A 55-year-old man comes to the physician with an intensely pruritic rash under his left arm. He has used an old prescription of 1% triamcinolone cream for the past 2 weeks without relief and believes that the rash is expanding. The patient was diagnosed with Sjögren's syndrome 6 months ago when he developed dry eyes, dry mouth, and positive anti-SS-A and anti-SS-B antibodies. Labial salivary gland biopsy at that time showed lymphocytic infiltration of salivary glands, confirming the diagnosis. He was treated with hydroxychloroquine, topical moisturizing eye drops, and artificial saliva. His other medical problems include type 2 diabetes mellitus, which has been well controlled with metformin. Physical examination findings are shown in the image below.

Complete blood count and comprehensive metabolic panel are unremarkable. His hemoglobin A1C is 6.1%.
After confirming the diagnosis, which of the following is the most appropriate next step in management of this patient?

Question

A 55-year-old man comes to the physician with an intensely pruritic rash under his left arm. He has used an old prescription of 1% triamcinolone cream for the past 2 weeks without relief and believes that the rash is expanding. The patient was diagnosed with Sjögren's syndrome 6 months ago when he developed dry eyes, dry mouth, and positive anti-SS-A and anti-SS-B antibodies. Labial salivary gland biopsy at that time showed lymphocytic infiltration of salivary glands, confirming the diagnosis. He was treated with hydroxychloroquine, topical moisturizing eye drops, and artificial saliva. His other medical problems include type 2 diabetes mellitus, which has been well controlled with metformin. Physical examination findings are shown in the image below.

Complete blood count and comprehensive metabolic panel are unremarkable. His hemoglobin A1C is 6.1%.
After confirming the diagnosis, which of the following is the most appropriate next step in management of this patient?

Complete blood count and comprehensive metabolic panel are unremarkable.  His hemoglobin A1C is 6.1%.
After confirming the diagnosis, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9707_efb7_853d_bbbe8ff646ec_MD0002_00 This patient's presentation is consistent with tinea corporis. Tinea corporis is a dermatophyte infection that begins as a pruritic and scaly patch or plaque with erythema in a circular or oval pattern. It can involve the flexural areas or the axilla. The rash has irregular margins that develop central clearing and expand into an annular (ring-like) shape. Multiple lesions can coalesce to form a flower petal shape. Risk factors for tinea corporis include contact with infected humans, animals, or inanimate objects. Mild-to-moderate disease can occur in otherwise healthy patients. However, more extensive disease suggests possible underlying immunocompromised states (eg, HIV, uncontrolled diabetes). Outbreaks have occurred in athletes who have had skin-to-skin contact with infected athletes. flower petal shape Diagnosis is usually confirmed by potassium hydroxide (KOH) preparation of skin scrapings showing the characteristic segmented hyphae and arthrospores seen in dermatophytes. Mild-to-moderate disease usually responds to 2-4 weeks of topical antifungals (eg, clotrimazole). However, topical nystatin is ineffective against dermatophytes and is not recommended. Oral/systemic therapy is indicated for patients with severe or widespread disease, underlying immunocompromised states, or who fail topical therapy. Oral terbinafine, fluconazole, and itraconazole are preferred over griseofulvin due to greater efficacy and fewer side effects. (Choice A) Increasing the dose of oral hydroxychloroquine is indicated for treatment failure of Sjögren's syndrome. Refractory disease usually presents with worsening exocrine (eg, xerostomia) or extraglandular (eg, palpable purpura with cutaneous vasculitis, peripheral neuropathy) disease. However, tinea corporis does not suggest treatment failure of underlying Sjögren's syndrome. (Choice B) Topical steroids are effective against inflammatory skin conditions that can mimic tinea corporis, such as granuloma annulare. However, granuloma annulare has erythematous or violaceous annular plaques without scaling. Increasing the potency of the steroids may also worsen the tinea corporis. granuloma annulare (Choice C) Calcipotriene is a topical vitamin D analogue used to treat moderate-to-severe plaque psoriasis, which usually occurs on the extensor surfaces on the elbows, knees, hands, and feet. However, it is not effective for either Sjögren's syndrome or tinea corporis. plaque psoriasis (Choice E) Topical tacrolimus is an immunosuppressive agent approved for treating inflammatory skin conditions such as atopic dermatitis and discoid lupus. However, it is not effective for dermatophytosis and may worsen the condition. atopic dermatitis discoid lupus Educational objective: Tinea corporis is a dermatophyte infection that begins as a pruritic and scaly patch or plaque with erythema in a circular or oval pattern. The rash has irregular margins that develop central clearing and expand into an annular (ring-like) shape. Mild-to-moderate disease usually responds to 2-4 weeks of topical antifungals. Oral agents are reserved for severe or widespread disease, immunocompromised patients, and failure with topical therapy. __________ References: Superficial fungal infections. (http://www.ncbi.nlm.nih.gov/pubmed/22474120) Topical treatment of common superficial tinea infections. (http://www.ncbi.nlm.nih.gov/pubmed/12046779) Dermatophyte infections. (http://www.ncbi.nlm.nih.gov/pubmed/12537173)

A 55-Year-Old Man Comes to the Physician with an Intensely