Treating A Patient With Multiple, Pruritic Open Lesions On Both Feet

By G. “Dock” Dockery, DPM, FACFAS
This may then generate the “itch-scratch” cycle that, in some patients, develops into chronic dermatitis. The generalized pruritus that results can also lead to emotional conditions such as anxiety or depression and, subsequently, progression to self-inflicted skin conditions.    Unlike xerosis in older patients, atopic dermatitis predominantly affects infants, children and young adults. Approximately 60 percent of the cases of atopic dermatitis are diagnosed with the first year of life and 90 percent of all cases are diagnosed by the age of 5. Only 10 percent of atopic dermatitis cases are diagnosed over the age of 5 and it is rare for the condition not to be identified before a patient reaches his or her teens.    The condition follows a relapsing course and most adults who suffer from atopic dermatitis have had it nearly all of their lives. In both of these conditions, xerosis and atopic dermatitis, simply rehydrating the skin, applying moisturizing creams or applying products like MimyX cream (Stiefel Laboratories) will replace the fatty acids and repair the skin barrier function, and thereby decrease most of the patient’s symptoms.

A Guide To Prevention And Treatment

Prevention of factitial dermatitis includes getting patients to understand that their actions are making the condition worse and if they stop rubbing, scratching and excoriating the skin, the problem will quickly resolve. This is not as easy as it might seem. Most authorities agree that when one suspects dermatitis artefacta, one should avoid direct confrontation. One should evaluate the patient’s emotional situation or stresses, and refer the patient for psychiatric counseling. In some cases, referral to a university-based dermatologist with experience treating psychocutaneous disorders is the best approach.    Treatment options for self-inflicted lower extremity dermatitis are relatively limited. As stated earlier, the initial approach when one suspects this diagnosis is to cover the affected area with a medicated paste Unna’s boot dressing. Other dermatologic approaches include the use of antibiotics, topical steroids and lubricants, as well as adjunctive therapy such as MimyX cream. If there is significant crusting and/or secondary bacterial infection of the erosions and excoriations, antibiotic therapy (topical mupirocin 2% ointment) is indicated.    Applying steroid topicals twice a day can be very effective in reducing the erythema and inflammation of the area. Try low-potency (group IV–V) topical steroids first and gradually progress to high-potency steroids (group I–II) if there is slow response. Long-term use of topical steroids is not recommended due to the increasing side effects with chronic usage. I have found that one can reduce much of the compulsive scratching and rubbing by having the patient apply a corticosteroid-impregnated occlusive tape cover (Cordran Tape) to problem areas. This provides both a physical barrier to skin trauma as well as an effective form of short-term relief.    As with other dermatology conditions, it is best to recommend that the patient learn to use only mild soaps and decrease the frequency of bathing. Reducing the temperature of the bath water or showers also helps to reduce drying of the skin. They should try to increase the moisture in their home environment by adding humidifiers whenever possible. Additionally, patients can also try substituting regular application of skin lubricants and lotions that are without fragrance or alcohol in place of rubbing and scratching. The most difficult time for many patients is at night and, in these cases, the patient may sleep with a pair of thin cotton gloves in an attempt to reduce the amount of scratching that occurs subconsciously.    Counseling should be supportive and empathic but should also be open to other approaches as new issues emerge. Cognitive-behavioral approaches may focus on helping the patient understand his or her illness through education and finding alternative responses to the pruritic sensations. The podiatric physician should maintain a close working relationship with the patient’s family physician and therapist, and offer education and explanations to the patient’s family. Treatment aimed at a primary psychiatric diagnosis is usually fundamental for effective results in these patients.

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