User login
For several months, a 60-year-old woman has had a rash on the right side of her groin, which her primary care provider diagnosed as a “probable yeast infection.” The patient was given a prescription for nystatin cream; when this did not help, she was prescribed a combination clotrimazole/betamethasone cream. Initial signs of improvement prompted her to continue application daily.
However, although the original rash cleared, other skin changes occurred in the area. These alarmed the patient’s primary care provider, who observed them during a follow-up exam. In response, the patient requested a referral to dermatology.
EXAMINATION
The entire right crural area is bright red and shiny. Multiple blood vessels are seen coursing over the surface of the area. There is no edema, increased warmth, or tenderness on palpation.
Punch biopsy shows marked epidermal atrophy and fails to show any evidence of cellular atypia.
What is the diagnosis?
DISCUSSION
When the patient was advised to stop using the combination cream, the “new” problem resolved quickly and her skin returned to normal. Although the source of the original rash remains unknown, what is clear is that the prescribed steroid induced marked atrophy. This then became “the problem.”
The groin is particularly susceptible to these types of changes. Why? Three reasons are occlusion, thin skin, and hydration. Read on for further explanation!
Occlusion, intentional or not, is known to potentiate the effects of topical steroids. The nature of intertriginous skin (skin folds) is that it effectively occludes the medicated skin, magnifying positive and negative effects. This means that the steroid works better and faster, but it also makes atrophy more likely (and equally quick to develop). When steroids are used for sufficient duration in susceptible areas—groin, axillae, under the breasts—focal areas of epidermis can wither totally, leaving an actual hole in the skin through which subcutaneous fat can be seen.
Furthermore, intertriginous skin is inherently thin (as are eyelids, neck skin, and the face). As a result, it takes less time for these changes to develop. The groin is especially prone to this problem because well-hydrated skin facilitates better penetration of the steroid.
This situation would likely have been avoided if the patient had used the prescribed product for only a week or two. A better option might have been a prescription for a weaker steroid (eg, hydocortisone 2.5%), although even that can be problematic if the medication is used for an extended period.
Though not quite as effective, topical NSAID preparations (calcineurin inhibitors such as pimecrolimus and tacrolimus) cause no such problems. They can help to reduce steroid use—for example, the patient can apply the steroid every third day and the calcineurin inhibitor on the other days.
The vehicle (the base in which the steroid is mixed) matters as well. Steroid ointments are inherently “self-occlusive,” especially in intertriginous areas—a fact that calls for increased caution in their use.
The atrophic look seen in this patient’s groin could have had other causes, such as T-cell or B-cell lymphoma. These were effectively ruled out by the biopsy.
TAKE-HOME LEARNING POINTS
• Epidermal atrophy is especially common on intertriginous skin (skin folds).
• The stronger the steroid (classes 1 through 7, with 1 being the strongest), the faster the atrophy occurs.
• Occlusion—caused by opposing skin folds or by other material (eg, socks, plastic wrap)—potentiates the positive and negative effects of topical steroids.
• Thin, moist skin allows better penetration by topical steroids, making them work better but also making atrophy more likely.
• Calcineurin inhibitors (eg, tacrolimus or pimecrolimus) have no such adverse effects and can help to reduce overuse of topical steroids in susceptible areas.
For several months, a 60-year-old woman has had a rash on the right side of her groin, which her primary care provider diagnosed as a “probable yeast infection.” The patient was given a prescription for nystatin cream; when this did not help, she was prescribed a combination clotrimazole/betamethasone cream. Initial signs of improvement prompted her to continue application daily.
However, although the original rash cleared, other skin changes occurred in the area. These alarmed the patient’s primary care provider, who observed them during a follow-up exam. In response, the patient requested a referral to dermatology.
EXAMINATION
The entire right crural area is bright red and shiny. Multiple blood vessels are seen coursing over the surface of the area. There is no edema, increased warmth, or tenderness on palpation.
Punch biopsy shows marked epidermal atrophy and fails to show any evidence of cellular atypia.
What is the diagnosis?
DISCUSSION
When the patient was advised to stop using the combination cream, the “new” problem resolved quickly and her skin returned to normal. Although the source of the original rash remains unknown, what is clear is that the prescribed steroid induced marked atrophy. This then became “the problem.”
The groin is particularly susceptible to these types of changes. Why? Three reasons are occlusion, thin skin, and hydration. Read on for further explanation!
Occlusion, intentional or not, is known to potentiate the effects of topical steroids. The nature of intertriginous skin (skin folds) is that it effectively occludes the medicated skin, magnifying positive and negative effects. This means that the steroid works better and faster, but it also makes atrophy more likely (and equally quick to develop). When steroids are used for sufficient duration in susceptible areas—groin, axillae, under the breasts—focal areas of epidermis can wither totally, leaving an actual hole in the skin through which subcutaneous fat can be seen.
