Case report: Burning and peeling

A frequently seen patient at our walk-in clinic, probably lonely, with apparently few social contacts, is known to suffer from an aesthetically unpleasant rash—which has been diagnosed in the past. A 54-year-old fair-skinned man with no medical concerns apart from his skin condition, taking no medications, allergic only to morphine, was seen again recently for a recommendation regarding changes in the skin on his arms. The patient is known to suffer from a generalized, severe form of ichthyosis—an uncommon condition which occurs with variable severity in families, is associated with colour blindness and is very difficult to treat. As the name suggests, skin is scaly and thickened—responding poorly to moisturizers or other topical agents. It requires regular use of urea-based creams to reduce appearance and soften the skin.With several dermatological referrals not improving the condition, the patient is seen for sympathy and support. There is often a reported change in symptoms, although the underlying dermatitis remains basically incurable.At the patient’s most recent appointment, the rash on his arms was reported to have become more raised, peeling and burning. This had occurred over the past week, with no exposure to sun, other irritants and no change in treatment. Examination, interestingly, evealed the usual darkly pigmented, thickened skin on both forearms, sparing his hands and slightly reduced under short sleeves (see picture). It was circumferential, reducing the number of possible exaggerating factors. It apparently had become symptomatic for some unknown reason and was more prominent than usual, but was not inflamed. The rest of his body was not more symptomatic than usual. I suggested that due to the distribution, the arm rash was probably enhanced by exposure to light, heat or contact. Treatment was, as usual, soaking and gentle moisturizing. If other physicians have had success in treating ichthyosis, I would be delighted to hear.The patient always needs a focus for discussion of a basically unchanging rash.Dr. Robert Dickson is a family physician in Hamilton. This report is based on a real case from Dr. Dickson’s files.

Case report: Burning and peeling

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