A member presented a medical case:
20 yr old woman with a blistering rash
A blistering, painful recurrent rash in a 20 yr old woman associated with sun exposure, unclear if this is actinic prurigo or something else.
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Patient demographics
Gender
Age
20
Ethnicity
Hispanic or Latin American
Occupation
Chief complaint or problem to solve
Painful, blistering rash after sun exposure
Case history
Rash began in 2009 during summer marching band camp. Itchy bumps appeared on arms and nose was red with blisters and blackish fluid coming from it. Dermatologist treated me for impetigo (Keflex and mycolog cream), but rash did not go away. Went back and dermatologist said rash looked like a chemical burn. Tried Locoid and Mupirocin cream. Rash got worse... Blood test, lupus screen, and biopsy on arm did not reveal any definite diagnosis. Extremely painful rash with redness and yellow blisters continued to appear after sun exposure, now on my lips, nose, cheeks, and arms. Caused so much pain that I had to sleep on ice and take pain pills. Went to the ER on Nov. 2, 2009. Tests for herpes viral, bacterial, strep, and staph came back negative. Another skin biopsy taken and diagnosed with Lupus Miliaris Disseminatus Faciei. Given Prednisone, Doryx, and Aczone gel. None of these helped rash to go away. Rash continued to occur, painful and oozing. Skin resembles a burn, wiping off and wet underneath. Skin biopsy performed on cheek mid Dec. 2009. Rash has started to appear despite cloud cover outside. Porphyria test negative in March 2010 and I was advised to wear long sleeves, a hat, and avoid sun exposure. Diagnosis of exclusion in Actinic Prurigo. Abdominal pain begins in April 2010, leading to appendectomy. Rash now occurs on back as well, despite 85 spf sunscreen. Rash causes extreme fatigue. Constipation and abdominal pain occurs frequently. Went to Mayo Clinic in Florida in Sept. 2010. Bloodwork, porphyria, feces, and urine tests don't reveal anything. Diagnosis is actinic prurigo, and advised to schedule photolight treatment. Inconclusive biopsy done on neck in Oct. and feeling terrible in Dec. with terrible rash pain, nausea, and diarrhea. Doctor refuses to do photolight treatment because she is sure it isn't actinic prurigo. Rash continues to come out after being outside. Biopsy of ear, nose, and arm in May 2011 show photoallergic contact. Right breast lumpectomy in July showed benign tumor. Plaquenil in March 2012 helped rash, but it returned after stopping. Accepted to National Institute of Health Undiagnosed Diseases Program, but program lost some funding and had to drop some patients, including me. I have avoided sun exposure, but rash will come out if I get in the sun. I still have abdominal pain and am unsure if these are related.

PMH:
Meds:
Allergies:none
Other tests:
Xrays:
Procedures:
Purpose of case discussion
Diagnostic dilemma: "What's the diagnosis?"
Supplemental Materials

Dr. Julan Crane
Pediatrics
16 doctors agree

In brief: Painful rash

More information and a photo would hobby it sounds serious so get an examination

In brief: Painful rash

More information and a photo would hobby it sounds serious so get an examination
Thank
4 comments
Dr. Richard Zimon
Is the patient taking any medication ( the "classic example" is Tetracycline...photosensitivity to medication even OTC meds deserve a "look see"
Dr. John Ebner
It is more likely to be a common condition called "Polymorphous Light Eruption" This is a condition causing pain, bumps, blisters after sun exposure. It commonly occurs on the forearms and upper chest. Actinic Prurigo is rare and happens in people much older with lots of sun damage. Of course, there are many causes of a reaction like you are describing, so send a photo or see your doctor.
Dr. Heidi Fowler
Psychiatry
12 doctors agree

In brief: Rash

This can't be diagnosed with the information that is available.
A history, physical examination & other studies may be needed to determine cause/causes. Once accurately assessed a treatment plan can be developed.

