Plenary Discussion

21C

Scenario 4: Bullae on Dermias Skin

Dermia, a four year-old girl brought to Community
Health Centre by her mother because of a presence of furuncle
on her forehead and bullae on her armpit and her chest since 4
days ago. This abnormality emerged on the forehead initially
with a small size. It grew bigger and bigger, and in the middle
of it, seen a tiny pus spot. And the bullae on her chest can
easily pop. According to the anamnesis; the patient doesnt
have fever, have normal appetite, and still can play normally.
Her mother only worried because this is different from the skin
condition that Dermias already had before, which occurred on
her elbows and her knees recurrently.

Her mother had her controlled to the doctor ever since. Her
neighbor also said that the blisters could be a sign of herpes
From the physical examination, the general appearance
seemed normal. Foreheads dermatological status revealed
circular localized lesion, the pattern was not specific , the
border was distinct, size: lenticular, efflorescence: nodus
erythematous, pustule, papul erythematous. Chests
dermatological status revealed bullae, hypopyon bullae,
erosion, and squama. Elbows and knees dermatological status
revealed bilateral symmetrical distribution, pattern and
morphology: unspecific, indistinctive border,
hyperpigmentation plaque, lichenification, and squama.

The doctor explained that theres no nothing to

worry about, because Dermias only got skin infection. The
blisters could be caused by various infections (bacterial,
viral, fungi). Specific lab tests were not necessary, except
for skin scraping to make sure whether the lesion were
tinea corporis or not. The mother asked if the disease can
be healed or will it occur again?
How do explain about what happened to Dermia?

Terminology
Hypopion Bullae: The pus settles inside the thebulla (fluid-filled sacs or
lesions) and forms a layer.
Lichenification: means the skin has become thickened and leathery. This
often results from continuous rubbing or scratching the skin.
Tinea Corporis: a superficial dermatophyte infection on the body skin (ie,
skin regions other than the scalp, groin, palms, and soles)
Scaling: dry scaly skin that caused by the shedding of stratum corneum
from the epidermis.
Herpes (zoster): is aviral diseasecharacterized by apainfulskin rash
withblistersinvolving a limited area (dermatomal region).

Problem Identification
1. Why did Dermia have boil (furuncle) on her forehead?
2. What causes the blisters on her chest and armpit that
occurred since 4 days ago?
3. Is there any relationship between Dermias condition
with her age and gender?
4. Why didnt the patient have fever, eating problem,
and malaise?

5. What are the skin conditions that happen on Dermias elbow

crease and knees?
6. Could we diagnose the blisters as herpes?
7. How are the interpretation of the dermatological status of
Dermias forehead?
8. How are the interpretation of the dermatological status of
Dermias chest and armpit?
9. How are the interpretation of the dermatological status of
Dermias elbow crease and knees?

10. Why did the doctor say that theres no necessary lab test to
do beside skin scrapping?
11. How is the prognosis of Dermias case?
12. What are the treatment for Dermias case?

Problem Analysis
1. Why did Dermia have boil (furuncle) on her forehead
and how could it grow bigger?
Aboil, also called afuruncle, is a
deepfolliculitis,infectionof thehair follicle. It is most
commonly caused by infection by thebacterium
Staphylococcus aureus, resulting in a painful swollen area
on theskin caused by an accumulation ofpusand dead
tissue.
Boils which are expanded are basically pus-filled nodules.

2. What causes the bullae on her chest and armpit that occurred since 4 days
ago?
Possible cause of bullae:
Friction. Friction blisters appear most often on your hands and feet.
Contact Dermatitis. An allergic reaction that also causes bullae.
Other Causes:
disorders of the skin, like impetigo
chickenpox
thermal burns, or sunburns
frostbite
trauma to your skin
Because the scenario tolds us the predilection location (chest and armpits) and also the
effloresences; the most likely diagnosis is Impetigo Bullosa.

3. Is there any relationship between Dermias condition with

her age and gender?
A child with immature immune system may predispose easily to
skin infections.

