MKSAP: 32-year-old man with an intermittent pruritic rash

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

A 32-year-old man is evaluated for an intermittent pruritic rash of 8 years’ duration. Medical history is significant for mild persistent asthma. His only medications are an albuterol inhaler and an inhaled glucocorticoid.

On physical examination, vital signs are normal. There is mild xerosis with erythematous plaques on the bilateral antecubital fossae, volar wrists, and anterior lower legs. Lichenification is present on the dorsal hands. Linear excoriations are found within many of the erythematous plaques on the arms.

Which of the following is the most appropriate treatment?

A. Oral cephalexin
B. Oral prednisone
C. Topical glucocorticoids
D. Topical ketoconazole
E. Topical mupirocin

MKSAP Answer and Critique

The correct answer is C. Topical glucocorticoids.

This patient has atopic dermatitis, and the most appropriate treatment is topical glucocorticoids. Eczematous dermatitis is a type of inflammation characterized by inflamed, dry, red, itchy skin. The terms eczema and dermatitis are often used interchangeably. There are multiple types of eczematous dermatoses. Atopic dermatitis is genetically driven and often affects areas such as the antecubital and popliteal fossae and typically presents in childhood. It is characterized by xerotic, pink, scaly skin and is most commonly seen on the periocular areas, posterior neck, antecubital and popliteal fossae, wrists, and ankles. The initial treatment for atopic dermatitis consists of good skin care with mild cleansers and thick emollients (petrolatum) along with topical glucocorticoids to decrease inflammation and pruritus.

Oral cephalexin is a first-generation cephalosporin antibiotic that can be used to treat selected skin infections. The use of oral antibiotics should be limited to conditions in which there is evidence of extensive bacterial infection. Clinical signs of bacterial infection typically include weeping of serous fluid, pustules, honey-colored crusting, unexplained worsening of dermatitis, or failure to respond to correct therapy. There is no indication for treatment with systemic antibiotics in this patient.

Oral prednisone should be considered only in severe, acute exacerbations of atopic dermatitis and not for regular management. Chronic oral glucocorticoid treatment can lead to side effects such as diabetes, osteoporosis, and compromised immune function, so this treatment would not be appropriate before treatment with topical glucocorticoids.

Topical ketoconazole is a treatment for superficial fungal infections. This patient has atopic dermatitis, so antifungal creams would not be used.

Topical mupirocin is the treatment for localized bacterial infections of the skin, such as impetigo. Although patients with atopic dermatitis are often secondarily colonized or infected with Staphylococcus aureus, routine use of topical antibiotics is not recommended. There is no indication in this patient that the skin is infected.

Key Point

  • The initial treatment for atopic dermatitis consists of good skin care with mild cleansers and thick emollients along with topical glucocorticoids to decrease inflammation and pruritus.

This content is excerpted from MKSAP 18 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 18 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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