In brief: Rash

This can't be diagnosed with the information that is available.
A history, physical examination & other studies may be needed to determine cause/causes. Once accurately assessed a treatment plan can be developed.
Thank
1 comment
Dr. Nico Mousdicas
Folliculitis either bacterial yeast or heretic. Needs a scarping and viral and bacterial swabs
Dr. Jalal Zuberi
Pediatrics
11 doctors agree

In brief: Possible

Pl see attached info on Actinic Prurigo and see if the images and description match with yor condition.
While it is manageable with topical emmolients, steriods etc, by a GP, long term follow up with a Dermatologist may be helpful. Feel better!

In brief: Possible

Pl see attached info on Actinic Prurigo and see if the images and description match with yor condition.
While it is manageable with topical emmolients, steriods etc, by a GP, long term follow up with a Dermatologist may be helpful. Feel better!
Thank
Dr. Thomas Mcgowan
Family Medicine
10 doctors agree

In brief: Rash

Best to see a doctor like a dermatologist.
Painful blister recurrent rash in one area of the body, especially if only one side of your body makes me think of shingles. Go see a doctor for an evaluation.

In brief: Rash

Best to see a doctor like a dermatologist.
Painful blister recurrent rash in one area of the body, especially if only one side of your body makes me think of shingles. Go see a doctor for an evaluation.
Thank
Dr. Donald Colantino
Internal Medicine
10 doctors agree

In brief: Sun senstivity

Photosensitivity can occur with diseases like lupus or can occur while taking certain medications.
Of course you could just have simple sunburns each time. Some diseases like porphyria can cause blistering rashes. A dermatologist is best qualified to evaluate and advise you.

In brief: Sun senstivity

Photosensitivity can occur with diseases like lupus or can occur while taking certain medications.
Of course you could just have simple sunburns each time. Some diseases like porphyria can cause blistering rashes. A dermatologist is best qualified to evaluate and advise you.
Thank
1 comment
Dr. Cynthia Archer
That's why my answer to this question said "see a doctor in real life". You need an assessment. None of these things can be reasonably sorted out without an in person assessment.
Dr. Thomas Kaspar
Internal Medicine - Infectious Disease
8 doctors agree

In brief: Quit messing around

This may be a serious rheumatologist problem, need to be seen by a board certified dermatologist ASAP, preferably during the rash.

In brief: Quit messing around

This may be a serious rheumatologist problem, need to be seen by a board certified dermatologist ASAP, preferably during the rash.
Thank
Dr. Patrick Kohlitz
Internal Medicine
7 doctors agree

In brief: Rash

A recurrent blistering rash caused by the sun needs to be evaluated in person.
Certain types of porphyria such as cutanea tarda can sometimes present in this manner.

In brief: Rash

A recurrent blistering rash caused by the sun needs to be evaluated in person.
Certain types of porphyria such as cutanea tarda can sometimes present in this manner.
Thank
1 comment
Dr. Vicki Levine
This needs a biopsy and you need to be photo-tested. If you can see a dermatologist with an interest in this, that would be best. Most likely to fine a doctor at a teaching hospital. You do not have shingles or herptes
Dr. John Goldman
Internal Medicine - Rheumatology
7 doctors agree

In brief: Something else

Ask your dermatologist it could be porphyria

In brief: Something else

Ask your dermatologist it could be porphyria
Thank
Dr. Krishna Anand
Pediatrics
7 doctors agree

In brief: See allergist

Dermatologist is the best to help you but allergist may help to r/o any allergy component contributing .

In brief: See allergist

Dermatologist is the best to help you but allergist may help to r/o any allergy component contributing .
Thank
Dr. Frank Kuitems
Internal Medicine
6 doctors agree

In brief: Unlikely

Unlikely that the rash is actinic keratosis.
In order to diagnose and treat a rash you need to really do a video visit can't be done by just descriptions

In brief: Unlikely

Unlikely that the rash is actinic keratosis.
In order to diagnose and treat a rash you need to really do a video visit can't be done by just descriptions
Thank
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