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Comprehensive i-Human Case Study Week #4: A 25-
Year-Old Male Patient with Skin Problem (Class
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i - Human Week #4 Case Study: Evaluation and Treatment of Seborrheic Dermatitis in a Young Adult .
- Location: Face (primarily cheeks), anterior neck, upper chest
- Character: Red papules, some with fine scale and occasional vesicles
- Severity: Mild discomfort; no sleep disturbance
- Aggravating Factors: Heat and sweating may worsen symptoms
- Relieving Factors: Cool compresses; some relief with OTC hydrocortisone
- Associated Symptoms: No fever, no fatigue, no systemic complaints
- Prior Episodes: Denies previous similar episodes
- Exposures: No new skin care products, no known allergens, no recent outdoor exposure, no sick contacts
4. Past Medical History (PMH)
- Chronic Illnesses: None
- Childhood Illnesses: Normal childhood history
- Previous Dermatologic Conditions: Denies eczema, psoriasis, or acne vulgaris history
- Hospitalizations/Surgeries: None
5. Medications
- Current: None routinely
- Over-the-Counter: Occasional ibuprofen for headaches; hydrocortisone 1% cream used once daily for past 3 days
- Supplements: None
6. Allergies
- Medications: No known drug allergies (NKDA)
- Food/Environmental: Denies any known food or environmental allergies
7. Immunizations
- Up to date on routine adult vaccinations
- COVID-19 vaccines completed
- No recent travel-related vaccines
8. Family History (FH)
- Mother: Alive and well, age 55, no known chronic conditions
- Father: Alive, age 58, hypertension
- Siblings: One younger brother, healthy
- Skin Conditions: No family history of atopic dermatitis, psoriasis, or autoimmune diseases
9. Social History (SH)
- Living Situation: Lives in an apartment with a roommate
- Occupation: Office worker in IT; desk job with moderate screen time
- Tobacco: Denies use
- Alcohol: Occasional social drinking (1–2 drinks/week)
- Drugs: Denies recreational drug use
- Sexual History: Sexually active with one female partner, monogamous, uses condoms regularly
- Pets/Animals: No pets
- Travel: No recent travel; no hot tub, hiking, or tropical exposure
10. Review of Systems (ROS)
(Pertinent positives/negatives only) General
- Denies fever, chills, fatigue, weight loss Skin
- Positive for red rash, mild pruritus, some flaking
- Denies pain, oozing, open wounds, or bleeding HEENT
- No eye discharge or visual changes
- Chief Complaint (CC): 25 - year-old male presents with a new rash on his face and neck, accompanied by mild itching.
- History of Present Illness (HPI): Onset ~1 week ago with initial red papules on cheeks. Gradually spread to neck and upper chest. Occasionally vesicular, with clear fluid. Mild pruritus, no pain. No fever or other systemic symptoms. No prior similar episodes. 2. Patient Data
- Age/Gender: 25 - year-old male
- Medical History: Generally healthy, no chronic diseases. No known allergies.
- Medications: No regular prescriptions. Occasionally uses ibuprofen.
- Social History: Non-smoker, occasional alcohol. Works in an office environment. No recent travel. No pets.
- Sexual History: Monogamous relationship, no new partners.
- Family History: No significant dermatological or autoimmune conditions. 3. Symptoms & History
- Onset: 1 week
- Location: Face, neck, upper chest
- Quality: Papular/vesicular rash, red, itchy
- Severity: Mild itching, tolerable
- Timing: Persistent since onset
- Modifying Factors: Mildly relieved by over-the-counter hydrocortisone cream
- Associated Symptoms: No fever, malaise, or systemic signs 4. Differential Diagnosis
- Contact dermatitis (allergic or irritant)
- Atopic dermatitis
- Seborrheic dermatitis
- Viral exanthem or herpetic infection
- Folliculitis
- Dermatophytosis (tinea)
- Acneiform eruption
- Pityrosporum (Malassezia) folliculitis
5. Examination Findings
- Skin exam: Erythematous papules and occasional vesicles on malar areas, neck, and upper chest.
