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Probability diagnosis

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Atopic dermatitis (eczema)

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Contact dermatitis (irritant and allergic)

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Urticaria

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Insect bites/infestations

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Psoriasis

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Simple pruritus (cause not found)

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Other disorders

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Infection/infestations:

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  • scabies

  • pediculosis (scalp, body, pubic)

  • tinea cruris

  • Candida intertrigo

  • bed bugs

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Non-infection:

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  • pityriasis rosea

  • lichen planus

  • dermatitis herpetiformis

  • asteatosis (dry skin)

  • prickly heat (miliaria/heat rash)

  • Grover disease

  • chilblains

  • seborrhoeic dermatitis (usually mild)

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Consider (rare):

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  • myeloproliferative disorders

  • cutaneous T-cell lymphoma

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Masquerades checklist

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Depression

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Diabetes

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Drugs

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Is the patient trying to tell me something?

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Psychogenic including dermatitis artefacta.

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Key history

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Includes past history, especially chronic dermatoses (particularly atopic dermatitis and contact dermatitis), diabetes and psychological disorders. Enquire about exposure to infestations such as ‘backpacker’ lodgings, scabies and sexual contact. Drug history is important.

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Key examination

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  • General and localised examination of the skin

  • Note any scratch marks

  • Look for evidence of insects such as scabies, lice and bed bugs, the violaceous rash of lichen planus and the vesicles of dermatitis herpetiformis

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Key investigations

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  • FBE/ESR

  • Blood sugar

  • Microscopic examination of skin scrapings

  • Skin biopsy

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Diagnostic tips

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  • Pruritus is a feature of dry skin, common in the elderly.

  • An intense localised itch is suggestive of scabies or bed bugs.

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