The "What's Your Assessment?" series includes a short case presentation and differential diagnosis. It is followed by a discussion of the disease or condition and the rationale used in each step of the assessment.
This 38-year-old male has had repeated visits to the dermatology clinic over the past 6 years for a hand dermatitis that "comes and goes." The dermatitis started in his 20s on his hands only but, over the last 10 days, has also involved his feet. He states that he can be clear of lesions, then suddenly develop many small vesicles along the sides of his fingers. Initially, the vesicles are intensely pruritic. When they drain, the lesions may become very painful. His palms are spared. He describes his hands and feet as "being on fire." Currently, he has no lesions on his feet. He is a draftsman and denies any causal relationship between the lesions and his job. The lesions do not improve on the weekend and are worse during the week. He denies any medical problems and his only medications are topicals for his hands. No other family member has ever experienced a similar eruption. KOH preparation of an intact vesicle is negative.
Description of Skin Lesions
The primary lesion is a vesicle.
There are multiple erythematous papules and vesicles on both hands (see Figure 1). Looking at the right hand, there are lesions on all of the...