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28-Year-Old Female With Itchy Rash On Both Hands

Can you diagnose this case?

David L. Kaplan, MDSeries Editor

Signs and Symptoms

This 28-year-old woman presented for evaluation of an itchy rash on both hands, particularly along the edges, of approximately 2 weeks’ duration. She had been seeing her primary care physician over the past few months for a variety of gastrointestinal tract symptoms, including abdominal cramping and frequent loose stools, that had eluded diagnosis. She was being seen for a biopsy to evaluate for celiac disease or dermatitis herpetiformis. Her only medication was oral contraceptives, which she had been taking for years.

Which of the following explain this patient’s lesions?

Choose one to reveal diagnosis and discussion

Tinea manuum
Dermatitis herpetiformis
Bullous impetigo

ANSWER: Dyshidrosis

See the full case at Consultant360

A biopsy was performed, the results of which confirmed the clinical diagnosis of dyshidrosis.

The presentation of tinea manuum can be bullous but would be expected to have more scale than the lesions seen here. Psoriasis has a pustular variant, but it has a more erythematous, confluent base than what is seen here. Bullous impetigo usually has crusted erosions because the bullae are so fragile, unlike this patient’s lesions. Dermatitis herpetiformis usually affects the elbows and the knees, and its characteristic vesicles are minute and difficult to find, because the intense pruritus frequently results in lesions being excoriated.

This patient’s dyshidrosis was due to her atopic diathesis and excessive hand-washing associated with frequent loose stools. Unfortunately, the dyshidrosis diagnosis was not helpful in determining the etiology of her gastrointestinal tract symptoms.

David L. Kaplan, MD, is a clinical assistant professor of dermatology at the University of Missouri–Kansas City School of Medicine in Kansas City, Missouri, and at the University of Kansas School of Medicine in Kansas City, Kansas. He practices adult and pediatric dermatology in Overland Park, Kansas.