Clinical Guidelines from ACP

Featured Clinical Guideline

ACP's Best Practice Advice for Cervical Cancer Screening

Full text

Recent Guidelines Topics from ACP

Risk Assessment and Prevention of Pressure Ulcers

Full text
View ACP Guidelines on your smartphone. Mobile

ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

Access all Guidelines

Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.

Of Interest and Note...

Online High Value Cases
  • Online High Value Cases: A series of High Value Care case studies are available for free to help clinicians understand the benefits, harms, and costs of tests and treatment options for common clinical issues so they can pursue care that improves health and eliminates wasteful practices.
  • ACP's Mobile Resources include a variety of applications, mobile web resources, and mobile documents to support your clinical practice.

A 72-year-old man sustains a laceration on his left index finger while preparing chicken. He immediately washes the area and applies neomycin and an occlusive bandage. He changes the bandage and reapplies the medication twice daily. Two days later, he develops itching and redness at the wound site. He has had no fever or other systemic symptoms. Medical history is significant for well-controlled type 2 diabetes mellitus. His only medication is metformin.

On physical examination, vital signs are normal. The left index finger shows a 1.0-cm superficial wound with well-approximated margins without purulence or drainage, and no pain on palpation. There are pinpoint papules and vesicles in an area extending 0.5 cm around the laceration site in a rectangular pattern approximating the bandage. There is no lymphangitic streaking. The remainder of the physical examination is unremarkable.


Which of the following is the most likely diagnosis?

This patient most likely has allergic contact dermatitis from the neomycin. Neomycin is a commonly used over-the-counter topical aminoglycoside antibiotic (often used either alone or as part of combination topical antibiotic preparations). With repeated use, especially on abraded or lacerated skin, neomycin can lead to contact sensitization, which is a T-cell mediated hypersensitivity reaction. Patients and clinicians often mistake this for a wound infection, but if the area is pruritic and there is a geometric, well-defined pattern generally corresponding with the contact area, a contact allergy should be suspected. Discontinuation of the medication and future avoidance are generally recommended.

Group A streptococcal infections would cause skin infections such as impetigo, cellulitis, or erysipelas. None of these infections tend to present with a well-demarcated pattern of involvement, as seen in this patient. This patient has no pain, wound drainage, or discharge that could be associated with bacterial impetigo. There is no pain or lymphangitic streaking typical of cellulitis. Erysipelas would appear as violaceous-red, edematous, well-demarcated plaques on the face or lower extremities, unlike this patient's presentation.

The classic presentation of herpes simplex virus infection is a group of painful, small vesicles on an erythematous base, transitioning to pustules and subsequent crusting of the lesions over time. Herpetic infection would be painful with no pruritus.

Staphylococcus aureus infection would present with eczematous plaques and open erosions on the flexural folds with pustules in those areas, not in a geometric pattern on a compromised skin barrier typical of allergic contact dermatitis.

Key Point

  • Use of neomycin on abraded or lacerated skin can lead to contact sensitization, which is often mistaken for a wound infection; a contact allergy should be suspected if the area is pruritic and there is a geometric, sharply bordered pattern.
Selected ACP Member Benefits
ACP JournalWise
ACP JournalWise

Online and optimized for mobile use, ACP JournalWise alerts you to the highest quality, most clinically relevant new articles in your preferred areas of specialty and with a frequency that you select.

Begin Search | Learn More

DynaMed Plus
DynaMed PlusTM

The next-generation clinical information resource delivers the most current, evidence-based recommendations at the point-of-care.

Sign In | Learn More

In the Clinic
In the Clinic

Evidence-based answers to frequently asked questions about screening, prevention, diagnosis, and therapy for common clinical conditions. Plus, downloadable slide sets to improve quality of care are available free to members.

In the Clinic | Access Slide Sets
Clinical Multimedia