39 y/o F h/o hypothyroidism, depression/anxiety on sertraline and levothyroxine. Presents via a telehealth visit for evaluation of multiple skin lesions to her left foot. Pt states she has had these lesions for about 2 years now. Pt reports that they can be intermittently itchy and sometimes she endorses fluid or that they are “Moist”. Denies any other lesions elsewhere. Pt denies any family history of skin issues such as eczema or psoriasis. Pt has just finished 2 weeks of daily clobetasol 0.05% ointment. Pt reports some improvement with lesions, but no resolution. Denies any issues with circulation or cold/pale feet. No known issues with diabetes or blood sugar issues. Denies any numbness or tingling to her feet. States she initially saw a dermatologist who stated that this was diagnosed as eczema and skin scrapings were done. Recently pt was given some steroid ointment for these skin issues.
I prescribed clotrimazole cream bid x 4 weeks. Pt questioned if there could be a fungal component to this issue. Didn’t see the harm in an antifungal.
What other treatments do you recommend for this patient? What skin care (hygiene and moisturizing) do you recommend? Should this patient be seen in person by a dermatologist?
Thank you for the consult! The findings are not entirely specific, but in the setting of a prior negative KOH scraping, I agree this could be compatible with a chronic eczematous dermatitis, such as allergic contact dermatitis. I think your plan to treat empirically for dermatophyte infection is reasonable given the potential for false negatives on KOH–she can treat the entirety of both feet including between toes–but I would have a low threshold to continue or quickly resume the clobetasol BID in cycles of 2 weeks on, 2 weeks off. It often takes multiple cycles (at least 3-4) to be considered an adequate trial, and if this does not resolve her symptoms, I would consider a biopsy in your office or referral to in person derm for further evaluation. Subsequent treatment options include other topicals such as tacrolimus ointment, phototherapy, or systemic agents such as MTX or dupilumab. For her general skin care, I recommend the following: – The patient is to use warm water, avoid hot water. – Use mild soaps such as Cetaphil restoraderm sparingly. No scrubbing. – Upon exiting the bath or shower, the skin should be pat dry. – Within 2 min of exiting shower apply emollients immediately to the skin. – Recommend cetaphil or vanicream cream (not lotion) or other bland emollient. – Emollients should be used at least BID and ad lib t/o the day. Those are my initial thoughts and I hope this helps. I am happy of course to discuss further. Thanks again for the case!