Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Itchy skin rash (location, severity)
Burning sensation
Scaling or blistering (if present)
II. History of Present Illness:
Onset and duration of rash
Progression of rash (spreading, worsening, improving)
Exposure to potential irritants or allergens (occupational, household products, medications, personal care products)
Activities or exposures preceding the rash
Attempts at self-treatment and response
III. Past Medical History:
Atopic dermatitis (eczema) or other skin conditions
Allergies (medications, food, environmental)
IV. Social History:
Occupation (potential for irritant exposure)
Hobbies and activities (potential for irritant/allergen exposure)
Use of personal care products (soaps, lotions, cosmetics)
V. Medications:
Current medications (topical, oral)
VI. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
Skin exam:
Location and distribution of rash (evolves with different types of contact dermatitis)
Appearance of rash (erythema, scaling, papules, vesicles, weeping)
Sharp demarcation between exposed and unexposed areas (suggestive of contact dermatitis)
Lymph node exam (may be enlarged in allergic contact dermatitis)
VII. Assessment:
Type of contact dermatitis suspected (irritant vs. allergic) based on history, clinical presentation, and distribution of rash.
Severity of dermatitis (acute, subacute, chronic)
Identification of potential causative agents
VIII. Plan:
Treatment:
Irritant contact dermatitis:
Remove or avoid identified irritant.
Topical corticosteroids (low-potency to medium-potency) to reduce inflammation.
Emollients to moisturize and soothe the skin.
Allergic contact dermatitis:
Identify and avoid allergens through patch testing (if indicated).
Topical corticosteroids (medium-potency to high-potency) for inflammation.
Calcineurin inhibitors (tacrolimus, pimecrolimus) – alternative for chronic cases or corticosteroid-sparing.
Oral corticosteroids (brief course) – for severe cases.
Patient education on:
Identifying and avoiding triggers.
Proper use of topical medications.
Moisturizing the skin regularly.
Recognizing signs of infection (worsening redness, warmth, pus)
IX. Follow-up:
Schedule for re-evaluation to assess response to treatment and need for adjustments.
Consider patch testing for suspected allergens (performed by a dermatologist).
X. Notes:
Include any additional observations or concerns, such as patient’s adherence to recommendations, impact of the rash on daily life, and potential need for referral to a dermatologist (complex cases, suspicions of other skin conditions).
XI. Resources:
Consider providing patient education materials on contact dermatitis from reputable sources (e.g., American Academy of Dermatology, National Eczema Association).