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Dermatology Practice Today

Top 5 Summertime Dermatoses

Published June 28, 2013 11:11 AM by Raymond Shulstad
As the temperatures rise and people begin to venture outdoors to enjoy all the activities that come with beautifully sunny days, providers will see an influx of patients presenting with a variety of dermatoses. Over the last 12 years in practice, this is my empirically derived top 5 list of what to look for and how to treat it.
  1. Irritant/Allergic Contact Dermatitis: As the diagnosis implies, these patients will present with a pruritic eruption after coming in contact with something that they were either allergic to or sensitive to. The distribution is usually seen in exposed skin areas on the arms and legs. Most people will report that they were working in the yard, pulling weeds, trimming bushes, cleaning with harsh chemicals, fertilizing, or spraying weed/insect killers. If patients were going without a shirt or wearing a tank-top or bathing suit top, the rash can also appear on the abdomen or chest; the back is usually spared. The reason is that people will cut limbs, pull weeds, cut the grass and then pick up the clippings and hold them against their body to put in lawn bags/compost areas. The eruptions are erythematous with evidence of excoriations. Treatment includes topical steroids class 1-3 (5-6 for face) twice daily until clear or no longer than 2 weeks and avoidance of repeat exposure. This is a self-limited condition and would resolve if we did nothing, so symptom management is the key.
  2. Discoid Lupus: Presents as multiple annular/semi-annular erythematous pruritic plaques erupting in sun exposed regions, usually within 24 - 48 hours. Patients may believe they have contracted a fungal infection but the pruritis and rapid development can eliminate this as a potential diagnosis. Gutatte psoriasis and nummular eczema can be excluded because they tend to improve with sun exposure. Biopsies should be taken to confirm the diagnosis and an ANA ordered to rule out systemic lupus. Treatment once again relies heavily on topical steroids classes 1-3 and avoiding sun exposure. Sun block and protective clothing should be used daily.
  3. Tinea Versicolor: Fungal infection presenting most commonly after sun exposure. Common presentations include hypopigmented, annular macules on the exposed areas of the trunk, upper arms and thighs. The sun has nothing to do with the infection itself, the affected areas just don't pigment normally and patients will say they have "sun spots" or look like a leopard. Mild pruritis can be seen, but is rare. Treatment includes topical antifungal shampoos applied like a lotion to the exposed areas, allowed to sit for 15 minutes then rinsed. Done correctly every day for two weeks, most will be clear of the infection but should continue to use the shampoo in this fashion once or twice a week. Repigmentation can take several months to occur. In extreme cases, oral ketoconazole can be used.
  4. Cutaneous Herpes Simplex Type I: The same virus that causes "cold sores" can result in a cutaneous eruption. Seen commonly on the back 24 - 28 hours after sun exposure, the patient will present complaining of an itchy, slightly burning sensation on the affected area. On examination, there is usually a well demarcated erythematous patch with multiple small vesicles or scabbed papules. This can be differentiated from shingles by its limited surface area; spots tend to be small and don't follow a dermatome. Also itching tends to be reported more than intense pain and this area tends to break out repeatedly in the same location whereas shingles is usually one and done. Treatment includes antiviral medication and sun protective measures. Patients should also be made aware that this is contagious so sharing of towels and clothes is ill advised.
  5. Photoallergic Drug Eruption: Differentiated from a drug allergy by the distribution and sun exposure being the precipitating factor. Eruptions occur most commonly on the forearms but can occur in any area of prolonged sun exposure. Unlike drug allergies which cause an overall erythematous eruption and is associated with an actual allergy to a medication, this eruption is caused by a metabolite of a medication reacting with UV radiation. It is important to differentiate because the patients do not need to change their medication - they need to avoid sun exposure. Topical steroids can be used to calm flares but UV avoidance is curative.

I hope this list can help narrow down the diagnoses that you will be seeing soon as temperatures rise and UV exposure increases. 

3 comments

Great information! Thank you!

Tiffany Contet, PA-C July 6, 2013 5:21 PM
CO

Excellent! Thank you for the tips on summer complaints.

Laurel, women's health - ARNP, clinic July 3, 2013 1:39 PM
Italy FL

Great article!!! I have shared this with my colleagues.

Karen, FNP July 3, 2013 11:27 AM

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    Occupation: Physician assistant and nurse practitioners
    Setting: Various dermatology settings
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