Dermatology

PCP submission

25 yo presents to clinic today for a follow up on a rash. He has a history of eczema that he treated in the community with topical steroids, and it was relatively well controlled. He arrived at WCC on 12/2/24 and feels this started before arriving at our facility, but says it became much worse since he arrived. He spent most of the prior year at Pierce County. He is on a no peanut diet but has no known other food allergies that he is aware of. He has lost his appetite, but denies abdominal pain, constipation, diarrhea, or nausea. He did see a dermatologist and had skin testing in Olympia, WA several years ago. He is currently taking loratadine. He ran out of triamcinolone, but it did help to some degree. He is using hydrophilic cream. He is feeling fatigued and lightheaded. His whole-body hurts. He is not taking any OTC analgesics. He says Benadryl didn’t help. He was on prednisone 30mg for 5 days and says there were no improvements with that. He denies any swelling in his mouth or oral symptoms but has swelling of his arms and face. He reports that his skin is weeping at night and soiling his linens. He had screening for syphilis CT/GC, HCV, HBV, and HIV on 12/23/24. A rapid strep and throat culture earlier this month were negative. He reports he is using Dove soap.

He has a rash that covers a good portion of his body. It is on his neck, forehead, scalp and cheeks. It is on his upper extremities, chest, back, and thighs. It spares his hands except for a few small areas towards the wrists. It also spares his feet and lower legs. It is maculopapular with significant dry scaling skin covering the surface. I saw no active weeping but noted some scant evidence on his clothing. His arms and face appear to be slightly swollen but there is no pitting edema.

He seems to be having what I suspect is a contact dermatitis. What he is exposed to is unclear, and it will be difficult to figure this out while he is incarcerated. There may be a dietary component, but DOC doesn’t allow more than one therapeutic diet at a time, and he is already on a no peanut diet. I am changing his triamcinolone to a stronger steroid, clobetasol. I also am going to try another 5-day course of prednisone at 40mg to see if we can get him some relief. I have also provided him with some acetaminophen and ibuprofen. He requested HSRs for daily showers and linen changes. This seemed reasonable so I provided them. I want him to follow up next week with his PCP. I ordered another CBC and CMP as well as an ANA, ESR, and CRP today. He also signed an ROI for his community dermatology records.

This patient has not responded to the usual treatments for eczema and contact dermatitis. Are we missing a different diagnosis? He is in prison and avoiding many things that one would try in the community will be very difficult.

Specialist response

Hi. Thank you for giving me the opportunity to consult with you. I appreciate you providing the excellent clinical photos and very concise history. I agree that the diagnosis is most consistent with allergic contact dermatitis or atopic dermatitis. My usual approach to these patients is to be much more aggressive with the use of systemic corticosteroids. They are safe for precise short-term uses. It is important to reduce the number of showers when possible to every other day. Excessive showering will make the skin more irritated by removing natural oils. It is also important to apply a moisturizing lotion or cream daily after showering. The most important part of treatment for this patient in my opinion is systemic prednisone taken as 60 mg a day as a single dose with food for four days then reduce the dose to 40 mg a day for four days then 20 mg a day for four days. There is a small risk of upset stomach. Short term dosing for 4 to 5 days is not useful. Is important to shut off the full inflammatory reaction in order to see if contact dermatitis is the cause. Secondly, I agree with using clobetasol cream if it is available. I generally prescribe a 60 g tube and have the patient apply it to all of these involved areas except the face twice a day for two full weeks. If clobetasol cream is not available, I then use betamethasone dipropionate cream and try to get two of the 45 g tubes for these large body areas. I do not see a sign of superficial fungus or scabies. I welcome follow up and questions at your convenience. All the best.