- Distribution: Symmetrical on cheeks and neck; some clustering around follicles.
- Skin texture: Slight scale in some vesicular areas.
- No excoriations or secondary infection noted.
- Lymph nodes: No palpable cervical lymphadenopathy.
- General exam: Within normal limits. 6. Diagnostic Workup
- Clinical evaluation is usually sufficient for common dermatitis cases.
- Diagnostics if needed: o KOH prep: Look for fungal elements if suspect tinea or Malassezia. o Patch testing: For allergic contact dermatitis. o Skin scraping/culture: If folliculitis (bacterial) suspected. o Viral PCR/swab: If herpetic process suspected. ✅ 7. Final Diagnosis Given the appearance (papulovesicular rash), distribution (seborrheic areas), mild itchiness, and lack of systemic symptoms, the most likely diagnosis is seborrheic dermatitis with possible superimposed Malassezia folliculitis. 8. Treatment Plan
First-line Management:
- Topical antifungal shampoo/cream: Ketoconazole 2% cream or shampoo applied to face/neck areas daily for 2–4 weeks.
- Mild topical corticosteroids: Low-potency hydrocortisone 1% cream, sparingly (≤ twice daily) to reduce inflammation.
- Topical calcineurin inhibitors: Pimecrolimus or tacrolimus, especially for facial application to avoid steroid-induced skin atrophy.
Adjunctive Measures:
Section Summary CC & HPI 1 - week itchy, papulovesicular rash on face/neck, no systemic symptoms Exam Red papules/vesicles, mild scale, seborrheic distribution Differential Contact dermatitis, seborrheic dermatitis, folliculitis, etc. Diagnosis Seborrheic dermatitis ± Malassezia folliculitis Treatment Topical antifungals + low-potency steroids + calcineurin if needed Follow-Up Reassess in 2–6 weeks, maintain therapy to prevent relapse Education & Complicas Proper skincare, potential steroid risks, infection prevention
Final Words
This case is a classic presentation of seborrheic dermatitis in a young adult. The combination of topical antifungals and mild steroids (or calcineurin inhibitors) addresses both yeast overgrowth and inflammation. Patient education and routine follow-up are essential to maintain skin health and manage flare-ups. . Full Treatment Plan
1. Pharmacological Treatment
Medication Dosage & Duration Purpose Ketoconazole 2% cream Apply twice daily for 2–4 weeks Antifungal for Malassezia overgrowth Hydrocortisone 1% cream Apply twice daily for 7–10 days, then taper Reduces inflammation, itching Pimecrolimus 1% cream Apply once daily after steroid course Steroid-sparing agent for face Ketoconazole shampoo Use 2–3x weekly as facial cleanser (leave on 2 – 5 minutes) Ongoing antifungal maintenance Optional (If Folliculitis Suspected):
- Oral Fluconazole 150 mg once weekly x 2–3 weeks (only if severe or persistent)
- Topical Clindamycin or Benzoyl Peroxide (for follicular involvement)
2. Skin Care & Lifestyle
Recommendation Purpose Use gentle cleanser (non-soap, fragrance-free) Avoid irritation and maintain skin barrier Moisturize with ceramide-based lotion Restore barrier and reduce flakiness Avoid facial scrubbing and exfoliants Prevent worsening inflammation Keep hair clean and avoid greasy products Seborrheic dermatitis thrives on oils Manage stress and sleep well Flare-ups often linked to stress Avoid alcohol and spicy foods (if flares noted) Reduce potential triggers
3. Patient Education
- Condition nature: Chronic, relapsing. Not contagious.
- Medication usage: Thin application, avoid overuse, monitor for irritation.
- Steroid caution: Short-term only to avoid atrophy or dependency.
- Signs of complications: Redness spreading, pain, pus = possible infection.
