Case report: Follow-up on previous rash

At our walk-in clinic, we try not to see patients in a longitudinal way—they are encouraged to find a family doctor. Unfortunately, this has become extremely difficult and, as a result, I do follow problems or initiate treatment in quite a few patients. One particular 62-year-old fair-skinned male, formerly a police officer for many years, has required frequent visits over months. Despite pain, he still attends in person for most visits.The patient—in good health with no allergies or underlying illness—twisted his left ankle over two years ago—sustaining a complex comminuted fracture of his distal tibia. Surgery was required—with placement of a lot of permanent hardware. Read: Case report: A frustrating rashWhen original surgical dressings were removed, a blister was reportedly found at the site of the incision. A rash developed subsequently—and the case was published online in the Medical Post last year. The picture showing the rash and hardware was included and will be repeated here (see picture at right). An ankle brace was prescribed by the orthopedic surgeon—still required when on his feet, although it rubs and inflames the rash at its lower portion and is removed as soon as possible when at rest.Despite treatment with Fucidin cream, oral Clavulin and dressings when necessary, the rash has not only persisted, but the incisional line anteriorly, splits open and bleeds recurrently in recent months (see current picture below right). Long courses of antibiotics, elevation, minimizing the brace and applying Steri-Strips almost continuously, improve the surgical area and rash—but it keeps recurring. Discomfort is controlled with Naprosyn and Percocet. Examination reveals very thin atrophic skin beneath the dermatitis. The orthopedic surgeon—who follows the case with me—concurs with my treatment and is suggesting referral to a plastic surgeon for consideration of a skin graft.I remain concerned about the scant tissue depth and potential failure of a skin graft. The metal will have to remain. Since the case is seen by a wide variety of practitioners, I would very much appreciate any thoughts about where to go from here. I am concerned that more invasive treatment might result in eventual amputation. Long-term antibiotics and Steri-Strips “hold the fort.” Dr. Robert Dickson is a family physician in Hamilton. This report is based on a real case from Dr. Dickson’s files.

Case report: Follow-up on previous rash

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