Diagnosis of Heat rash
Heat rash Diagnosis: Book Excerpts
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PRURITUS ANI:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
If the physical examination is normal, examination with an anoscope is essential. Sigmoidoscopy should also be done but is not adequate to detect hemorrhoids, anal fissures, and fistulas. If these are negative, a trial of antifungal creams (Lotrimin®, etc.) should be given before other expensive diagnostic tests are ordered. A Scotch tape test and stool for ovum and parasites are useful, especially in children.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PRURITUS, GENERALIZED:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the pruritus associated with a generalized rash? Almost every generalized rash may be associated with pruritus, but the most common ones are urticaria, dermatitis herpetiformis, eczema, scabies, and pemphigus.
- Is there hepatomegaly or jaundice? The presence of hepatomegaly or jaundice should make one think of obstructive jaundice, hepatitis, metastatic carcinoma to the liver, and biliary cirrhosis. However, almost any form of liver disease may be associated with pruritus.
- Is there polyuria, polydipsia, and polyphagia? These findings would suggest diabetes mellitus, hyperthyroidism, and pregnancy.
- Is there an unusual odor? The presence of an unusual odor should bring to mind the possibility of uremia, liver failure, or diabetic acidosis.
- Is there plethoric facies? The presence of plethoric facies suggests polycythemia vera.
DIAGNOSTIC WORKUP
If there is an associated skin rash, microscopic examination of a potassium hydroxide preparation of curetted burrows will be helpful. Additional examinations include Wood's lamp evaluation, a patch test, and skin biopsies. Therapeutic trials for scabies, fungal disease, or other disorders, however, are justified if testing is not economically feasible. Routine laboratory tests for the various systemic diseases that may cause pruritus include a CBC, sedimentation rate, urinalysis, chemistry panel, ANA assay, thyroid profile, and serum protein electrophoresis. A bone marrow examination and lymph node biopsy may be useful. A dermatologist, hematologist, or endocrinologist may help solve the diagnostic dilemma. Further workup may include plain films of the chest and abdomen and CT scans of the abdomen and pelvis. A bone scan may be useful in diagnosing metastatic carcinoma. HIV testing may be indicated if the patient has a history of high-risk sexual behavior.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PRURITUS, VULVAE:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there a vaginal discharge? The presence of a vaginal discharge should suggest candidiasis, trichomoniasis vaginitis, and bacterial vaginitis.
- Is there a rash? The presence of a rash would suggest eczema, herpes simplex, folliculitis, scabies, and tinea infections.
- Are there vulval or vaginal lesions? The presence of a lesion in the vulva or vagina would suggest kraurosis vulvae, leukoplakia or vulval carcinoma, condylomata lata, and condylomata acuminata.
DIAGNOSTIC WORKUP
If there is a discharge, microscopic examination of a potassium hydroxide preparation and saline preparation is necessary. A smear and culture of the discharge should be done for bacteria and fungi. Scrapings of the burrows for scabies may be useful. Skin biopsy may help diagnose the cause of a rash. Lesions should be biopsied also. If senile vaginitis is suspected, serum FSH and estradiol and a Pap smear may help determine if there is estrogen deficiency. A gynecologist should be consulted in all difficult diagnostic problems.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Pruritus:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Urticaria
–Hypersensitivity reaction causing edema via mast cell/basophil release of histamine, kinins, prostaglandins, and serotonin, mostly IgE-mediated
–Hives; subcutaneous and mucous membranes
–Angioedema: Most cases acute (resolving within 48 hours); chronic >6 weeks
–Anaphylaxis: May be life-threatening
-
Atopic dermatitis
–Incidence 2–10%; often begins in infancy
–Most cases improve with age
–Frequent remissions/exacerbations
–Increased risk of infection (herpes, eczema
herpeticum; staph, strep)
–Can be exercise-induced
-
Xerosis (dry skin)
–Idiopathic or due to excessive bathing, low humidity, etc.
