NARES local allergy cells in the nose

Patient is 34-year-old female who comes in today with this odd rash that seems to be erupting since the end of November. At that time, she does state that she just got a kitten a couple of days before this rash started. She also started running outdoors more frequently at this time as well. She does not associate this exercise causing the rash or being flared up during exercise or when her body temperature rises. She also does not notice the rash popping up after her feeding her kitten or being around her kittens specifically. She has beclomethasone steroid cream that she has applied intermittently and it does not seem to be helping much, although she has not tried this very consistently. She currently uses melaleuca oil or tea tree oil to help with itch and that does seem to help the most. She states that these lesions take about one week to clear up and then they heal but then new ones pop up. She saw her primary care physician, Dr. _____ for this and prescribed her Medrol Dosepak that did not seem to help in fact seemed to make it flare up worse she states. She also was given Zyrtec 10 mg twice daily and thinks it may have helped with itching but could not really tell if it helped that much.

She does admit to having some seasonal allergy problems including nasal symptoms with nose rubbing, postnasal drip, colored nasal drainage. This seems to happen most in the springtime and in fall. She admits to having problems of sinus infection and frequent headaches associated with these. She denies any nasal polyps, aspirin-induced nasal symptoms, nasal surgery, frequent bad cold, or frequent tonsillitis. She uses Claritin as needed for allergy medication. She has used nasal sprays in the past but does not currently use any and it has been sometimes since she has. She denies any problems of frequent ear infection, dizziness, lightheadedness, or hearing impairment.

She does admit to eye itching, dryness, burning, and light hurting her eyes. She denies redness, tearing, yellow discharge from eyes, eyelid swelling, and eyelid irritation occurring with the seasonal allergies.

She denies any history of asthma or lung problems.

She denies any allergic skin problems other than contact dermatitis with nickel products. She does state that she has very sensitive skin and uses hypoallergenic detergents and soaps due to this. She has never been evaluated for allergies before.

ASSESSMENT:
1. Rash. Differential includes nummular eczema or mite type infection.
2. NARES local allergy cells in the nose.
3. History of contact dermatitis to nickel.
4. Vespid sting allergy.
5. Allergic conjunctivitis.
6. Concern for food allergy.

PLAN:
1. At this time, I discussed with that the rash presents slightly unusually and does not seems to be associated with any specific allergy. She was negative for her cat allergy so I do not think that it necessarily is the cat. It does present similar like bedbugs or type of insect bite but also could be more of a nummular eczema. If they do not respond to prednisone or to topical steroids very well so we may need to try treating with antiparasitic medication like avermectin or Permethrin to see if she responds to that. She is going to see a dermatologist next week, so I encouraged her to show her dermatologist this and see what they say as they are more versed in different types of rashes that are not allergically sourced.
2. I also encouraged her to use Zyrtec or nasal spray during the time of allergies that she may have local allergy cells in her nose causing her rhinitis and conjunctivitis, even though she was negative on skin testing.
3. We discussed possibility of this rash occurring due to a drug eruption, Zoloft or her birth control and she can try tapering off one of these at a time and see if the rash resolves. She feels that she is ready taper off Zoloft that she is on a low dose and is willing to try this. She also could switch brands of her birth control to see if it is something associated with her medication.
4. We will follow up in one month’s time to see if she is getting any relief and we will communicate with her dermatologist at Ada West Dermatology to further identify what her rash may be.

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