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August 2015: Dermatology

A 32-year-old floor hand presents to the medic with a complaint of itching armpits for one week. He noticed some redness in his axillae about one week prior that began as a small area of redness that has significantly increased throughout the week. The irritation seemed to worsen during his shifts and while taking a hot shower. He is on day 14/21 of his hitch.

On review of systems he denies fever, chills, joint or muscle pains, dysuria, hematuria, diarrhea, constipation, nausea or vomiting

  • Past History: Diabetes
  • Past Surgical History: Bariatric surgery (2004)
  • Current Medications: Metformin (Glucophage) 500 mg bid
  • Immunization Status: Tetanus and influenza are up to date
  • Social History: Social drinker, dips 1 can/day
  • Family History: Mother with diabetes, father with vitiligo

Vitals

  • Temp: 99.3
  • Pulse: 68
  • Respirations: 14
  • Blood pressure: 129/78
  • Pulse Ox: 98% RA

Physical Exam

  • General: Alert and Oriented x 4, no acute distress
  • HEENT: AT/NC, eyes anicteric, TMs clear, nose clear, mucus membranes somewhat dry, no lesions appreciated
  • Cardio: regular rhythm and rate, no murmurs appreciated
  • Lung: clear to auscultation bilaterally
  • GU: normal external genital exam
  • Extremities: no clubbing, cyanosis or edema
  • Skin: Cool and dry, erythematous patches in the inguinal region bilaterally, erythematous patches in the axillae with surrounding miliaria rubra (red bumps)

 

Source: Michael D. Kotler, MD

Lab Work

 

How would you approach this patient?

Differential Diagnosis

  • Miliria (heat rash)
  • Folliculitis
  • Tinea corporis (ring worm)
  • Eczema
  • Hives
  • Acne
  • Impetigo
  • Hidradenitis suppurativa
  • Drug reaction

Diagnosis: Miliria (Heat Rash)

Treatment:

  • Clean skin with soap and water multiple times daily
  • Take cool showers/baths
  • Dry skin thoroughly
  • Change to dry uniform/shirt 2-3 times per shift
  • Topical hydrocortisone or triamcinolone
  • Antihistamines (loratidine, cetirizine, diphenhydramine)

Discussion:

Heat rash is commonly seen in hot, humid environments where excessive sweating occurs. Over time the pores of the skin become clogged and as they are continuously exposed to the heat, they become irritated and itchy.

When considering treatments for heat rash, the condition is usually self-limited lasting only for a few days. Avoidance is the key to preventing heat rash. To avoid heat rash it is important to

  • Change clothes frequently
  • Avoid excessive heat exposure when possible or take frequent breaks in a cool environment
  • Allow exposed skin to air dry
  • Maintain adequate hydration

However, if the rash persists additional care may be required such as a hydrocortisone cream along with an antihistamine. Be cautious using antihistamines as they may cause drowsiness, especially with diphenhydramine (Benadryl).  Be sure the patient does not take sedating medications while on tower.

Heat rash may also be complicated with bacterial or fungal infections requiring a topical antibiotic or antifungal. If the rash continues, the condition may not be heat related and would require further evaluation, possibly including a skin biopsy, which would require a CASEVAC.

 

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