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Longstanding plantar skin "rash"

Discussion in 'General Issues and Discussion Forum' started by Greg Fyfe, Nov 6, 2013.

  1. Greg Fyfe

    Greg Fyfe Active Member

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    I'd appreciate your thoughts on the attached rash

    86 year old, female with an approx 2yr history of this problem

    Has diabetes and osteoarthritis, not the easiest client to get a history from.

    Apparently started with a cut to the foot, was improved by rubbing "cream" into it, but obviously not cured.
    Is sometimes itchy, and is present on both feet. Clinic notes do not reveal what the "cream was, and the client is a sporadic attendee to the clinic

    On examination there are some small pustular looking lesions along with the broken,flaking skin.

    I first saw her about 4 mnths ago and took a swab and scrapings.
    swab came back with a moderate growth of staph aureus resistant to penicillin
    no bacterium or white cells seen

    culture and microscopy did not find any fungal alements present.

    no diabetic neuropathy or peripheral vascular deficiet noted

    GP has started her on doxycycline 100mg 1x a day for 7 days, recently.and referred her to dermatology.

    Any input welcome.



    Attached Files:

    Last edited: Nov 6, 2013
  2. blinda

    blinda MVP

    Hi Greg,

    Great pic.

    Certainly looks like a chronic Staph Aureus infection (which is a bacterium, last time I checked ;)), with the tell-tale`golden halo`, crusting.

    IMO, the GP is quite right to prescribe a broad-spectrum AB, until the dermatologist can offer insight as to what caused a breach in the epidermis to allow entry for the bacteria. Could just well be anhidrosis/fissuring due to maturity and DM.

    I`d recommend simple daily emollient, once the staph infection has cleared, to preserve integrity of the fragile epidermis.

  3. Leigh Shaw

    Leigh Shaw Active Member

    Hi Greg
    I have a similar patient, his diagnosis is :pustular psoriasis
    Hope that helps.
  4. blinda

    blinda MVP

    Good DDx. :drinks

    However, as skin samples revealed "no white cells seen", which is what the sterile white pustules consist of, I would not put this at the top of the list.

    Also, whilst Ps may manifest at any age, generally there are two peaks of onset, the first at 20-30 years and the second at 50-60 years.

    Greg, thanks for sharing this interesting case and please do let us know the outcome.

  5. Greg Fyfe

    Greg Fyfe Active Member

    Thanks Leigh, pustular psoriasis was a possibility I'd thought of too. Having had one other patient with it in my 20 + years of practice.

    Bel, I'll put up the outcome , it wil be a few months before I get back to that clinic.

  6. Greg Fyfe

    Greg Fyfe Active Member

    I'm pleased to be able to finally provide some follow up to this case

    The patient managed to get to a dermatology consult , diagnosing the presentation as Palmoplantar Pustulosis.

    Which can be aggravated by smoking, I hadn't noted this initially however it seems the patient is a smoker.

    Currently the treatment is applying diprosome cream.

    These details are taken from the patient notes, I haven't sighted her feet since June last year. So unfortunatley can't relate how thats progressing.
    Nor do I have any detail of the dermatologists report +/- investigations.

    I don't recall examing her palms at the time, so if your wondering how it was expressed there I can't say.

    Re reading Bels comment about that staph aureus is a bacterium. The initial culture and microscopy showed " no bacterium or white cells seen on microscopy but a modest growth of s. aureus cultured" I wondered if it's possible that there were so few that they were not seen on the sample microscopied , however there were enough present to be cultured?

    I might have to do some reading to find an answer to that.

    Last edited: Apr 7, 2014
  7. blinda

    blinda MVP

    Hi Greg,

    Thanks for the follow up.

    It could be that whilst there was "a modest growth of a. aureus cultered", which most of us are carriers of anyway, there was not enough to be deemed pathological, nor colonisation of staph.


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