74 yo Male with Expanding Rash

74 yo male, very healthy, comes in for a rash on the left axilla. Was already seen for this one month ago and given topical clotrimazole. the rash has since spread in the axilla. It itches minimally and he has had no blistering or pain in the area. He is here in the urgent care because he noticed over the past week it has spread to the left nipple. At some point he did try a topical steroid but for a very short course and it was something over the counter.

No significant PMHx.
No current meds.
No recent URI sxs. No recent sore throat.
No fevers/chills/body aches/GI sxs.
Denies any recent travel.
Has been taking a men’s multivitamin sporadically.

 

Started out small 1 month ago, spreading in a concentric manner since.
Started out small 1 month ago, spreading in a concentric manner since.
Notice small scaly lesion below left nipple.
Notice small scaly lesion below left nipple.

On exam the rash is well demarcated.
Erythematous and large macule noted in the left axilla with no scaling.
On the left nipple the rash is more scaly with slightly raised edges.
No oral lesions noted.
No nail pitting.
No other lesions noted on the rest of the body.

Upon further questioning he reports that his dad used to have psoriasis and that on occasion the patient has had a small pinkish patch that would come and go. The last one he recalled was a quarter sized area on the left thigh. Patient was treated with topical betamethosone 0.5% cream due to the thin area of skin in question.

Dx? Psoriasis.
Confirmed? No biopsy done.
Outcome? Improved with topical steroid cream in less than 7 days.

A good petroleum based moisturizer is important for patient to continue using. Skin that’s traumatized even from just being dry is more likely to develop a psoriatic reaction. Topical steroids can be used for 2-4 weeks to decrease the reaction. Thinning of the skin is not a major concern since the skin is already thick in the affected areas. Care should be taken not to overuse high potency steroids due to systemic effects. Pulse dosing such as once a week treatment can be used to keep the outbreak under control.

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