-
Tinea (dermatophytoses, “ringworm”)
–Fungal infection (Trichophyton,
Microsporum, Epidermophyton)
–Scalp (tinea capitis), face, trunk, extremities
(t. corporis), feet (t. pedis)
–complications: superinfection and kerion
-
Contact dermatitis
–Allergens (poison ivy, cosmetics, dyes,
drugs, foods, jewelry/nickel, animals)
–Irritants (soap, chemicals, wool, fiberglass)
-
Scarlet fever (group A strep): “Sandpaper rash,” incubation period 1–7 days; age 5–15 years, 15–20% colonized (oropharyngeal)
-
Herpes: Varicella, zoster, herpes simplex
-
Lice (pediculosis): Head or pubic area
-
Mites (scabies [Sarcoptes scabiei])
-
Pinworms (Enterobius vermicularis)
-
Cholestasis (TPN, biliary atresia)
-
Erythema multiforme (“bull's eye rash”): Stevens-Johnson syndrome
-
Drug-induced: Opiates, barbiturates, isoniazid, phenothiazines, erythromycin
-
Systemic diseases: Malignancies, renal failure, mastocytosis, SLE, JRA, hypo- and hyperthyroidism, DM
-
Prurigo gestationis
-
Parasites (“swimmer itch,” trematodes)
-
Chronic skin diseases (psoriasis)
Workup and Diagnosis
- History and physical exam
–Location, duration, rash, exposure, chronic illness, associated symptoms, ill contacts
–Urticaria: Exposure to foods, drugs, bacteria, viruses, insect bites, etc.; wheals (erythematous, raised, well-circumscribed lesions) usually self-limited; may also have angioedema, wheezing, stridor, hoarseness, anaphylaxis, hypotension
–Atopic dermatitis: Family history; ill-defined, erythematous, scaly plaques; in infant, head, extensor surfaces, and trunk; in child, antecubital/popliteal fossae, neck, wrist/ankle; may also have Morgan folds (lines under lower eyelids)
–Tinea: Erythematous, scaly, circular plaque with central clearing; kerion is inflammatory, painful mass with sterile pustules and regional lymphadenopathy
–Poison ivy: Linear streaks of vesicles, may last several weeks; exposure to poison ivy, oak, or sumac
–Lice: Nits on hair shafts
–Mites: 1–2 mm papules and burrows on palm, sole, interdigital web, axilla, genitalia, wrist, ankle
–Pinworm: Nocturnal anal pruritus
–Scarlet fever: Erythematous, finely granular rash, most
prominent in axilla and groin, circumoral pallor
-
Pinworm: Apply tape to anus, see microscopic egg
-
Scarlet fever: Throat culture or antigen detection
-
Tinea: KOH preparation, culture, or Wood lamp to confirm diagnosis (usually diagnosed clinically)
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
PRURITUS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
It should be obvious that the clinical approach to pruritus without an obvious dermatologic manifestation is to order appropriate tests. See below to rule out the above systemic disorders.
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Source: Differential Diagnosis in Primary Care, 2007
Pruritus:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after he falls asleep. (Generally, pruritus related to dermatoses prevents — but doesn’t disturb — sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (physical exertion, bathing, applying makeup, or the use of perfumes)?
Ask the patient how he cleans his skin. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants, such as glass fiber insulation or chemicals? Ask about the patient’s general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Then obtain a complete drug history.
Examine the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Heat intolerance:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when he first noticed his heat intolerance. Did he gradually use fewer blankets at night? Does he have to turn up the air conditioning to keep cool? Is it hard for him to adjust to warm weather? Does he sweat in a hot environment? Find out if his appetite or weight has changed. Also, ask about unusual nervousness or other personality changes. Then take a drug history, especially noting the use of amphetamines or amphetamine-like drugs. Ask the patient if he takes a thyroid drug. If so, what’s the daily dose? When did he last take it?
As you begin the examination, notice how much clothing the patient is wearing. After taking his vital signs, inspect his skin for flushing and diaphoresis. Also, note tremors and lid lag.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Pruritus ani:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
A detailed patient history is essential. Rectal examination rules out fissures and fistulas; biopsy rules out cancer. Allergy testing may also be helpful.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Pruritus:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after hefalls asleep. (Generally, pruritus related to dermatoses prevents—but doesn’t disturb—sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (physical exertion, bathing, applying makeup, or use of perfumes)?
Ask the patient how he cleans his skin. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants such as glass fiber insulation or chemicals? Ask about the patient’s general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have any pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Obtain a complete drug history.
Examine the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Heat intolerance:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when he first noticed his heat intolerance. Did he gradually use fewer blankets at night? Does he have to turn up the air conditioning to keep cool? Is it hard for him to adjust to warm weather? Does he sweat a lot in a hot environment? Find out if his appetite or weight has changed. Also, ask about unusual nervousness or other personality changes. Then take a drug history, especially noting use of amphetamines or amphetamine-like drugs. Ask the patient if he takes a thyroid drug. If so, what is the daily dosage and when did he last take it?
As you begin the examination, notice how much clothing the patient is wearing. After taking vital signs, inspect the patient’s skin for flushing and diaphoresis. Also, note tremors and lid lag.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Pruritus:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The history frequently suggests whether the pruritus is primary or secondary, and often provides clues to its cause. In taking the history, ascertain the location and duration of the pruritus, exacerbating and alleviating factors, and the patient’s medications, occupation, travel, bathing habits, and family history of atopy or cancer. Also ask about possible pregnancy, diabetes mellitus, chronic renal failure, or hepatic disorders. Onset or worsening of the itching in winter would suggest xerosis. The presence of itching in family members or a household pet raises concern that the cause is an infection from a scabies or a nonscabies mite. Pruritus during or after bathing is characteristic of aquatic pruritus. Exposure to chemicals, new soaps, or detergents could cause allergic or irritant dermatitis. The review of systems often reveals other medical disorders that can be associated with pruritus (section
I.C.).
Physical examination
The physical examination includes a thorough examination of the skin in adequate lighting. Direct special attention to skin areas not easily observed or reached by the patient. Such areas may reveal a primary skin disorder or evidence of a systemic disease because some disorders present in particular areas. For example, scabies involves the interdigital webs, volar wrists, and genitalia, whereas atopic dermatitis occurs in the antecubital or popliteal fossae. Pityriasis rosea typically has a “herald patch” on the trunk. Fungal infections tend to occur in warm, dark, moist body surfaces (e.g., genitalia, feet, and inguinal folds).
