A spreading, chronically itchy rash

A 72-year-old white male presented with an “itchy rash” that had begun on his chest 2 months ago and had now spread to his upper back. No lesions were noted on the extremities. There was no generalized erythema, warmth, or fluctuance of the surrounding skin. The rash and the itching had increased with the warmer weather. OTC cortisone creams had offered only minimal relief. The patient, who had mildly elevated BP, denied previous rashes, recent illnesses, drug or environmental allergies, new medications, or new exposures. No family members were affected. He had no exposure to pets. Numerous small, discrete, erythematous, nontender papules, some of which were crusted or excoriated, were seen on the upper chest and back (see Figure 1).