Photo Rounds Friday Archive
Post Date: 10/23/2009
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A 56-year-old man sought care for an extensive rash over his entire body. It had started 2 months earlier in the gluteal region and spread to his hands, arms, trunk, legs, feet, and most recently, his face. He had extensive pruritus and was uncomfortable. He said he drank 1 bottle of gin a day and had done so for the last 20 years. He denied previous skin problems. He also denied any fevers, chills, or night sweats. On physical exam he had large erythematous plaques with white scales on his hands and most of his body. He also had extensive nail changes on his right hand. A 4-mm punch biopsy was performed.
What's your diagnosis?
The biopsy ultimately indicated that the patient had eczematous dermatitis.
The treating physician had initially considered erythroderma from psoriasis, eczema, a drug reaction, fungal infection, seborrheic dermatitis, and mycosis fungoides as part of the differential. The physician had also suggested the patient be hospitalization for detox and dermatologic treatment, but he declined.
Given that the lab work would not be ready for a few days, the physician sent the patient home with a 1-pound tub of 0.1% triamcinolone ointment to apply to the affected areas twice daily. For the first few days, the patient was to apply the triamcinolone extensively, soak cotton pajamas in warm water and put those on, and wrap himself in a blanket. He was told to remove the pajamas in 15 minutes. The physician also told the patient to cut back on his alcohol intake, drink plenty of fluids, and return the following day. When the patient returned, the appearance of his skin had improved.
The biopsy results followed, and confirmed that he had eczematous dermatitis.
Knowing this was not psoriasis, the physician prescribed a course of systemic steroids along with the topical ointment. The patient continued to improve, but reached a plateau at 3 weeks. Again, the physician urged the patient to enter the hospital for detoxification. He agreed, and after a rocky period in the intensive care unit, left the hospital sober, and with almost completely clear skin.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Henderson D. Erythroderma. In: Usatine R, Smith M, Mayeaux EJ, Chumley H, Tysinger J, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:643-647.
To learn more about The Color Atlas of Family Medicine, see: