Working Diagnosis:
Initial working diagnosis:
Boot dermatitis (irritant versus allergic) with secondary impetiginization and concern for possible herpetic overlay

Truncal/upper extremity involvement initially attributed to a brisk resultant id eruption

Treatment:
Initial clinical improvement in boot dermatitis. Levaquin valtrex were discontinued per sensitivities noted above. The patient completed his oral clindamycin outpatient course.

Good initial improvement in background widespread dermatitis, discharged to home.

Outcome:
Subsequent progression of background dermatitis on outpatient basis with progression over days to >75% BSA involvement with erythematous papules, plaques, and background erythema that was bordering on erythroderma.

At this point punch biopsy obtained, with a new differential diagnosis to include new onset psoriasis, widespread autoeczematization.

At this time a course of oral cyclosporin at 2.5 mg/kg was initiated.

The punch biopsy results were consistent with psoriasis with abrupt onset in setting of significant background secondarily infected boot dermatitis.

Final diagnosis:
New-Onset Psoriasis Triggered by Acute Boot Dermatitis, likely exacerbated by systemic steroid dosing

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Outpatient treatment following final diagnosis:

Topical regimen optimized with a super-potent topical corticosteroids to truncal/extremity involvement BID M-F and low-potency topical corticosteroids to face/intertriginal involvement M-F. Calcipotriene BID on weekends as well.

Modified cyclosporin 2.5 mg/kg was continued for three weeks and then slowly tapered over the next three weeks (six weeks total).

At that time maintenance regimen was instituted with narrow band UVB light therapy. He now has approximately 100% clearance of lesions.

He currently does not require any topical treatment and has transitioned to a maintenance regimen with NB-UVB treatments only once weekly.

Allergen and patch testing pending:
This was held in light of cyclosporin dosing and current light therapy. The soldier has returned to full duty.

Editor's Comments:
The working diagnosis for this case included boot dermatitis (irritant versus allergic). The clinical features of irritant and allergic contact dermatitis are helpful in differentiating between the two. Irritant dermatitis usually has a shorter latency period, typically occurring within 48 hours after exposures, while allergic contact dermatitis may take up to 5-6 days. The demarcation of irritant dermatitis is typically located to the area of exposure, while allergic dermatitis commonly spreads beyond the area of exposure. Irritant dermatitis usually resolves within 48 hours following removal of the irritant while allergic dermatitis may last days to months.

This case also highlights the possibility of an Id reaction. Id reactions, or autoeczematization, are generalized acute cutaneous reactions resulting from a variety of stimuli, including infectious and inflammatory skin conditions. The pruritic rash that characterizes the id reaction, which is considered immunologic in origin, has been referred to as dermatophytid (fungal), pediculid (parasitic) , or bacterid (bacterial) when associated with a corresponding infectious process. Id reactions may also be associated with viruses.

The Sports Medicine physician or Military physician needs to have a high clinical suspicion for the common irritants and allergens in his or her sport or military environment.

References:
1. Henning, JS, Firoz, BF, Lehman, KA. Allergic Contact Dermatitis in Operation Iraqi Freedom: Use of T.R.U.E. Test in the Combat Environment. Dermatitis. Vol 20. No. 6. 2009

2. Dever, TT, Walters, M, Jacob, S. Contact Dermatitis in Military Personnel. Dermatitis. Vol 22, No 6, 2011.

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