How to manage a 19-year-old T1DM patient with hand and facial lesions suggestive of fungal infection, psoriasis, or contact dermatitis, and in need of a diabetes medication refill?

Management of Hand and Facial Lesions in a 19-Year-Old with Type 1 Diabetes

For this patient with suspected contact dermatitis from artificial nails and hair treatments, immediately discontinue all potential allergens (artificial nails, eyelash extensions, chemical hair treatments), apply a mid-potency topical corticosteroid like triamcinolone 0.1% twice daily to affected areas for 1-2 weeks combined with aggressive moisturization, and treat the confirmed wart with cryotherapy or salicylic acid rather than antifungal therapy. 1, 2

Critical First Step: Distinguish Contact Dermatitis from Fungal Infection

The clinical presentation strongly suggests contact dermatitis rather than fungal infection:

• Temporal relationship: Facial lesions appeared the morning after nanoplasty hair treatment, which is highly suggestive of allergic or irritant contact dermatitis 3, 4
• Distribution pattern: Periorbital and forehead involvement with "peachy white appearance" and stinging with moisturizer is classic for contact dermatitis from cosmetic products 3
• Exacerbating factors: Years of artificial nail use, eyelash extensions, and recent chemical treatments all represent significant allergen/irritant exposures 1

The recommendation to treat empirically as fungal infection should be reconsidered because the clinical features do not support this diagnosis, and inappropriate treatment delays proper management. 3, 2

Immediate Management Steps

1. Complete Allergen/Irritant Avoidance

• Remove all artificial nails immediately and permanently - this is the most likely culprit for hand dermatitis 1
• Discontinue eyelash extensions - chronic ocular area exposure increases sensitization risk 3
• Avoid all chemical hair treatments for at least 3-6 months until skin barrier is restored 1
• Stop using any stinging moisturizers - this indicates barrier disruption or allergic reaction 2

2. Topical Corticosteroid Therapy

For hand lesions (excluding the wart):

• Apply triamcinolone 0.1% cream twice daily for 1-2 weeks to areas of dermatitis 2
• This is appropriate for localized contact dermatitis on hands 1, 2

For facial lesions:

• Use lower potency topical steroid (hydrocortisone 1-2.5%) on face due to increased absorption risk 2
• Avoid high-potency steroids on facial skin - risk of atrophy and striae 2
• Consider tacrolimus 0.1% ointment as steroid-sparing alternative for facial/periorbital areas if steroids cause adverse effects or prolonged use needed 2

3. Aggressive Moisturization Protocol

• "Soak and smear" technique: Soak hands in plain lukewarm water for 20 minutes, then immediately apply thick moisturizer to damp skin nightly for up to 2 weeks 1, 2
• Apply moisturizer immediately after every hand washing using two fingertip units for adequate coverage 1
• Choose fragrance-free, dye-free moisturizers in tubes (not jars) to prevent contamination 1

4. Hand Hygiene Modifications

• Use lukewarm or cool water only - hot water damages skin barrier 1
• Pat hands dry gently rather than rubbing 1
• Use soap substitutes without allergenic surfactants, preservatives, fragrances, or dyes 2
• For hand sanitizers, use alcohol-based products with at least 60% alcohol and added moisturizers 1

Specific Lesion Management

Hand Warts (Confirmed on Ring Finger)

• Cryotherapy or salicylic acid treatment - standard wart therapy, not antifungal 1
• The wart is a separate issue from the dermatitis and requires different treatment

Possible Fungal Infection (Thumb Nail Edge)

• If truly fungal paronychia: Consider topical antifungal like clotrimazole or miconazole after confirming diagnosis 5
• However, this could also be irritant paronychia from artificial nail trauma - more likely given the history 3
• Do not use Mycozole cream on facial lesions - the facial presentation is not consistent with fungal infection 3, 4

Diabetes Management Considerations

Insulin Pump Prescription

• Confirm current insulin requirements with diabetes team before issuing repeat prescription as documented in the plan 1
• Provide Dexcom G7 sensor prescription to maintain continuous glucose monitoring 1
• Total daily dose of 75-100 units NovoRapid with 29 units basal appears stable 1

Diabetes and Skin Infections

• While diabetic patients have increased risk for mucocutaneous candidiasis, this patient's presentation does not fit candidal infection 6
• Well-controlled Type 1 diabetics are not at significantly increased risk for dermatophyte infections 6, 7
• The presence of diabetes does not change the contact dermatitis management approach in this case 6

Follow-Up Plan

10-14 Day Reassessment

• If no improvement after 2 weeks of appropriate topical steroid therapy: Perform patch testing to identify specific allergens 2
• If improvement: Continue moisturization indefinitely, gradually taper topical steroids 1
• If worsening: Consider secondary bacterial infection or incorrect diagnosis 2

Patch Testing Indications

• Strongly recommended given multiple potential allergen exposures (nail products, hair chemicals, eyelash adhesives) 3
• Should be performed by dermatologist familiar with cosmetic allergens 3
• Testing identifies specific allergens to avoid permanently 3, 4

Referral to Dermatology

Refer if:

• No response to initial treatment after 6 weeks 1
• Suspected allergic contact dermatitis requiring patch testing 1
• Need for advanced therapies (phototherapy, systemic immunosuppressants) 2

Common Pitfalls to Avoid

• Do not empirically treat as fungal infection without confirming diagnosis - delays appropriate treatment 3, 2
• Do not apply high-potency steroids to face - use lower potency or calcineurin inhibitors 2
• Do not allow patient to resume artificial nails or chemical treatments until skin completely healed and ideally after patch testing 1
• Do not use oil-based moisturizers under gloves if patient needs glove protection - breaks down latex/rubber 1
• Do not wash hands with very hot water or dish detergent - common barrier-damaging practices 1

Key Takeaway

This is contact dermatitis from cosmetic allergen/irritant exposure, not fungal infection. The treatment priority is complete allergen avoidance, topical corticosteroids appropriate for anatomic location, and aggressive barrier repair with moisturization. 3, 1, 2