Mrs. Jones is a 70-year-old woman you are admitting to the skilled nursing facility after a total hip replacement. When you obtain her past medical history, she reports a problem with a chronic rash under her breasts and in her supragluteal fold. She has tried a number of topical antifungal treatments without success. She has never seen a dermatologist. While she finds the rash a nuisance and experiences an occasional increase in itchiness, it is something she can live with. Her primary care provider diagnosed the rash as Candida and encouraged her to keep the area clean and dry and to use antifungals. Recently, her 42-year-old daughter was diagnosed with psoriasis and asked about a family history of the disease. Mrs. Jones was unaware of anyone in her or her husband’s family with that diagnosis. On physical examination, you note a shiny, erythematous lesion with symmetrical distribution under both breasts. It is well demarcated without drainage and without the presence of any satellite lesions. Examination of the gluteal fold reveals a similar well-demarcated, shiny, erythematous lesion without drainage. On close inspection of the rest of the body around the umbilicus, you note an erythematous patch with silvery scale. You ask Mrs. Jones about the lesion, and she states that it has been there for years. The lesion is worse in the winter, but she attributes this to the closures on her skirts and pants causing irritation. She reports some improvement when applying OTC hydrocortisone cream, although when she stops using the cream, the lesion returns. For this case, the answers and rationale for your decision making need to be provided. 1. What clues in Mrs. Jones’ history can help you determine her diagnosis? 2. What signs on physical examination are most helpful to defend or refute the differential? 3. How would you classify the severity of Mrs. Jones’ disease? Be specific in your explanation.
Mrs. Jones is a 70-year-old woman you are admitting to the skilled nursing facility after a total hip replacement. When you obtain her past medical history, she reports a problem with a chronic rash under her breasts and in her supragluteal fold. She has tried a number of topical antifungal treatments without success. She has never seen a dermatologist. While she finds the rash a nuisance and experiences an occasional increase in itchiness, it is something she can live with. Her primary care provider diagnosed the rash as Candida and encouraged her to keep the area clean and dry and to use antifungals. Recently, her 42-year-old daughter was diagnosed with psoriasis and asked about a family history of the disease. Mrs. Jones was unaware of anyone in her or her husband’s family with that diagnosis.
On physical examination, you note a shiny, erythematous lesion with symmetrical distribution under both breasts. It is well demarcated without drainage and without the presence of any satellite lesions. Examination of the gluteal fold reveals a similar well-demarcated, shiny, erythematous lesion without drainage. On close inspection of the rest of the body around the umbilicus, you note an erythematous patch with silvery scale. You ask Mrs. Jones about the lesion, and she states that it has been there for years. The lesion is worse in the winter, but she attributes this to the closures on her skirts and pants causing irritation. She reports some improvement when applying OTC hydrocortisone cream, although when she stops using the cream, the lesion returns. For this case, the answers and rationale for your decision making need to be provided.
1. What clues in Mrs. Jones’ history can help you determine her diagnosis?
2. What signs on physical examination are most helpful to defend or refute the differential?
3. How would you classify the severity of Mrs. Jones’ disease? Be specific in your explanation.
4. What would be the treatment(s) of choice in her case?
5. What are some important points to include in patient education?
6. What would require a referral to a dermatologist?
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