- Follow-up importance: Needed to monitor response and prevent recurrence. Progress & Monitoring Plan Timeline Action/Goal Evaluation Criteria Day 1– 3 Start treatment, reduce inflammation ↓ redness, ↓ itch, improved comfort Day 7 Evaluate steroid response; taper if improving Papules resolving, no new lesions Week 2 Stop steroids; continue antifungal and introduce pimecrolimus No flare after steroid withdrawal Week 3– 4 Assess for full resolution; begin maintenance plan Clear or near-clear skin
Test Result Reference Range Interpretation CMP (Comprehensive Metabolic Panel) Glucose 92 mg/dL 70 – 99 mg/dL Normal BUN 13 mg/dL 7 – 20 mg/dL Normal Creatinine 0.9 mg/dL 0.6–1.3 mg/dL Normal renal function AST / ALT
U/L
10 – 40 U/L / 7– 56
U/L
Normal liver function Electrolytes (Na, K, Cl) Normal Within reference limits No imbalances
Dermatology-Specific or Targeted Tests
Test Result Interpretation KOH Prep (Skin scraping) Negative for hyphae No dermatophytes (rules out tinea) Bacterial Culture No growth after 48h No bacterial infection (rules out folliculitis) Viral Culture / PCR (HSV) Not performed No vesicular pattern suspicious for HSV Patch Testing (if done) Not performed Consider if allergic contact dermatitis suspected Skin Biopsy Not indicated Diagnosis consistent with seborrheic dermatitis
Optional/If Case Indicates Advanced Testing
Test Result Interpretation Serum IgE Normal Rules out atopy as primary cause HIV Test (if immunosuppression suspected) Negative Immunocompetent patient ANA Negative No autoimmune involvement (e.g., lupus) Fungal Culture (Sabouraud) Negative No fungal growth (supports seborrheic Dx) Interpretation Summary
- All routine labs are normal , indicating no systemic illness.
- Skin scraping and cultures are negative , ruling out tinea or bacterial folliculitis.
- The lack of eosinophilia or elevated IgE suggests it's not a classic atopic or allergic reaction.
- The clinical picture and lab findings support the diagnosis of seborrheic dermatitis , possibly with Malassezia involvement , which typically does not show on KOH prep and is diagnosed clinically. Differential Diagnosis – Comprehensive List
✅ 1. Seborrheic Dermatitis
Most Likely Diagnosis
- Reasoning: Common in young adults; affects sebaceous-rich areas (face, scalp, neck, upper chest).
- Features: Erythematous patches with greasy scale; may be itchy or mildly inflamed.
- Distribution: Symmetrical, involves face and neck.
- Chronicity: Can flare intermittently, especially in stress or climate change.
- Justification: Fits patient’s age, location, clinical pattern; no systemic symptoms.
2. Irritant or Allergic Contact Dermatitis
- Reasoning: Exposure to irritants (soaps, creams, shaving products) or allergens.
- Features: Acute rash with vesicles or crusts, well-demarcated; very itchy.
- Distribution: Often follows a pattern of exposure (e.g., beard line, neck).
- Clues to Rule Out: No new products, no known exposures, and mild itching only.
3. Malassezia (Pityrosporum) Folliculitis
- Reasoning: Inflammatory condition involving Malassezia yeast; follicular papules/pustules on chest, neck, back, or face.
- Features: Itchy, monomorphic papules, often in young males, worsens with sweating or humidity.
- Distribution: Upper trunk, face, neck—matches case.
- Justification: May co-exist with seborrheic dermatitis; antifungal therapy helps both.
- Features: Mid-face erythema, no comedones, flushing triggered by alcohol, heat.
- Clues to Rule Out: No triggers or chronicity; patient lacks flushing.
❌ 9. Herpes Simplex Virus (HSV) or Zoster
- Reasoning: HSV can cause painful vesicles; zoster follows a dermatome.
- Features: Clusters of painful vesicles on erythematous base.
- Clues to Rule Out: No pain, no dermatomal pattern, vesicles are non-tender and not grouped.
❌ 10. Systemic Lupus Erythematosus (SLE)
- Reasoning: Malar rash is possible, especially with systemic symptoms.
- Features: Fixed erythema across cheeks and nose (butterfly), often with fatigue, joint pain.
