaneous rashes or lesions
  • Initial lab tests may include CBC with differential (look for eosinophilia associated with parasites), LFTs (alkaline phosphatase is the best screening test for hepatobiliary disorders), renal function tests, thyroid function tests
  • Rule out internal malignancies (e.g., chest X-ray, mammogram, stool for occult blood)
  • Other labs to consider: HIV test, hepatitis B and C panel, serum iron and ferritin, serum and urine protein electrophoresis, stool for ova and parasites, blind skin biopsy with or without immunofluorescence

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Scalp Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Seborrheic dermatitis (“cradle cap,” “dandruff”)
    –The most common scalp condition, it occurs across all age ranges
    –May be caused by Pityrosporum ovale
    –An inflammatory condition that causes itching and loose, silvery-white scale on scalp, and occasionally blepharitis
    –May also affect the eyebrows, nasolabial folds, external auditory canals, chin, anterior chest, upper back, and groin
    –Does not cause hair loss
    –The scalp is not usually erythematous, but other affected skin areas may be red, greasy, or oily
  • Tinea capitis
    –Most commonly caused by Trichophyton tonsurans or rarely Microsporum canis
    –Presents as patches of scale and/or pruritus with broken hairs, patchy hair loss (i.e., “black dot alopecia”)
    –May progress to a kerion (see below)
  • Kerion
    –A boggy, tender, subcutaneous fungal infection (dermatophyte)
    –Often has associated drainage and hair loss
  • Scalp folliculitis
    –Presents as recurrent, itchy, crusted papules or pustules
    –An overgrowth of Staphylococcus aureus
    • Psoriasis
      –Usually presents with plaques of thick, silvery, adherent scalp scale that overlies well-demarcated patches of erythema
      –Often occurs at the ears and occipital area
      –May be limited to the scalp, but often has skin disease, nail pitting, or nail dystrophy
    • Dissecting cellulitis of the scalp
      –Chronic, tender, boggy, often suppurative subcutaneous fluctuant masses
      –Occurs in black patients
      –May be associated with acne keloidalis, which can cause a scarring hair loss at the occiput
    • Discoid lupus
      –Presents initially as well-demarcated erythematous plaques of patchy, scarring scalp hair loss, then spreads centrifugally
  • Contact dermatitis

    • Workup and Diagnosis

    • History and physical examination
      –If the scalp scale is diffuse, white, and nonadherent, seborrheic dermatitis is the likely diagnosis
  • Bacterial culture from any intact scalp pustule or suppurating area may be helpful to confirm bacterial folliculitis or dissecting cellulitis
  • KOH prep of scalp scale or scalp hair can be assessed under a microscope in the office to confirm the presence of endothrix (spores within the hair shaft) in the hair or branching hyphae in the scalp scale
  • Fungal cultures can be obtained from the drainage of a kerion or from scalp scale scraped by a tongue depressor or sterile toothbrush
    –Hairs from the affected area can also be sent for fungal culture to rule out tinea capitus; the hairs must be plucked so that the root of the hair is available
    –Cultures may take several weeks and sensitivity varies widely based on clinician technique and lab handling
    • A punch or shave biopsy is usually unnecessary, but can aid in the diagnosis of seborrheic dermatitis
    • In cases of tinea capitis, only M. canis, which is uncommon in the U.S., fluoresces with a Wood's lamp

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    RASH, LOCAL: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis is similar to that of the general rash (see page 446).

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Papular rash: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Your first step is to fully evaluate the papular rash: Note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed changes in the rash since then? Is it itchy or burning, or painful or tender? Has there ever been discharge or drainage from the rash? If so, have the patient describe it. Also, have him describe associated signs and symptoms, such as fevers, headaches, and GI distress.

    Next, obtain a medical history, including allergies; previous rashes or skin disorders; infections; childhood diseases; sexual history, including sexually transmitted diseases; and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Papular rash: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Your first step is to fully evaluate the papular rash: Note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed any changes in the rash since then? Is it itchy or burning, or painful or tender? Have him describe associated signs and symptoms, such as fever, headache, and GI distress.

    Next, obtain a medical history, including allergies, previous rashes or skin disorders, infections, childhood diseases, sexual history, including any sexually transmitted diseases (STDs), and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Scaling Rash: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Eczema

    ❑ Atopic dermatitis

    ❑ Seborrheic dermatitis

    ❑ Tinea versicolor

    ❑ Pityriasis rosea

    ❑ Psoriasis

    ❑ Contact dermatitis

    ❑ Tinea corporis

    ❑ Tinea manuum

    ❑ Stasis dermatitis

    ❑ Drugs

    ❑ Lichen planus

    ❑ Secondary syphilis

    ❑ Reiter

    ❑ Bowen disease

    ❑ Cutaneous T-cell lymphoma

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Papular rash: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Find out when the rash erupted. Has the patient noticed any changes in the rash since then? Is it itchy or burning, or painful or tender? Have the patient describe associated signs and symptoms, such as fever, headache, and GI distress.

