Differential Diagnosis for an 11-year-old Boy with Painful, Itchy, Pus-filled Lesions on the Hand
Single Most Likely Diagnosis
- Pompholyx (Dyshidrotic Eczema): This condition is characterized by recurrent, itchy, vesicular lesions on the palms and soles, often starting in childhood. The description of papulovesicles, pustules, and skin changes such as hyperkeratosis, acanthosis, spongiosis, and subcorneal vesicles filled with neutrophilic debris aligns with pompholyx, especially given the chronic and recurrent nature of the condition.
Other Likely Diagnoses
- Acropustulosis: As mentioned, this is a plausible diagnosis given the presentation of pustular lesions on the hands. Acropustulosis can be a primary condition or secondary to another dermatosis like psoriasis.
- Psoriasis: Although less common in children, psoriasis can present with pustular lesions, especially on the palms and soles. The presence of hyperkeratosis, acanthosis, and subcorneal vesicles could support this diagnosis.
- Eczematous Dermatitis (Atopic or Contact): Given the itchy and chronic nature of the lesions, along with the presence of spongiosis, an eczematous dermatitis should be considered. Allergic contact dermatitis or atopic dermatitis could present similarly, especially if the child has a history of atopy or exposure to irritants.
Do Not Miss Diagnoses
- Infectious Causes (Bacterial, Fungal, or Viral): It's crucial to rule out infectious causes, such as impetigo, herpetic whitlow, or fungal infections, which could present with similar symptoms but require different treatments.
- Keratoderma: Certain types of keratodermas, which are disorders of keratinization, could present with hyperkeratosis and skin lesions on the hands.
Rare Diagnoses
- Pustular Psoriasis: A rare form of psoriasis that can present with pustules on the palms and soles, which could be considered given the description of pustules and skin changes.
- Hyperkeratosis Palmaris et Plantaris: A rare genetic disorder characterized by thickening of the skin on the palms and soles, which might be considered if the primary complaint was hyperkeratosis without a clear inflammatory component.
- Darier Disease: A rare genetic disorder that affects the skin and sometimes presents with keratotic papules and vesicles, although it typically has a more widespread distribution and other systemic manifestations.
Each of these diagnoses should be considered in the context of the patient's full history, physical examination, and potentially, further diagnostic testing such as skin scrapings, cultures, or biopsies to determine the underlying cause of the symptoms.