What's Your Assessment? Part I
What's Your Assessment? Part I
This 58-year-old male presented to the dermatology clinic complaining of a painful dermatitis on both buttocks for the past 3 days. The rash started after an all-day fishing trip. The weather was very hot and he wore snug-fitting pants that covered him from the waist to his ankles. He denies any rash similar in the past. He has applied his wife's dry skin cream to the site for 2 days but with no improvement. Yesterday his wife noted small pustules around the boarder of the dermatitis. He is an insulin-dependent diabetic and has been self-administering insulin daily for 10 years. He also has hypertension and takes metoprolol XL 50 mg daily. He is employed as a stockbroker and was on vacation prior to the onset of the rash.
The primary lesion is a very erythematous papule (see Figure 1). A large, confluent plaque is present on his right buttock extending laterally from the intragluteal cleft. On closer view of the dermatitis (see Figure 2), the eruption extends down the thigh. Note that the areas on the thigh and the lateral boarder on the hip have small pustules. There are also small satellite pustules surrounding the boarder.
(Enlarge Image)
A large, confluent plaque on the right buttock extends laterally from the intragluteal cleft.
(Enlarge Image)
Small pustules are present on the thigh and the lateral boarder of the hip.
1. Candidiasis is the correct answer. A dermatitis caused by a candida or yeast infection is characterized by a very red, angry-appearing dermatitis and may have satellite pustules. It is caused by the organism C. albicans. It is a cutaneous disease that occurs in moist, dark, body folds such as the buttocks, under the breast in obese patients where the breast is very pendulous, and on the glans penis in uncircumcised males.
2. Contact dermatitis should be considered because of the sharply marginated boarders. This dermatitis could be a contact dermatitis except for two factors: first, the patient wore full length pants the day he went fishing; second, there are small satellite pustules which is a hallmark of a yeast infection.
3. Tinea corporis is a common infection in persons with diabetes. It can occur anywhere on the body and is characterized by a plaque with central clearing. Tinea does not present with satellite lesions. Tinea usually presents with scale on the plaque and always around the boarders of the plaque.
4. Drug eruption would be highly unlikely due to the distribution of the dermatitis. A drug eruption is characterized by macules and papules, not plaques. Also, a drug eruption involves the entire body, never just a particular area, such as the buttocks.
Candidiasis can be very uncomfortable. Cool soaks can provide soothing comfort and, if the lesions are moist, can aid in drying the lesions. Tight pants should be avoided because they can rub and cause more discomfort. Topical anti-yeast preparations can clear the lesions slowly.
A Candida infection in a person with insulin-dependent diabetes can take a long time to resolve with topical therapy alone. Warm weather further complicates the healing process. Usually an extensive Candida infection in a person with insulin-dependent diabetes is best treated with an oral antifungal such as fluconazole taken for 10 to 14 days. Topical therapy should also be continued in addition to the oral medication. This dermatitis will resolve with post-inflammatory hyperpigmentation that may take months to resolve.
This 58-year-old male presented to the dermatology clinic complaining of a painful dermatitis on both buttocks for the past 3 days. The rash started after an all-day fishing trip. The weather was very hot and he wore snug-fitting pants that covered him from the waist to his ankles. He denies any rash similar in the past. He has applied his wife's dry skin cream to the site for 2 days but with no improvement. Yesterday his wife noted small pustules around the boarder of the dermatitis. He is an insulin-dependent diabetic and has been self-administering insulin daily for 10 years. He also has hypertension and takes metoprolol XL 50 mg daily. He is employed as a stockbroker and was on vacation prior to the onset of the rash.
The primary lesion is a very erythematous papule (see Figure 1). A large, confluent plaque is present on his right buttock extending laterally from the intragluteal cleft. On closer view of the dermatitis (see Figure 2), the eruption extends down the thigh. Note that the areas on the thigh and the lateral boarder on the hip have small pustules. There are also small satellite pustules surrounding the boarder.
(Enlarge Image)
A large, confluent plaque on the right buttock extends laterally from the intragluteal cleft.
(Enlarge Image)
Small pustules are present on the thigh and the lateral boarder of the hip.
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1. Candidiasis is the correct answer. A dermatitis caused by a candida or yeast infection is characterized by a very red, angry-appearing dermatitis and may have satellite pustules. It is caused by the organism C. albicans. It is a cutaneous disease that occurs in moist, dark, body folds such as the buttocks, under the breast in obese patients where the breast is very pendulous, and on the glans penis in uncircumcised males.
2. Contact dermatitis should be considered because of the sharply marginated boarders. This dermatitis could be a contact dermatitis except for two factors: first, the patient wore full length pants the day he went fishing; second, there are small satellite pustules which is a hallmark of a yeast infection.
3. Tinea corporis is a common infection in persons with diabetes. It can occur anywhere on the body and is characterized by a plaque with central clearing. Tinea does not present with satellite lesions. Tinea usually presents with scale on the plaque and always around the boarders of the plaque.
4. Drug eruption would be highly unlikely due to the distribution of the dermatitis. A drug eruption is characterized by macules and papules, not plaques. Also, a drug eruption involves the entire body, never just a particular area, such as the buttocks.
Candidiasis can be very uncomfortable. Cool soaks can provide soothing comfort and, if the lesions are moist, can aid in drying the lesions. Tight pants should be avoided because they can rub and cause more discomfort. Topical anti-yeast preparations can clear the lesions slowly.
A Candida infection in a person with insulin-dependent diabetes can take a long time to resolve with topical therapy alone. Warm weather further complicates the healing process. Usually an extensive Candida infection in a person with insulin-dependent diabetes is best treated with an oral antifungal such as fluconazole taken for 10 to 14 days. Topical therapy should also be continued in addition to the oral medication. This dermatitis will resolve with post-inflammatory hyperpigmentation that may take months to resolve.
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