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Snapshot diagnosis - what's that rash?

Dr Mike Wyndham discusses a case in which what appeared to be a relatively innocuous rash turned out to be more serious.

Dr Mike Wyndham discusses a case in which what appeared to be a relatively innocuous rash turned out to be more serious.



The patient

A 46-year-old accountant presented with a slowly developing rash on his trunk and rear. He explained that he was too embarrassed to go swimming but, worst of all, the rash was now itching ‘like crazy'.

First instinct

Discoid eczema. In view of the significant itch, I prescribed a potent steroid ointment and a supply of antihistamines.

Differential diagnosis

• Discoid eczema

• Psoriasis

• Cutaneous T-cell lymphoma

Getting on the right track

I was surprised to see him six weeks later. The irritation was a little better but the promised resolution of the patches had not taken place. Additional patches were developing.

The hidden clue(s)

The failure to respond to the steroid application suggested that eczema was unlikely. The rash looked too red for psoriasis and there was not much surface scale on the patches.

Outcome and treatment

If in doubt, biopsy it. Well, that's what the dermatologist did and a diagnosis of cutaneous T-cell lymphoma was made. In this condition, the patches may look similar to eczema.

After about 10 years or longer, the patches may convert to plaques. Eventually, ulcers or nodules may develop in the plaques and finally there may be systemic involvement. Treatment may commence with topical steroids but later PUVA may be required. The tumour stage can be treated with radiotherapy.

Dr Mike Wyndham is a GP in north London

Arse cheeks rash

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