Case of Migratory Urticarial Rash in a Young Female Under Significant Stress

Case at a Glance

A 24-year-old female with a significant psychiatric history presented with a one-week history of a pruritic, migratory rash. Despite initial suspicion of contact dermatitis, the clinical picture, including the urticarial nature of some lesions and a strong correlation with severe psychosocial stress, pointed towards a diagnosis of acute urticaria.

Patient's Story

A 24-year-old Caucasian female presented with a one-week history of an evolving rash. The patient has a past medical history significant for severe depression, anxiety, obsessive-compulsive disorder, and tachycardia, as well as undiagnosed chronic pain. Her current medications include bupropion XL 450 mg, buspirone 7.5 mg, and hydroxyzine 50 mg as needed. She reports occasional smoking and frequent use of ibuprofen. The patient described the sudden appearance of lesions on her arms and face. She initially suspected an allergic reaction to poison ivy, to which she has a known severe allergy, as she had recently done yard work in an area with high exposure. However, she noted that as some spots began to resolve, new ones would appear in different locations, including her abdomen and near her ear. The lesions were predominantly pruritic, and some on her arm had a hive-like (urticarial) appearance, especially in the evening. Symptoms, particularly pruritus and erythema, would flare up at night. The patient reported being under immense psychosocial stress, stating she felt on the verge of a 'nervous breakdown' daily. She recalled a similar 'stress rash' episode several years prior.

Initial Assessment

The patient first sought care at a walk-in clinic. The examining practitioner was uncertain of the etiology. Contact dermatitis from poison ivy was considered less likely due to the migratory pattern of the lesions. The patient had made no recent changes to her diet, detergents, lotions, or soaps. She has two indoor cats with no signs of fleas, and the lesions were not characteristic of bedbug bites. Prior to the visit, the patient had been self-treating with topical diphenhydramine and hydrocortisone creams, as well as oral loratadine. Due to the urticarial appearance of the rash one evening, she also took oral diphenhydramine. The clinic physician prescribed a topical steroid cream, opting against oral steroids due to patient-reported contraindications.

The Diagnostic Journey

The differential diagnosis was broad.

Allergic Contact Dermatitis: Initially high on the list due to a known severe allergy to poison ivy and recent potential exposure. This was largely ruled out by the migratory nature of the rash; contact dermatitis typically remains in the area of contact and follows a more predictable resolution course.
Occupational Dermatitis: The patient works with various chemicals, including urethane plastics, silicone, and paints. However, the rash was not localized to areas of direct skin contact, and it persisted even after a week of no exposure to some of the materials.
New Environmental or Food Allergen: This was deemed unlikely, as the patient maintained a highly consistent diet and had not introduced any new personal care products or detergents into her environment.
Acute Urticaria: This became the leading diagnosis. The appearance of wheals (hives), intense pruritus, and the transient, migratory nature of the lesions are hallmark features. The patient's report of a prior 'stress rash' and current extreme levels of psychological stress provided a strong potential trigger, as stress is a well-documented cause of urticaria.

Final Diagnosis

Acute Urticaria, secondary to psychosocial stress.

Treatment Plan

The treatment plan focused on symptomatic relief and addressing the likely underlying trigger.

Pharmacotherapy: The patient was instructed to begin the prescribed topical steroid cream for localized inflammation. She was advised to continue with a second-generation, non-sedating antihistamine (e.g., loratadine) for daytime pruritus control and to use a first-generation antihistamine (e.g., hydroxyzine, diphenhydramine) at night to aid with sleep and manage nocturnal itching.
Supportive Care: Use of cool compresses and oatmeal baths was encouraged for symptomatic relief.
Stress Management: The patient was counseled on the strong connection between her stress levels and the physical manifestation of the rash. She was strongly encouraged to follow up with her mental health provider to address the acute stressors.

Outcome and Follow-up

The patient was discharged from the walk-in clinic with the new treatment plan. She was advised to follow up with her primary care physician if the rash persisted for more than six weeks (transitioning to chronic urticaria) or if her symptoms worsened. The importance of managing her underlying mental health conditions as a key component of managing her physical symptoms was emphasized.