A 65-year-old woman comes to the physician with a pruritic rash. This is the second year the rash has appeared, both times during the onset of winter. She has intensely pruritic areas on her lower extremities along the shins and above the right lateral malleolus. The patient sometimes experiences pruritus on her lower back and the extensor surfaces of the forearms. One area usually predominates. There is no visible rash initially, but the involved areas can become rough and scaly after a few weeks of frequent scratching. Her only other medical problem is perennial rhinitis. Her medications include cetirizine, calcium plus vitamin D supplements, and a multivitamin.
Skin examination findings are shown in the photograph.

Which of the following is the best next step in management of this patient?

Question

A 65-year-old woman comes to the physician with a pruritic rash.  This is the second year the rash has appeared, both times during the onset of winter.  She has intensely pruritic areas on her lower extremities along the shins and above the right lateral malleolus.  The patient sometimes experiences pruritus on her lower back and the extensor surfaces of the forearms.  One area usually predominates.  There is no visible rash initially, but the involved areas can become rough and scaly after a few weeks of frequent scratching.  Her only other medical problem is perennial rhinitis.  Her medications include cetirizine, calcium plus vitamin D supplements, and a multivitamin.
Skin examination findings are shown in the photograph.

Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation of dry, scaly, itchy, and red skin is consistent with skin dryness (xerosis). Xerosis ('winter itch') is more common in the winter months due to dry weather. The elderly (who have decreased sebaceous/sweat gland activity) and patients who bathe frequently or take offending medications (eg, doxycycline) are at particularly high risk. The dry skin can easily become irritated, leading to pruritus and excoriations. One or a few areas are usually involved and systemic pruritus is not present. Patients eventually develop thickened and scaly lichenified plaques in pruritic areas. Areas not within reach of the hands are typically not involved. Most cases can be managed with daily skin moisturizers and topical emollients. Patients should also use gentle cleansers (eg, moisturizing bar soaps) and lukewarm (rather than hot) water when bathing. Other alleviating treatments include lotions (eg, calamine, menthol-containing) for cool skin relief, reducing possible skin irritants, using a humidifier in the winter, and stress reduction. More advanced cases may require topical corticosteroids. (Choice A) Capsaicin is derived from chili peppers and can be effective for neuropathic (eg, notalgia paresthetica, brachioradial pruritus) and certain pruritic conditions (eg, prurigo nodularis, aquagenic pruritus, pruritus associated with chronic renal disease). However, it is not as effective for xerosis. (Choice B) Generalized pruritus due to systemic causes requires further investigation, including thyroid-stimulating hormone, creatinine, bilirubin, calcium, and blood glucose levels. However, this patient's seasonal symptoms and localized pruritus make this less likely. (Choice D) Xerosis is usually a clinical diagnosis and requires a skin biopsy only in cases with unclear etiology. (Choice E) Topical terbinafine is effective for tinea corporis, a fungal infection that usually presents with ringlike papulosquamous eruptions on the arms and legs. tinea corporis Educational objective: Xerosis is dry skin due to depleted moisture that results in intensely pruritic areas. Recurrent excoriation of the area can expand the lesion and lead to lichenification. Most cases can be managed with daily skin moisturizers and topical emollients. __________ References: Dry skin in the elderly: complexities of a common problem. (http://www.ncbi.nlm.nih.gov/pubmed/21146730) Skin xerosis. Clinical report on the effect of a moisturizing soap bar. (http://www.ncbi.nlm.nih.gov/pubmed/348407)

A 65-Year-Old Woman Comes to the Physician with a Pruritic