Management of a Unique Presentation of a Common Dermatologic Condition.

Casey P Schukow,Madeline Schaeffer,David Fivenson,Katherine Boss

doi:10.51894/001c.24501

Casey P Schukow, Madeline Schaeffer + Show 2 more

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https://doi.org/10.51894/001c.24501

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Abstract

CONTEXTSkin rashes are a common complaint seen in the primary care setting. There are many dermatologic conditions which a primary care provider (PCP) should be able to recognize and manage. One such condition is granuloma annulare (GA), which commonly presents as smooth, annular plaques on the trunk and/or extremities. Rashes like GA rarely present as unique variants and may be difficult for PCPs to determine from patient history and physical exam alone. Patch granuloma annulare (patch GA) is an example that may clinically mimic a cutaneous lymphoma known as mycosis fungoides (MF). PCPs should ideally be able to recognize the utility of performing a skin biopsy and/or referring the patient to a dermatologist when history and physical exam alone are insufficient. The histologic findings of skin biopsies often become essential in establishing a proper diagnosis and guiding patient management in unique dermatologic variants.EXAMPLE CASEThe patient in this clinical practice report is a Caucasian female in her late 60s who presented to a dermatology clinic with a two-year history of a worsening widespread eruption on her trunk and extremities. She had been evaluated previously by her PCP about 4 months prior and, without obtaining skin biopsies, treated her with a medium potency topical corticosteroid cream. The eruption had spread over her hips, buttocks, back, thighs, wrists, and elbows. Multiple skin biopsies of affected sites were taken by the second author and revealed findings consistent with patch GA. The patient was started on topical betamethasone dipropionate 0.05% ointment twice daily and noted marked improvement of her symptoms.CONCLUSIONSAlthough GA is a benign condition of the skin that may be readily detected by PCPs, skin biopsies may be necessary to establish a proper diagnosis when this condition presents as a unique variant (e.g., patch GA). Therapy for patch GA often begins with a trial of high-potency topical steroid therapy in combination with ultraviolet light exposure, depending on disease severity and patient preference. Early evaluation with a skin biopsy by her PCP or an earlier referral to a dermatologist to have skin biopsies performed likely would have helped establish a prompter diagnosis and treatment plan for this patient.

Highlights

A study conducted by Lowell et al in 2001 determined that approximately one in three patients present to their primary care provider (PCP) with at least one dermatologic complaint (e.g., “rash”).[1]
The authors concluded that roughly 37.5% of patients presenting with rashes are referred from their PCP to a dermatologist.[1]
One condition that tends to be recognized by PCPs is granuloma annulare (GA), which involves a benign accumulation of macrophages called a “granuloma” in the skin’s dermis.[6]

Summary

CONCLUSIONS

GA is a benign condition of the skin that may be readily detected by PCPs, skin biopsies may be necessary to establish a proper diagnosis when this condition presents as a unique variant (e.g., patch GA). Therapy for patch GA often begins with a trial of high-potency topical steroid therapy in combination with ultraviolet light exposure, depending on disease severity and patient preference. Evaluation with a skin biopsy by her PCP or an earlier referral to a dermatologist to have skin biopsies performed likely would have helped establish a prompter diagnosis and treatment plan for this patient

INTRODUCTION

Findings

DISCUSSION

CONFLICT OF INTEREST