4. Why didnt the patient have fever, eating problem, and

malaise?
It could mean that the condition shes having is not systemic. Its
probably because the areas only involved epidermis (such as in
impetigo); hair follicle and the surrounding subcutaneous tissue
(furuncle).

5. What are the skin conditions that happen on Dermias elbow

crease and knees?
From the predilection (elbow crease and knees) and also the
information about the recurrency, and also the clinical
manifestation such as thickened and scaly skin, we can suspect
atopic dermatitis. We can ask about the atopy history such as
rhinitis and allergic conjunctivitis.
The other differential diagnosis is tinea corporis. But if it is,
it should have a distinct border

6. Could we diagnose the blisters as herpes?

If it were herpes, itll appears unilaterally, according to the
dermatomal region thats involved.
It may have a prodromal symptoms, and the patient may
complain about pain and paresthesia.
Varicella zoster usually appear first.
Herpes are more common in older patients.

7. How are the interpretation of the dermatological status of

Dermias forehead?
circular localized lesion, the pattern was not specific , the border
was distinct, size: lenticular, efflorescence: nodus erythematous,
pustule, papul erythematous. The dermatological status suggested an
active inflammation (erythem) in the form pus-filled nodus furuncle.
8. How are the interpretation of the dermatological status of
Dermias chest and armpit?
Chests dermatological status revealed bullae, hypopyon bullae,
erosion, and squama suggestive of bullous impetigo.

9. How are the interpretation of the dermatological status of

Dermias elbow crease and knees?
bilateral symmetrical distribution, pattern and morphology:
unspecific, indistinctive border, hyperpigmentation plaque,
lichenification, and squama suggestive of atopic dermatitis.
10. Why did the doctor say that theres no necessary lab test to do
beside skin scraping?
A potassium hydroxide (KOH) examination of skin scrapings, used to
visualize fungal elements removed from the skin's stratum corneum.
The doctor did this test to exclude tinea corporis. The other lab tests
are not necessary because it couldve been diagnosed clinically

11. How is the prognosis of Dermias case?

The prognosis is excellent for boils that are treated in the healthcare setting by opening or lancing. Complications of a boil are rare
and are more likely to occur in people with suppressed immune
systems. Complications include a worsening or spreading to adjacent
areas of skin or soft tissue and very rarely, spread of the infection
through the bloodstream to sites elsewhere in the body.
The sores of impetigo heal slowly. Scars are rare.The cure rate is
very high, but the problem often comes back in young children
About half (50%) of the children who get AD will have it as an adult.
The good news is that the AD often becomes milder with age.

12. What are the treatment for Dermias case?

Topical Antibiotics:
Bacitracin, neomycin.

Antihistamine
Topical Corticosteroid.
Prevent the AD from getting worse: calm the skin, relieving
pain and itch, reduce emotional stress, prevent infections, stop
the skin from thickening.

Physical
exam: General
Appearance
normal

Dermatologica
l Status:
Predisposing factors:
Close contact with a
person who has a staph
infection.
Diabetes.
Other skin conditions.
Compromised
immunity.

Dermia, a
four year old
girl

Infection
, such as
bacteria

Boil on the
forehead
Hypopyon
bullae

Pus

Vesicle
Pustule

blisters

Lesion on
elbow and
knees

Treatment:
Antibiotics
Antihistamine
DA prevention
Topical
corticosteroids

Scheme
Inflammation
Non-infection
such as allergic
reaction
Atopic
dermatitis
DD: Tinea corporis

Learning Objectives
Students are able to understand the epidemiology,
etiology, and risk factors of infection and non-infection
skin disease.
Students are able to understand the pathogenesis and the
pathophysiology of infection and non-infection skin
disease.
Students are able to understand the clinical manifestation,
diagnosis, and differential diagnosis of infection and noninfection skin disease.

Students are able to understand further examination

and lab tests for infection and non-infection skin
disease.
Students are able to understand the treatment of
infection and non-infection skin disease.
Students are able to understand the prevention,
prognosis, and referral cases of infection and noninfection skin disease