What is the initial approach to an 18-year-old female presenting with a red spot on her hands?

SOAP Note for Red Spot on Hands in 18-Year-Old Female

Subjective

Chief Complaint: Red spot on hands 1

History of Present Illness:

• Onset and duration: When did the red spot first appear? Has it been present for days, weeks, or months? 1
• Distribution: Is it unilateral or bilateral? Palmar, dorsal, or both surfaces? Single lesion or multiple? 1
• Associated symptoms: Pruritus, pain, burning, tingling, or asymptomatic? 2, 1
• Aggravating factors: Recent increase in hand washing, use of new soaps/detergents, glove use, occupational exposures, or contact with irritants/allergens? 2
• Relieving factors: Does it improve on weekends/holidays or away from work/school? 3
• Previous treatments: Any topical medications, moisturizers, or home remedies tried? 1
• Medical history: Personal or family history of atopic dermatitis, psoriasis, autoimmune conditions, or skin cancer? 1
• Substance use: Any history of intravenous drug use (consider red puffy hand syndrome)? 4
• Systemic symptoms: Fever, joint pain, or other systemic manifestations? 4

Objective

Physical Examination:

• Morphology: Describe the lesion precisely—macule, papule, patch, plaque, vesicle, pustule, or scale? 1
• Color: Bright red, dusky red, violaceous, or with hypopigmentation? 5
• Size and borders: Measure dimensions; are borders well-defined or diffuse? 1
• Texture: Smooth, scaly, hyperkeratotic, or with fissuring? 2
• Distribution pattern: Symmetrical vs. asymmetrical; palmar vs. dorsal; periarticular involvement? 2, 1
• Associated findings: Edema, warmth, tenderness, nail changes, or hair involvement? 4, 1
• Other body areas: Examine face, trunk, feet, and other sites for similar lesions 1

Differential Diagnosis Considerations:

• Irritant contact dermatitis (ICD): Most common; history of frequent hand washing, soap/detergent exposure, or wet work 2, 3
• Allergic contact dermatitis (ACD): Exposure to specific allergens (fragrances, preservatives, gloves, topical antibiotics) 2, 3
• Atopic dermatitis: Personal or family history of atopy 1
• Dyshidrotic eczema: Vesicles on palms/fingers 1
• Psoriasis: Well-demarcated plaques with silvery scale 1
• Tinea manuum: Unilateral involvement, consider KOH prep 1
• Red puffy hand syndrome: Bilateral dorsal hand edema and erythema in patients with IV drug use history 4
• Drug-induced (hand-foot syndrome): If on chemotherapy agents 2

Assessment

Working Diagnosis: [Based on clinical presentation]

Most likely: Contact dermatitis (irritant vs. allergic) given the high prevalence in this age group and common exposures 2, 3, 1

Plan

Diagnostic Workup

If contact dermatitis is suspected and recalcitrant or unclear etiology:

• Patch testing is the gold standard for diagnosing ACD and should be performed when ACD is suspected, as clinical features alone cannot reliably distinguish between ACD and ICD 3
• Consider KOH preparation if fungal infection is in the differential 1
• Bacterial/viral/fungal cultures if superinfection is suspected 2

Treatment Approach

For Irritant Contact Dermatitis (most common):

• Identify and avoid irritants: Reduce frequency of hand washing, avoid dish detergents, hot water, disinfectant wipes, and bleach 2, 3
• Barrier restoration: Apply moisturizer immediately after hand washing and before wearing gloves 2, 3
• Moisturizer regimen: Use tube-packaged moisturizers (not jars) to prevent contamination; apply 2 fingertip units to hands after each wash 2
• "Soak and smear" technique: For intensive treatment, soak hands in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks 2, 3
• Topical corticosteroids: If conservative measures fail, apply low-to-moderate potency topical steroid (e.g., hydrocortisone 1-2.5% applied 3-4 times daily) 2, 3, 6
  • Caution: Use topical steroids judiciously in ICD as prolonged use may damage the skin barrier further 2, 3

For Allergic Contact Dermatitis:

• Allergen avoidance is the cornerstone of treatment 3
• Patch testing should be performed to identify clinically relevant allergens 3
• Topical corticosteroids: Low-to-moderate potency steroid to affected area 2, 3
• For glove-related ACD: Switch to accelerator-free gloves (rubber-free neoprene or nitrile) 2, 3
• Avoid common allergens: Products containing neomycin, bacitracin, fragrances, preservatives, and benzalkonium chloride 2

For Recalcitrant Cases (either ICD or ACD):

• Dermatology referral for patch testing and consideration of:
  • Stronger topical steroids 2, 3
  • Phototherapy (PUVA for chronic hand eczema) 3
  • Systemic therapy 2, 3
  • Occupational modification 2, 3

Patient Education

• Hand hygiene: Use fragrance-free, dye-free synthetic detergents with added moisturizers; avoid antibacterial soaps 2
• Water temperature: Use lukewarm water, not hot or cold 2
• Drying technique: Pat dry, don't rub 2
• Glove use: Apply moisturizer before wearing gloves; use water-based moisturizers under all glove types 2
• Nighttime occlusion: Apply moisturizer followed by cotton or loose plastic gloves at night 2
• Avoid: Adhesive bandages with bacitracin, superglue on fissures, and occluding wraps without moisturizer 2

Follow-Up

• Reassess in 2 weeks (either in-person or via patient self-report) 2
• If no improvement or worsening, proceed to patch testing and dermatology referral 3
• Serial photographs should be used to monitor treatment response 2

Common Pitfalls to Avoid

• Failing to identify and remove the causative agent (allergen or irritant), which prevents healing 3
• Not considering patch testing in chronic or persistent dermatitis cases 3
• Continuing long-term topical steroids in ICD, which can damage the skin barrier 3
• Occluding hands without underlying moisturizer application 2, 3