    Obtain a medical history, including allergies, previous rashes or skin disorders, infections, childhood diseases, sexual history, sexually transmitted diseases (STDs), and cancers. Has the patient recently been bitten by an insect or a rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Papular rash: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Your first step is to fully evaluate the papular rash: note its color, configuration, and location on the patient's body. Find out when it erupted. Has the patient noticed changes in the rash since then? Is it itchy or burning, or painful or tender? Has there ever been discharge or drainage from the rash? If so, have the patient describe it. Also, have him describe associated signs and symptoms, such as fevers, headaches, and GI distress.

    Next, obtain a medical history, including allergies; previous rashes or skin disorders; infections; childhood diseases; sexual history, including sexually transmitted diseases; and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    RASH, LOCAL: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis is similar to that of the general rash .

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Rash - Case 9-2: 7-Week-Old Girl: I. History of Present Illness
    (Pediatric Complaints and Diagnostic Dilemmas)

    A 7-week-old Caucasian girl had initially presented to a hematologist for evaluation of bruising. Her mother had noted several small purple bruises on her right arm and a linear bruise across her left cheek at age 3 weeks. At 5 weeks of life, she had been noted to have linear and circular bruises along her buttocks and legs. Laboratory evaluation at that time revealed a normal complete blood count and differential, normal prothrombin time (PT) and partial thromboplastin time (PTT), and normal platelet aggregation studies in response to adenosine diphosphate (ADP), collagen, and ristocetin. Epinephrine-induced platelet aggregation studies were mildly low but consistent with testing variability. Factor XIII level was normal.
    At 11 weeks of life, she was brought to the emergency department after having had a possible seizure at home. Her father reported that she had an episode of stiffening of her arms and body during her afternoon feeding. Her eyes had rolled back in her head. After stiffening, her body became limp and she had shallow breathing, but no cyanosis. The child had had decreased oral intake during the day before the episode. There was no recent history of fever, vomiting, diarrhea, or trauma. Immunizations, including diphtheria-tetanus-pertussis (DTaP) vaccine, had been given 2 days before the episode.

    II. Past Medical History

    The child was born at full term, of an uncomplicated pregnancy and delivery, and weighed 3,500 g at birth. She was delivered vaginally without complication. She had previously been evaluated for the bruising at her pediatrician 's office at 3 and 5 weeks of age, as noted. Child protective services had been contacted by the pediatrician for the bruising, but the case was determined to be unfounded and was closed. Family history was significant for an uncle with frequent nosebleeds and a first cousin who was born with a “platelet problem” that necessitated platelet transfusion at birth.

    III. Physical Examination

    T, 37.0°C; RR, 43/min; HR, 180 bpm; BP, 113/53 mm Hg
    Height, 50th percentile; weight, 50th percentile
    The physical examination was remarkable for a hemangioma of the left occiput, a hematoma of the tip of the tongue, and two ecchymotic areas on the right mandible, each about 1 cm in diameter. She had three 3- to 4-cm ecchymotic areas on the left back. A caf é-au-lait macule (1 cm) was seen on the left thigh. Lungs were clear. Cardiac examination revealed tachycardia but no murmurs, rubs, or gallops. There was no hepatosplenomegaly and no prominent adenopathy. Neurologically she was alert, crying, and moving all extremities. Funduscopic examination revealed right retinal hemorrhages. The rest of her examination was normal.

    VI. Diagnostic Studies

    Laboratory analysis revealed 18,800 WBCs/mm3, with 39% segmented neutrophils, 49% lymphocytes, and 11% monocytes. The hemoglobin was 11.4 g/dL, and there were 406, 000 platelets/mm 3. PT and PTT were normal. Electrolytes, BUN, and creatinine were normal. Alkaline phosphatase was 270 mU/mL. Other liver function studies were as follows: alanine aminotransferase, 100 IU/L; aspartate aminotransferase, 220 IU/L; and γ-glutamyltransferase, 46 IU/L. Examination of the cerebrospinal fluid revealed 8 WBCs/mm 3and 5,250 red blood cells/mm3. The glucose concentration was 60 mg/dL, and the protein concentration was 36 mg/dL. There were no organisms on Gram staining of the CSF.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003


     » Next page: Signs of Diaper rash

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