MKSAP: 46-year-old woman with an intensely pruritic rash

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 46-year-old woman is evaluated for a 4-day history of an intensely pruritic rash on her face and neck. She started using a new facial moisturizer about 1 week before the onset of the rash. She has stopped using the moisturizer, but the rash has persisted. She has treated the rash with calamine lotion without improvement. Medical history is otherwise unremarkable, and she takes no medications.

On physical examination, she has poorly defined, red, weepy, eczematous-appearing patches on the cheeks and neck. A few fine vesicles, along with some serous crusting, are seen within the rash.

Which of the following is the most appropriate corticosteroid cream for this rash?

A: Betamethasone dipropionate
B: Clobetasol propionate
C: Desoximetasone
D: Hydrocortisone valerate

MKSAP Answer and Critique

The correct answer is D: Hydrocortisone valerate. This item is available to MKSAP 16 subscribers as item 4 in the Dermatology section.

MKSAP 16 released Part A on July 31. More information is available online.

Because this patient’s rash involves the face and neck, the lower potency corticosteroid hydrocortisone valerate is the safest choice. This patient likely has an allergic contact dermatitis to her moisturizer. Appropriate choice of a topical corticosteroid requires consideration of both the nature of the skin disease and the anatomic site being treated. Adverse effects of topical corticosteroids can include thinning of the skin, development of striae and hypopigmentation, and when used chronically, development of telangiectasia. Anatomic areas that are at particular risk of complications from topical corticosteroids include the face (particularly around the eyes, where skin is very thin) and any occluded areas of skin, such as the axillae, inguinal folds, and under pendulous breasts and the abdominal pannus. Lower potency corticosteroids are best used in these areas to minimize the risk of complications. Patients should be taught to use an adequate amount of corticosteroid to treat the affected skin; however, they should be encouraged to use it only as long as is necessary.

Clobetasol propionate is an ultrapotent corticosteroid, and both betamethasone dipropionate and desoximetasone are high-potency corticosteroids. Their routine use on the face and in other high-risk areas is not recommended.

Key Point

  • High-potency topical corticosteroids cause thinning of the skin and should be avoided on the face, in intertriginous skin folds, and on atrophic skin where absorption may be enhanced.

Learn more about ACP’s MKSAP 16.

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