PracticeUpdate: If eczema is not responding, what should I do next?
Dr. Mostow: First, eczema (redness, scaling, crusts, etc.) is really a clinical impression, so the first thing to do is to at least consider the possibility that your patient has scabies as the underlying cause of their scabies. In my office, I tell the staff, residents and students that everybody who's itching should be considered to have scabies until proven otherwise. Once you're thinking of it in those terms for someone itching, most physicians will look for signs of scabies in finger webs, wrists, and moist spaces such as under arms or, perhaps, genitalia.
Second, think about simple principles for treating the damaged skin that is manifesting as eczematous dermatitis. Hydrate the skin—recommend more moisturizers and perhaps less soaps. Less soap is a specific to using fewer things that are going to irritate the skin and I also encourage patients to avoid soap on their whole body. They can use soap under their arms, in the groin, and other skin folds, but they don’t need soap on every inch of their body. It's also a reminder to think about other things that might be touching the body including chemicals, perhaps in things like fabric softeners, which might be driving the eczema.
Third, if all you have used thus far is a class 6 steroid cream, certainly use a mid- to higher-potency steroid; if you are concerned about using more potent topical steroids, use them for a short period of time and see if it resolves the eczema, then switch to emollients or a less potent agent.
Finally, if it's not getting better, make sure to get an appropriate referral to a specialist because maybe it's a fungal disease or something else.
PracticeUpdate: What do I do about a fungal infection that remains, despite treatment?
Dr. Mostow: Again, if you’ve treated the same infection once or twice and it’s not getting better, it’s time to rethink your diagnosis. It turns out that it can be quite costly to keep treating fungal infections, especially with systemic antifungals and possibly bloodwork monitoring, so making sure you have the correct diagnosis with a positive potassium hydroxide (KOH) scraping, biopsy or culture is critical.
PracticeUpdate: How should one treat lower extremity redness?
Dr. Mostow: Oftentimes the patient has been treated for cellulitis with antibiotics for months or years, sometimes recurrently. Perhaps this is not an infection and doesn't need antibiotics.
The treatment of the presumptive diagnosis of cellulitis is one that's been shown in several studies lately to incur significant costs and to have of implications with respect to potential bacterial antibiotic resistance. Getting the proper diagnosis and considering things like psoriasis, eczema, stasis dermatitis, or even other diagnoses like pretibial myxedema, can go a long way toward reducing risk and improving patient outcome.
PracticeUpdate: Which moles need to be biopsied?
Dr. Mostow: Well, the “ugly duckling” sign is one term used to identify moles that need a biopsy. The lesion that is out of step with the other nevi on that particular patient.
The ugly duckling fits into what I said about using art or developing visual skills. It’s that whole idea of being able to scan the palette of the patient's skin and see what seems out of step with the others; almost like in the hidden pictures we all remember from Highlights magazine.
A patient’s phenotype, their biologic pattern of how they form nevi, is an overarching story of what his or her body does in terms of moles. But if you see one that’s out of step with the others, that ugly duckling, that may be extremely important and certainly deserves a closer look with a dermatoscope, perhaps, monitoring of photography or, perhaps, an excision or biopsy.
The other issue, of course, is using the clinical signs discussed above (the ABCDE of melanoma), especially the E of evolving, though one must take patient age into account as most acquired nevi form from adolescence until the mid to late thirties. That being said, a recently reviewed study in PracticeUpdate discussed adult onset acquired nevi as a different subset that can be identified with particular dermatoscopic criteria.