'I Can't Take This Rash Anymore!'

Dermatology for the Primary Care Clinician

Charles P. Vega, MD; Temitayo A. Ogunleye, MD


January 03, 2018

Clinicians see a variety of perplexing skin conditions in the primary care setting. Medscape talked with a primary care clinician, Charles P. Vega, MD, and a dermatologist, Temitayo A. Ogunleye, MD, to learn their thoughts about how best to diagnose and manage dermatology-related symptoms in primary care. This consultation is the first in a series addressing these common concerns.

Dr Vega: This case is a 25-year-old woman whose chief complaint is, "I can't take this rash anymore!" That sounds severe to me. She has had dandruff for years but now notices that there is some redness and scale on her face. The rash is also evident inferior to her breast and in her axillae. Asking what she has tried already to alleviate the symptoms is always important. She reports that she tried an over-the-counter antifungal cream but saw no change, which is interesting. She also tried hydrocortisone cream, which helped a little, but then the symptoms came back a week later. Her only complaint is some minimal amount of pruritus with the rash, but otherwise she feels well. She has no other systemic complaints. She denies any exposures to new soaps, new detergents, or new clothing. She reports no other changes in her life.

How would you approach this patient who can't take the rash anymore?

Figure 1. Seborrheic dermatitis with pink scaling of paranasal skin and nasolabial folds.

Dr Ogunleye: A couple of differential diagnoses come to mind for someone complaining of a rash in areas like this. When someone who has had dandruff for years develops a rash on the face and perhaps the chest, I immediately think of seborrheic dermatitis. Some of the clues that suggest that diagnosis include the location where the rash is occurring, notably the glabella, paranasal, or nasolabial folds. Those areas of the face are high sebum-production areas and can be prone to involvement with seborrheic dermatitis.

Figure 2. Example of seborrheic dermatitis with light scaling of the glabella and eyebrows.
Figure 3. Mild seborrheic dermatitis of the chest.

Dr Vega: If the history is taken carefully, I believe that the patient often leads you to the diagnosis. The key there is the dandruff. That really makes me think that seborrheic dermatitis is going to be a leader in this differential as well. It all corresponds to what it might look like when it spreads to the face and/or the trunk.

While we always like to have one unifying diagnosis, it is important to remember that sometimes patients have multiple diagnoses.

Dr Ogunleye: Exactly. You have to listen to what the patient is saying. Patients don't know that seborrheic dermatitis/dandruff is a spectrum of disease and can involve more than just the scalp. However, when the rash spreads to the trunk, you also have to start thinking about diagnoses such as inverse psoriasis, intertrigo, and tinea versicolor as well.

And another important consideration: While we always like to have one unifying diagnosis, it is important to remember that sometimes patients have multiple diagnoses. A patient may have seborrheic dermatitis, but if they have involvement of their chest, maybe they also have tinea versicolor.

Figure 4. Seborrheic dermatitis versus intertrigo of the axilla.
Figure 5. Inverse psoriasis in the axilla.
Figure 6. Tinea versicolor of the back.

Dr Vega: I see a lot of psoriasis as a primary care clinician, but inverse psoriasis is something I'm less familiar with. Could you tell me more about that?

Dr Ogunleye: Inverse psoriasis, sometimes called flexural psoriasis, is psoriasis that happens in intertriginous areas of the body. Patients may have full involvement of the axillae, inguinal folds, gluteal cleft, inframammary skin, umbilicus, or sometimes even under the stomach. It tends to happen in areas with skin folds. Unlike traditional psoriasis, you may not have as much scale because when psoriasis happens in areas with folds, those areas tend to be moister, so you don't have as much scaling. Instead, you tend to have well-demarcated pink patches in these areas.

Figure 7. Inverse psoriasis of the gluteal cleft.
Figure 8. Psoriasis of the midline chest and inframammary skin. Note the absence of scale.

Dr Vega: Does inverse psoriasis lead to the same risk, for example, for psoriatic arthritis?

Dr Ogunleye: Inverse psoriasis is just another form of psoriasis in a specific distribution. A patient can definitely have nail involvement and has the same risk for psoriatic arthritis. Sometimes you can see pits in the nails that you would see in more traditionally distributed psoriasis. This can serve as clue for diagnosis in patients when the diagnosis is unclear. Patients can also have scalp psoriasis. Patients who have had what they have called dandruff may actually have psoriasis.

Figure 9. Psoriasis of the scalp with well-demarcated pink plaques with overlying white scale. Note that the scale and erythema of the plaques are more than typically would be seen in seborrheic dermatitis.
Figure 10. Note the pitting of the nails sometimes seen in patients with psoriasis.

Dr Vega: Is a history of using an over-the-counter antifungal at home without improvement important to you in making a diagnosis? That makes a difference to me, as it makes me think that this rash, which has spread to the intertriginous areas, may be less likely to be fungal. Is that a reasonable assumption?

Dr Ogunleye: I think that can help with narrowing the diagnosis. For example, if you were thinking of a diagnosis of tinea versicolor, that should get better with a topical antifungal. Sometimes it doesn't get better as quickly as you would expect, so length of treatment can be important, but lack of response to an antifungal is something to consider.

If I suspect seborrheic dermatitis, I always think of two arms of treatment. The first is an antifungal, which targets the yeast that may play a role in the pathogenesis of seborrheic dermatitis. That can be helpful but sometimes is not enough for clearance. Secondly, you should also try targeting the inflammation that results from the patient's response to the yeast on the skin by adding an anti-inflammatory agent.

The bottom line is that, on average, a patient should not use a topical steroid on the face any more than about 7 or 8 days a month.

Dr Vega: So, assuming that we agree on a diagnosis of seborrheic dermatitis, how long should clinicians feel comfortable using corticosteroids on an area like the face? Do you try to limit that therapy or switch to calcineurin inhibitors?

Dr Ogunleye: I think it's a matter of the strength of the steroid. Initially, with a very severe rash, you may need to use a topical steroid for perhaps 2 weeks to get things under control. Once the rash is under control, you can often put patients on maintenance therapy. I typically recommend a low-potency topical steroid such as hydrocortisone 1% or 2.5% and have them use the topical steroid twice daily for 1-2 weeks.

After that period, for maintenance, the patient can have the option of using the steroid once or twice a week, only if they have redness or itching. Other patients may prefer to use the steroid 1 week out of each month. The bottom line is that, on average, a patient should not use a topical steroid on the face any more than about 7 or 8 days a month.

Dr Vega: That's very practical and important information.

Dr Ogunleye: I think it is also easy for patients to remember that as well. To answer your next question, I start thinking about calcineurin inhibitors when patients are unable to wean themselves off or taper down their topical steroid use. If patients are complaining of itch every day or that "the redness comes right back," calcineurin inhibitors are a great option for maintenance, particularly in areas like the face or other intertriginous areas.

Dr Vega: Here is a related question. Do you ever sense a conflict with patients who really want a very strong cosmetic result and will perhaps overuse their steroid because of a fear of redness and the rash returning? Does that happen? I sometimes find that there is always some big meeting or other event that is coming where they want to look their best. Does that ever come up in your practice?

Dr Ogunleye: It comes up often, especially because not everyone is symptomatic with itching. For many people, having scale and redness in those areas is most bothersome. In those situations, calcineurin inhibitors are a good option because they get at the inflammation. And occasionally in those patients, you can get away with also using a topical antifungal on a daily basis.

Dr Vega: Thank you very much for the good advice. This is very practical information that I think clinicians will find very useful.


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