I often joke with my colleagues in primary care who tell me there is nothing worse in their world then a 4pm Friday patient with the chief compliant of “rash” (besides perhaps “dizziness”). To me (a dermatology PA) I get excited when I see that chief compliant and practically break out in a sweat when I think of the many other primary care chief complaints that would send me head into a tail spin. Here are two pearls to help you approach the next “rash” chief compliant that walks through your door.
1) Take a throughout history and you are half way there: Go back to school and remember those laborious long H&Ps we used to have to write up? Remember all those cute little sayings to help you remember all the right questions (onset, provocation, quality…etc.)? Well, bring out all those all sayings because history if your first major clue to a rash. Perhaps some of the most important (and often over looked) questions are:
• Have you ever had this before?
• Think of everyone who sleeps under the same roof or that you come to close enough contact to constitute a hug or more – are any of them have a rash?
• Does anyone in your family have any skin problems at all?
• When did this start and what have you tried on it prescription and over the counter? When they answer “yes, but xyz did not work.” Ask them to explain that. Did it feel good initially? I have many a chronic eczema patient think that a cream “didn’t work” because it didn’t cure their rash forever and make it never comes back.
2) If you are not sure if the rash is fungal or inflammatory in nature treat is with an anti-fungal first. Do not harm do not put a steroid on a fungal infection. And do not punt and use a combination cream with both an antifungal and steroid in it. You know who I am talking to here! If you’ve ever done this you are not being fair to your patients. You’re guessing and treating both and hoping it does the trick. That’s not fair and it is not quality medicine. Perform a fungal culture and give them a plain topical anti-fungal cream (some have some great anti-inflammatory properties anyway such as (ciclopirox topical). Two weeks of an anti-fungal cream and bring them back for follow up. I have seen patients partially treated with clotrimazole/betamethasone topical improperly for years (and quite unhappy when they develop steroid induced secondary skin changes such as atrophy, rosacea, stretch marks, and blood vessel formation).
Skin rashes are tough diagnoses to make. Educate yourself on the approach to rashes and come up with a way to approach each skin rash based on the history you discover.
Learn more at one of our Dermatology CME Conferences at Skin, Bones, Hearts & Private Parts.