				Using the search form

If you prefer to view this article in PDF form, click here.

Joe R. Monroe, PA-C, MPAS, DEPARTMENT EDITOR

When the treatment becomes the problem

Joe R. Monroe, PA-C, MPASThe author practices at The Dermatology Clinic, Oklahoma City, Okla, and is the founder and President of the Society of Dermatology Physician Assistants. He has indicated no relationships to disclose relating to the content of this article.

“Infection” is a very attractive bandwagon onto which many clinicians climb. Take the case of a 62-year-old woman who had been suffering with an “infection” for more than 18 months despite numerous courses of antibiotics carefully prescribed to combat the different pathogenic microorganisms found on multiple cultures. The woman, who was otherwise reasonably healthy, complained of itching and burning in the intergluteal and perianal area, but her biggest complaint was constantly draining fluid—which she called “pus”—that necessitated changing pads several times a day. In addition to the oral antibiotics she had taken, the patient had applied a number of topical preparations, none of which had done the slightest bit of good. Several had made her problem markedly worse. Examination revealed that the entire area was quite red and superficially eroded (see Figure 1). There was only modest edema and almost no tenderness or increased warmth on palpation. The surface was wet with clear fluid. The results of past cultures were reviewed and showed, at various times, group A beta-hemolytic streptococci, Staphylococcus epidermidis, Klebsiella species, and Escherichia coli.

Given these facts, the most likely diagnosis is

•   Contact and irritant dermatitis
•   Extramammary Paget’s disease
•   Intraepidermal squamous cell carcinoma
•   Lichen sclerosus et atrophicus (LS&A)

Discussion

The correct answer is contact and irritant dermatitis. In this syndrome, multiple medications are applied to the problem area—often at the same time—converting what would have been a small problem into a much larger one. More common in women, extramammary Paget’s disease appears to originate in the sweat glands and often causes burning and itching. Had this patient not responded to treatment for dermatitis, a biopsy would have been indicated to rule it out. A biopsy would also have been needed to rule out intraepidermal squamous cell carcinoma, which can manifest as a rash. LS&A is not usually as eroded as this patient’s rash was. Again, if the patient had not responded to treatment for the dermatitis, a biopsy would have been required. Comment and treatment No model of bacterial infection manifests as broad-based erosions, itching, and burning and is completely unresponsive to treatment with multiple antibiotics. The patient did not have pain, and there was copious clear drainage. Neither of these is consistent with bacterial infection. This patient’s clinical picture is consistent with inflammation associated with a probable contact dermatitis, made even more likely by the sheer multiplicity of products applied.

“Treatment as problem” is a common theme in dermatology. Yes, something else undoubtedly kicked this whole thing off, but it had long since been eclipsed by overattention. On any given day, this patient would apply up to six different products, including alcohol. Ironically, had any of them helped, she would never have known which one it was! The patient was treated first by strict cessation of all other topical medications and then by topical application of fluocinonide cream twice daily and Burow’s solution three times daily.