Be able to recognize the classic signs of common skin disorders. Dematographism and wheals typically indicate uticaria (hives) (Chapter 13.7). Flat-topped polygonal papules with delicate white lines (“Wickham’s straiae”) are characteristic of lichen planus. Silver plaques on an erythematous base with a positive Auspitz sign (punctuate bleeding of the scale after blunt scraping) are characteristic of psoriasis. The application of lateral pressure on superficial, crusting lesions resulting in dislodging the epidermis, referred to as Nikolsky’s sign, indicates pemphigus foliaceus. The differential diagnosis of lymphadenopathy includes mycosis fungoides (Chapter 15.1). Pustular or lesions over hair follicles is a sign of folliculitis. Pay attention to new unscratched lesions because chronically excoriated skin from any cause has similar secondary changes. If lesions are present in unreachable areas, a systemic disease should be considered. In addition to the skin, examine other organ systems for organomegaly, lymphadenopathy, goiter, pregnancy, and signs of anemia or psychiatric disorders.
Diagnostic tests
If the history and physical examination do not reveal the diagnosis, certain tests can be helpful. For primary skin disorders the testing should include a wet preparation, the addition of potassium hydroxide (KOH), microscopic examination of scrapings, and as a last resort, skin biopsy. If a systemic disorder is suspected, include the following in the evaluation: a complete blood count with differential; tests for liver, renal, and thyroid function; stool for occult blood; human immunodeficiency (HIV) screen; serologic test for syphilis; and a chest radiograph. If the history and physical examination suggest other systemic diagnoses, additional recommended tests to consider include urinalysis, serum iron studies, stool for ova and parasites, serum glucose, and serum electrophoresis.
Diagnostic assessment
The diagnostic approach should initially be limited to the history and physical examination because most patients have a primary skin disorder (section I.A., I.B.). If the diagnosis is still unclear, 2 weeks of empirical treatment for the most common cause of pruritus (xerosis) is recommended. This includes less-frequent baths, use of lukewarm water and a mild soap, “pat” drying after a bath, immediate application of a lubricant, and avoidance of irritating fabrics (e.g., wool) (5). Further diagnostic tests for systemic disorder can be considered to rule out the more obscure diagnoses listed above. Because malignancy can present several years after pruritus, follow-up is important. Sometimes, no cause is found. Remember, a diagnosis of psychogenic pruritis is a diagnosis of exclusion. The relationship between the psyche and organic disease is unclear. Depression, anxiety, and other psychiatric disorders can be secondary instead of the primary illness. It is important to follow up with appropriate psychiatric or dermatologic consultation as needed.
References
1. Greco PJ, Ende J. Pruritus: a practical approach. J Gen Intern Med 1992;7:172–181.
2. Leshaw SM. Itching in active patients. Phy and Sports Med 1998;26(1):47–53.
3. Beacham BE. Common dermatoses in the elderly. Am Fam Physician 1993;47(6):
1445–1450.
4. Lober CW. Should the patient with generalized pruritus be evaluated for malignancy? [Editorial]. J Am Acad Dermatol 1988;2(Part 1):350–352.
5. Phillips WG. Pruritus. What to do when the itching won’t stop. Postgrad Med 1992;
92(7):34–53.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Pruritus:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after hefalls asleep. (Generally, pruritus related to dermatoses prevents — but doesn’t disturb — sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (exercising, bathing, applying makeup, or using perfumes)?
Ask the patient how he cleans his skin. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants, such as glass fiber insulation or chemicals? Ask about the patient’s general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have any pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Then obtain a complete drug history.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Pruritus:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after he falls asleep. (Generally, pruritus related to dermatoses prevents—but doesn't disturb—sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (physical exertion, bathing, applying makeup, or the use of perfumes)?
Ask the patient how he cleans his skin and clothes. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants, such as glass fiber insulation or chemicals? Ask about the patient's general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Obtain a complete drug history. Ask about abdominal pain and the appearance of stools.
Examine the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses. Note any jaundice. Check for hepatomegaly or abdominal pain.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Heat intolerance:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when he first noticed his heat intolerance. Did he gradually use fewer blankets at night? Does he have to turn up the air conditioning to keep cool? Is it hard for him to adjust to warm weather? Does he sweat in a hot environment? Find out if his appetite or weight has changed. Also, ask about unusual nervousness or other personality changes. Then take a drug history, especially noting the use of amphetamines or amphetamine-like drugs. Ask the patient if he takes a thyroid drug. If so, what's the daily dose? When did he last take it?
As you begin the examination, notice how much clothing the patient is wearing. After taking his vital signs, inspect his skin for flushing and diaphoresis. Also, note tremors and lid lag.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
PRURITUS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
It should be obvious that the clinical approach to pruritus without an
obvious dermatologic manifestation is to order appropriate tests. See below
to rule out the above systemic disorders.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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