I saw a 26-year-old male who came in with the complaint, “I have spots on my back

So to begin with the Summary:
I saw a 26-year-old male who came in with the complaint, “I have spots on my back.”

When I took his history, I used the OLDCARTS format to guide my assessment.

• The onset was about three weeks ago, and he said the spots appeared gradually.

• The location was primarily on his upper back and neck.

• In terms of duration, the spots have been constant with no improvement.

• He described the character as light-colored, oval-shaped patches that are mildly itchy, and have some fine scaling.

• He hasn’t noticed any aggravating factors, but he does work out regularly, so sweating might be a contributing factor.

• There were no relieving factors since he hasn’t used any treatments yet, not even over-the-counter creams.

• The timing of the itching is constant, and not worse at any particular time of day.

• As for severity, he rated the itchiness at about 2 or 3 out of 10. It’s more of a nuisance than something painful or disruptive.

He denied using any new products, and didn’t report any fevers, fatigue, weight loss, or other skin issues.

On review of systems, everything else was negative. He denied any respiratory, GI, neurological, or musculoskeletal symptoms. His past medical history was unremarkable, and he wasn’t on any medications.

During the physical exam, his vital signs were normal, and he appeared healthy and in no distress. The skin exam revealed hypopigmented, oval-shaped patches with fine scaling on the back and upper neck. The lesions ranged from about half an inch to one inch in diameter, and some were merging into larger patches. The rest of his physical exam, including HEENT, heart, lungs, abdomen, neuro, and musculoskeletal was all within normal limits.

Now for the Narrowing of the differential:
Based on what I saw, I came up with four differentials:
1. Tinea versicolor
2. Pityriasis rosea
3. Vitiligo
4. Psoriasis

Next is the Analyze section:
Tinea versicolor was my leading diagnosis. The lesions were hypopigmented, mildly itchy, and scaly—all textbook features. The distribution on the back and neck is also typical, and his lifestyle includes frequent gym use, which adds to the risk because of heat and sweat.

I considered pityriasis rosea because the patches were oval and slightly scaly, but he didn’t have a herald patch or that typical “Christmas tree” distribution, so that moved it down my list.

Vitiligo was also a possibility due to the hypopigmentation, but his patches had scaling, which isn’t seen in vitiligo. Also, the lesions weren’t on common vitiligo sites like the face or hands, and he had no personal or family history of autoimmune disease.

Lastly, I thought about psoriasis, but the lesions weren’t erythematous or thick, and there were no silvery scales or joint complaints.

So, I ranked my differential diagnoses from most likely to least likely as:
1. Tinea versicolor
2. Pityriasis rosea
3. Vitiligo
4. Psoriasis

Moving on to the Probe section:
I had a few questions for my preceptor:
First, I asked if a KOH prep would be enough to confirm tinea versicolor, or if we should also do a Wood’s lamp exam.
I also wanted to know if selenium sulfide was preferred over topical azoles for first-line treatment in mild cases.
And finally, I asked how long we should wait before considering a referral to dermatology if there’s no response to treatment.

Now for the Plan:
At a novice level, I proposed the following:

For diagnostics, I recommended a KOH prep and Wood’s lamp exam to confirm the presence of Malassezia.
If needed, we could also send a culture or consider CBC if systemic signs appear.

For treatment, I advised the patient to apply selenium sulfide 2.5% lotion—Selsun Blue—to the affected area at night, leave it on overnight, and rinse it off in the morning. I instructed him to do this daily for 12 days.
I also counseled him on hygiene: avoid sweating in tight clothes, shower after workouts, keep skin dry, and avoid scratching the area.

I told him that if the lesions didn’t improve or worsened, we would reassess and consider other diagnoses or refer to dermatology.

Lastly, for my Self-Directed Learning:
One area I wanted to explore more was the comparative effectiveness of topical antifungals for tinea versicolor. I planned to look into whether azoles or selenium sulfide have better outcomes in terms of recurrence and patient compliance.

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