Case report: The cream works

Having cared for many patients in a longitudinal family practice—then more recently in a walk-in clinic—I constantly marvel at the variety of concerns which patients present. Hardly a day passes when there is not an opportunity to experience something new, and learn from the interaction. This, I guess, is one of the benefits of getting older and having been consulted by so many patients over the years. Always something interesting and challenging.Very recently, the opportunity for lifelong learning and new experiences was exemplified by a patient visit. A 42-year-old healthy, fair-skinned man of eastern European extraction came to the clinic with a simple request. He wished a repeat of the “cream” I had given him many months (maybe two years) ago. When he said he wanted it for the rash on his leg, I did recall having prescribed a 30 gram tube of Elocom cream in the distant past—for a small patch of dermatitis localized to one leg.Read: Case report: Is it stretch marks?The patient just wanted another tube of the same cream—because “it worked.” I asked to see the current state of the rash—and was surprised (to say the least) at the extensive, pruritic, rough dermatitis on his left leg. I asked to see the other leg—and was even more surprised (see picture). I was also shown the same extensive rash on both elbows. None of these other areas had been affected when I saw him previously. Besides using the cream, he admitted to scratching often.Now ensued the unexpected conclusion of the visit. I told the patient that I believed he was experiencing a rash called “psoriasis,” and with the extent to which it had developed (beyond my ability to treat), suggested that we should refer him to a dermatologist. The patient declined. As long as I knew what the rash was—and it wasn’t cancer—he was quite content to continue with my previous therapy—and just wanted another tube of “cream.” I found the interaction to be interesting, instructive and strangely satisfying. In an era when many patients request a referral, an X-ray, an MRI or “blood tests,” to encounter a patient with expectations limited to an encounter with a sympathetic doctor, was rewarding. I really don’t know what “worked.”Robert Dickson is a family physician in Hamilton. This report is based on a real case from Dr. Dickson’s files.

Case report: The cream works

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