Furthermore, intertriginous skin is inherently thin (as are eyelids, neck skin, and the face). As a result, it takes less time for these changes to develop. The groin is especially prone to this problem because well-hydrated skin facilitates better penetration of the steroid.
This situation would likely have been avoided if the patient had used the prescribed product for only a week or two. A better option might have been a prescription for a weaker steroid (eg, hydocortisone 2.5%), although even that can be problematic if the medication is used for an extended period.
Though not quite as effective, topical NSAID preparations (calcineurin inhibitors such as pimecrolimus and tacrolimus) cause no such problems. They can help to reduce steroid use—for example, the patient can apply the steroid every third day and the calcineurin inhibitor on the other days.
The vehicle (the base in which the steroid is mixed) matters as well. Steroid ointments are inherently “self-occlusive,” especially in intertriginous areas—a fact that calls for increased caution in their use.
The atrophic look seen in this patient’s groin could have had other causes, such as T-cell or B-cell lymphoma. These were effectively ruled out by the biopsy.
TAKE-HOME LEARNING POINTS
• Epidermal atrophy is especially common on intertriginous skin (skin folds).
• The stronger the steroid (classes 1 through 7, with 1 being the strongest), the faster the atrophy occurs.
• Occlusion—caused by opposing skin folds or by other material (eg, socks, plastic wrap)—potentiates the positive and negative effects of topical steroids.
• Thin, moist skin allows better penetration by topical steroids, making them work better but also making atrophy more likely.
• Calcineurin inhibitors (eg, tacrolimus or pimecrolimus) have no such adverse effects and can help to reduce overuse of topical steroids in susceptible areas.
For several months, a 60-year-old woman has had a rash on the right side of her groin, which her primary care provider diagnosed as a “probable yeast infection.” The patient was given a prescription for nystatin cream; when this did not help, she was prescribed a combination clotrimazole/betamethasone cream. Initial signs of improvement prompted her to continue application daily.
However, although the original rash cleared, other skin changes occurred in the area. These alarmed the patient’s primary care provider, who observed them during a follow-up exam. In response, the patient requested a referral to dermatology.
EXAMINATION
The entire right crural area is bright red and shiny. Multiple blood vessels are seen coursing over the surface of the area. There is no edema, increased warmth, or tenderness on palpation.
Punch biopsy shows marked epidermal atrophy and fails to show any evidence of cellular atypia.
What is the diagnosis?
DISCUSSION
When the patient was advised to stop using the combination cream, the “new” problem resolved quickly and her skin returned to normal. Although the source of the original rash remains unknown, what is clear is that the prescribed steroid induced marked atrophy. This then became “the problem.”
The groin is particularly susceptible to these types of changes. Why? Three reasons are occlusion, thin skin, and hydration. Read on for further explanation!
Occlusion, intentional or not, is known to potentiate the effects of topical steroids. The nature of intertriginous skin (skin folds) is that it effectively occludes the medicated skin, magnifying positive and negative effects. This means that the steroid works better and faster, but it also makes atrophy more likely (and equally quick to develop). When steroids are used for sufficient duration in susceptible areas—groin, axillae, under the breasts—focal areas of epidermis can wither totally, leaving an actual hole in the skin through which subcutaneous fat can be seen.
Furthermore, intertriginous skin is inherently thin (as are eyelids, neck skin, and the face). As a result, it takes less time for these changes to develop. The groin is especially prone to this problem because well-hydrated skin facilitates better penetration of the steroid.
This situation would likely have been avoided if the patient had used the prescribed product for only a week or two. A better option might have been a prescription for a weaker steroid (eg, hydocortisone 2.5%), although even that can be problematic if the medication is used for an extended period.
Though not quite as effective, topical NSAID preparations (calcineurin inhibitors such as pimecrolimus and tacrolimus) cause no such problems. They can help to reduce steroid use—for example, the patient can apply the steroid every third day and the calcineurin inhibitor on the other days.
The vehicle (the base in which the steroid is mixed) matters as well. Steroid ointments are inherently “self-occlusive,” especially in intertriginous areas—a fact that calls for increased caution in their use.
The atrophic look seen in this patient’s groin could have had other causes, such as T-cell or B-cell lymphoma. These were effectively ruled out by the biopsy.
TAKE-HOME LEARNING POINTS
• Epidermal atrophy is especially common on intertriginous skin (skin folds).
• The stronger the steroid (classes 1 through 7, with 1 being the strongest), the faster the atrophy occurs.
• Occlusion—caused by opposing skin folds or by other material (eg, socks, plastic wrap)—potentiates the positive and negative effects of topical steroids.
• Thin, moist skin allows better penetration by topical steroids, making them work better but also making atrophy more likely.
• Calcineurin inhibitors (eg, tacrolimus or pimecrolimus) have no such adverse effects and can help to reduce overuse of topical steroids in susceptible areas.
