Differential Diagnosis
- Single most likely diagnosis
- Eczema (Dyshidrotic Eczema): The patient's symptoms of inflammation, skin peeling, and improvement with fluconazole (which can have some anti-inflammatory effects) initially suggested a fungal infection, but the dermatology consultation leaning towards eczema, and the response to treatments, make eczema a strong consideration. The spreading inflammation and new onset of finger swelling could be indicative of a more severe or widespread eczematous reaction.
- Other Likely diagnoses
- Fungal Infection (Onychomycosis or Dermal Mycosis): Initially diagnosed and treated as such, the patient reported some improvement with fluconazole, suggesting a possible fungal component to their condition. The splitting under the nail could be consistent with a fungal infection of the nail.
- Psoriasis: Given the skin peeling, inflammation, and the involvement of multiple fingers, psoriasis could be a consideration, especially if the patient has a history of psoriasis or psoriatic arthritis, which is not mentioned but could be relevant.
- Contact Dermatitis: The use of tea tree oil, which can sometimes cause contact dermatitis, and the subsequent worsening of symptoms could suggest a contact dermatitis, especially if the patient is allergic or sensitive to certain ingredients in the treatments they've been using.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Infectious Flexor Tenosynovitis: This is a serious infection of the tendon sheaths in the fingers, which can lead to severe consequences if not promptly treated. The symptoms of finger swelling, inflammation, and the potential for spreading infection make this a critical diagnosis not to miss.
- Osteomyelitis or Septic Arthritis: Especially in the context of Sjögren's syndrome, which can increase the risk of infections, osteomyelitis (infection of the bone) or septic arthritis (infection of the joint) could be life-threatening conditions that need to be ruled out, particularly with the involvement of multiple fingers and the presence of swelling.
- Rare diagnoses
- Scleroderma: Given the patient's history of Sjögren's syndrome, an autoimmune disorder, and the symptoms of skin tightening and potential for digital ulcers (though not explicitly mentioned), scleroderma could be a rare but possible diagnosis to consider, especially if there are other systemic symptoms.
- Erythromelalgia: A disorder characterized by burning pain, heat, and redness in the hands and feet, which could potentially explain some of the patient's symptoms, though it's less likely given the context of the initial fungal infection diagnosis and treatment response.