Tuesday, May 7, 2013

An Itchy Skin Rash

I walked into the exam room after knocking on the door. 
“Hi, I’m Sharon, I’m a physician assistant who is helping out in this clinic until they can find another permanent provider.”
“Hi, I’m Kim.  I was told Merilee has left, and the medical assistant told me that you would be in.”
“Well, it’s nice to meet you.  You’re here for your annual pap smear, is that correct?”
“Okay, well let me start with your past medical history first.  Do you take any prescription medications or have any medical history?”
“I just take a birth control pill, that’s all.”
“You work at the local junior college?  What do you do?”
“I teach business classes.”
“Hmm, ok, well then do you have any new allergies, or previous surgical history that’s not on your medical record with us?”
“Do you have any new concern, or something you need me to look at?”
“No, . . . wait, I do.  I’ve been coming here for the past seven years for my annual exam and every year I’ve asked the medical provider what’s wrong with my hair/scalp.  Every year I’ve gotten a different answer, one person told me that it was nothing, another told me that it was just dandruff and to use dandruff shampoo, another didn’t even look at my hair/scalp.  I think you get the picture, seven different answers, none of them right.  I can’t stand how itchy my scalp/hair is and I know it’s not dandruff!  I’ve tried all kinds of over the counter medications for my scalp and nothing has worked.  I’ve done dandruff shampoo, T-gel shampoo, tried using the 1% hydrocortisone cream, all to no avail.”
“Seven years you haven’t had an answer?”
“Yeah, I even asked for a referral to a physician who sees skin disorders and they wouldn’t give it to me.” 
“Okay.  I’ll make sure to take a look at your hair/scalp.  Anything else?”
“Alright.  Well why don’t you go ahead and change into the paper gown and  put the paper cover over your lap, I’ll be back in to do your exam in a few minutes. “
After Kim changed over to the paper gown, I came back into the room with a small cup of water.  I asked Kim to swallow some water as I palpated her thyroid.  I then took a good look at her hair and scalp.  Her ears had yellow to red greasy raised macules on her earlobes.  She had scaly, yellow to red plaques on the edges of her hairline.  Her hair had a horrible case of dandruff.  All through her scalp her skin was erythematous and oily. 

Seborrhea dermatitis is a skin rash that affects 3-5% of the general population.  It typically affects areas of the skin that has sebaceous (oil) glands in it, i.e. face, scalp ,earlobes and/or trunk.  Lesions are usually described as being yellow tinged to red raised macules.  On the scalp patients also have lots of dandruff.  The lesions are very pruritic (itchy). 

Seborrhea is generally associated with a fungus found on the skin, Pityrosporon ovale.  Therefore by getting rid of the fungus with anti-fungal shampoo works to address the skin rash typical of seborrhea. 
“Kim, you have seborrhea dermatitis.   It’s very typical that it affects your scalp/hair line.  It can also affect other areas of your skin, such as your face or trunk.   Do you have any other skin lesions that are itchy?”
“Yeah, now that you mention it, I’ve got itchy lesions on my abdomen. “
“Okay, well let me look at them.”
Kim lifted her paper gown out of the way and showed me the additional skin lesions she had on her abdomen.  They were raised, yellow toned red plaques, again typical of seborrhea.
“Kim, these lesions are also seborrhea.”
“So, what do I do about all of this seborrhea?”
“Well, I’m going to give you a prescription for you to pick up a prescription strength 2% anti-fungal shampoo which is used in patients with seborrhea.  It should work really well for you.  Then I’ll give you prescription strength steroid cream to put on these lesions on your abdomen.  The shampoo should start working in about two weeks , if you find that you need additional help let us know.  You can also see a dermatologist (a physician who sees patients with skin disorders) if what I’ll give you hasn’t totally gotten rid of the seborrhea.  Fair enough?”
“So I do have ‘cradle cap’?”
“Cradle cap?”
“Yeah, I remember seeing a picture of an infant with cradle cap.  His scalp was just a sold red color with some yellow to red macules on them.  The description said it was ‘cradle cap.’ “
“Ah-h, okay.  In an infant , seborrhea  is called ‘cradle cap.’  With adults we call it seborrhea dermatitis.  So you were on the right track with your thinking. “
“Thanks for the encouragement that I can find the right information on the internet.”
“No  problem.”
I finished up the rest of her physical exam and sent her off to the lab to have her thyroid hormone level tested.  I also gave her a refill of her birth control pills as well as the two prescriptions for her seborrhea.  About a month later I heard from one of the medical assistants in the office that she had seen Kim in one of the local restaurants eating dinner with her husband.  Kim asked her to relay to me that the shampoo/steroid creams were really working for her and she wasn’t itching anymore.   That was news, I was glad to hear.      


  1. That is awesome that you took the time to help her analyze her situation. I had nummular eczema and it took a few months and it wasn't till I saw a 3rd dermatologist that I received an accurate diagnosis and treatment.

    Before that I was told it was scabies, then an allergic rash and a fungal rash.

  2. thanks for the compliment, Deb.