- Clues to Rule Out: No systemic signs, rash is vesicular/papular not classic malar rash, no photosensitivity. Differential Summary Table Diagnosis Likelihood Supporting Features Ruling Out Factors Seborrheic Dermatitis Very High Classic location, age, mild pruritus, no systemic sx
Contact Dermatitis Moderate Possible vesicles, itching No known exposure, not well-demarcated Malassezia Folliculitis Moderate Monomorphic papules, oily skin areas No pustules noted; mild inflammation Acne Vulgaris Moderate- Low Age, facial distribution No comedones, sudden onset Atopic Dermatitis Moderate- Low Facial rash possible No personal/family atopy, no chronicity Tinea Faciei/Corporis Low Itchy, scaly, annular KOH negative, no ring lesions Perioral Dermatitis Low Papules around mouth Distribution not consistent Rosacea Very Low Midface redness, papules No flushing, no triggers, not chronic
Diagnosis Likelihood Supporting Features Ruling Out Factors HSV/Zoster Very Low Vesicular lesions No pain, no dermatomal pattern SLE Very Low Malar rash possibility No systemic symptoms, rash not typical ✅ Final Working Diagnosis: Seborrheic Dermatitis with possible Malassezia Folliculitis . Full Physical Examination Findings
General Appearance
- Well-developed, well-nourished 25-year-old male in no acute distress
- Alert and oriented ×
- Appears generally healthy and cooperative
Vital Signs
Parameter Result Normal Range Temperature 98.4°F (36.9°C) 97.0–99.0°F Heart Rate (HR) 76 bpm 60 – 100 bpm Respiratory Rate 16 breaths/min 12 – 20 breaths/min Blood Pressure 118/76 mmHg <120/<80 mmHg Oxygen Saturation 98% on room air >95% BMI 23.1 kg/m² 18.5–24.9 (normal weight)
Skin
- No wheezes, rales, or rhonchi
Cardiovascular
- Regular rate and rhythm
- No murmurs, rubs, or gallops
Gastrointestinal
- Abdomen soft, non-tender, non-distended
- Bowel sounds present, no organomegaly
Musculoskeletal
- Full range of motion in neck and shoulders
- No joint swelling, erythema, or tenderness
Neurological
- Alert and oriented
- Cranial nerves II–XII grossly intact
- Normal gait and coordination
Psychiatric
- Mood and affect appropriate
- No signs of anxiety or depression during exam Exam Summary:
- Skin exam shows well-demarcated papular and vesicular rash in seborrheic distribution (face, neck, upper chest) with mild scaling and no signs of infection or scarring.
- No systemic findings such as fever, lymphadenopathy, or mucosal involvement.
- Other systems unremarkable , ruling out systemic or autoimmune conditions. Full Diagnostic Workup
A. Clinical Evaluation (Primary Tool)
- Diagnosis is primarily clinical , based on: o Lesion morphology: papular/vesicular o Distribution: sebaceous areas (face, neck, chest) o Absence of systemic symptoms
- No red flags noted (fever, joint pain, widespread rash, mucosal involvement)
B. Focused Diagnostic Tests
Test Indication Result/Expected Interpretation KOH Prep (Skin Scraping) Rule out tinea faciei or tinea corporis Negative No hyphae observed → rules out dermatophyte infection Skin Swab Culture Rule out bacterial folliculitis No growth (if done) No Staph or Strep → bacterial infection unlikely Wood's Lamp Differentiate fungal infections or pigment changes No fluorescence Helps exclude tinea versicolor and erythrasma Viral PCR/Swab (HSV) If vesicles raise suspicion for herpes simplex Not indicated No grouped painful vesicles or dermatomal pattern Skin Biopsy Only if atypical or refractory rash Not indicated Diagnosis consistent with common dermatoses
C. Optional Tests (If Diagnosis Unclear or Unresponsive)
Test Purpose Consider If... Fungal Culture (Sabouraud) Confirm fungal infection not seen on KOH Rash persists or worsens with antifungal therapy Patch Testing Detect allergic contact dermatitis Recurrent or sharply demarcated rash appears
