Weird dermatitis, advice pls

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Here's an interesting one. 13 year old caucasion boy. Went swimming in the sea 7 years ago in his trainers and this dermatitis started the next day - no previous history of dermatitis.

He's been to many dermatologists over the years who've prescribed corticosteroids - the lesions are non-responsive to this treamtment. His feet are painful, the skin is papery and thin and he suffers from recurrent onychocryptosis. Sometimes his feet are so painful he cannot go to school.

The dermatitis is confined to the forefoot, which is strange if this was an allergic dermatitis due to shoe components. He generally wears a trainer type shoe. His feet improve in the summer months when he wears flip flops and, in his words, the dog licks his feet (presumably growth factors contained within canine saliva). He was non responsive to oral and topical antifungals and non responsive to Fucidin Cream.

Any ideas anyone?

 

Just a thought-
Could it be a psoriatic condition- one nail is damaged in the image dont know if that is relevant. Also clears in the summer- sunlight has a great healing ability for psoriasis.

Cornmerchant

 

tinea

 

From appearance, definitely looks fungal. Possibly may have a secondary bacterial infection, which I have seen before.
Difficult one since you have already tried antifungals.
I think the key is persistance. I would opt for an oral antibiotic and topical terbinafine to be applied religiously 2 times daily for 2 weeks.

 

I'm sure it's not tinea. He was on oral terbinafine for 6 weeks whilst using Fucidin Cream 3 x daily. It made no difference whatsoever.

 

I would not see how oral terbinfine will affect a skin tinea; try a topical with a different active aganet to Fucidin (I can't recall what is in it). It sure looks like a tinea.

 

I am sorry if I am being thick, but surely if oral terbinafine will effect nail fungal infections, why would it not ameliorate cutaneous infections? I will be very happy to be corrected. It was my understanding cutaneous fungal infections respond to oral antifungals generally within 14 days and hand nail infections within 6 weeks and foot nail infections within 12 weeks. Am I missing something? It has always made sense to me that skin infections respond more quickly than nail infections because of skin cells being generally only 21 days old before being sloughed off and yet in nail we have to wait at least 3 months in nails before observing improvement in new nail growth emerging from the nail fold. May be I am incorrect. Please correct me if I am wrong.

 

Why dont you send a sample of the skin for analysis, then you would se if it was realy fungal our not?

 

Hi Leah,

My two pennies worth;

So, he was a 6 year old boy who kept his wet trainers on for some time - occluded damp environment on young skin which fungi thrive in.

This is not good. Steroid (corticosteroids) tx on TP = aggravated TP and inflammation. Overuse of steroids leads to the “papery thin/painful skin” you describe. The OC is probably a resultant Onychomicosis; dermatophytes migrated from the dorsal TP. OM nails in the young pt can be friable in nature and have a tendency to splinter causing OC. Is the recurring OC on the left 4th? It certainly looks fungal to me.

Very typical of TP, worsens in occlusive footwear (trainers) and improves when `aired` (flip- flops). Interesting point re the dog licks. Whilst fungus and animals live in a peaceful existence, without the animal ever showing any symptoms, the fungus can be transmitted to humans, who become symptomatic.

Look at the pattern on the dorsum. I would suggest Ringworm (tinea corporis) The fungi that are usually responsible for ringworm are zoophile and transmitted primarily through contact with animals.

6 weeks oral terbinafine is nowhere near enough to achieve a therapeutic effect. The active ingredient in Fucidin is fusidic acid, which is an antibacterial agent, not particularly helpful in tinea.

I would agree with Andre here and take skin scrapings for microscopy/culture to rule out or confirm the presence of micotic infection.

Hope this helps.

Cheers,
Bel

 

Of course oral terbinafine is efective in treating fungal infections of the skin as much as it is effective in treating nail fungal infections, in fact one of the indications for oral terbinafine is fungal infections of the skin that have been unresponsive to topical anti-fungals. Six weeks of oral terbinafine is plenty long enough to treat fungal skin infections. The treatment duration for tinea pedis with oral terbinafine is 2-6 weeks. For finger nail onychomycosis it is approx 6 weeks and toe nail onychomycosis is approx 3 months. So if this was a fungal skin infection & providing the patient was compliant with taking the once daily tablet then the condition should have resolved, or at the very least markedly improved.

Leah you mentioned the condition started the next day after being in the sea. Do you know if it started as a small area and then gradually increased, or was it pretty much always this bad from the start? Have any of the dermatologists taken skin samples / biopsies? If this hasn't been done that would be my first priority and will provide good information as to whether there is a fungal infection, allergic dermatitis or perhaps a psoriatic lesion.

Out of curiosity where exactly was he in the water i.e. geographically?

Regards,

David Kelly

 

Thanks David, I thought I was losing it.

He was a compliant patient and took his complete course of Lamisil. Partly through the treatment his dermatitis got considerably worse. That was when I introduced the Fucidin, reasoning that an opportunist bacteria was taking over from the fungus. I was convinced this condition was fungal originally because of the annular lesions. I also tried topical Lamisil, it made no difference. I have not taken skin samples - actually it is very hard to do so from his feet as there is not any loose bits. His nails do not look fungal at all. In fact the dermatitis is mildly exudative, you can see this in the photo.

When it started, he'd been to a beach party on the north coast of Cyprus (where I am) and as it was rocky he kept his trainers on. He was in soggy trainers for several hours until he got home. When he took them off his feet were red rore and painful, they have never recovered and gradually got worse. Could this be purely a contact dermatitis from shoe components - rubber, glues? It's really perplexing.

 

Shoe components could cerainly be a contributing factor. You mentiond that it worsens when he wears shoes, usually runners so this would certainly raise my suspicion. Perhaps some patch testing by an allergy clinic may be worthwhile.

Also there are an abundance of macro & microscopic organisms in seawater (including parasites that like to burrow into the skin) that may have been the inciting mechanism, although I think this is less likely if it occurred seven years ago & he doesn't regularly go back into the seawater. So a bit of a long shot, but then again after seven years with no improvement something to perhaps consider. Perhaps finding a marine toxicologist or doctor who has a speciality interest in marine occupational medicine may have some useful sugestions. Although most of the marine organism derived dermatitis usually resolve within a few days, they can occasionally become chronic.

Judging by what you have said about the onset (both feet affected quite significantly overnight) and the failure of numerous attempts at both topical and oral anti-fungal therapy I think it is unlikely this is a fungal infection. In having said that if lamisil (terbinafine) is the only anti-fungal tried then it may be woth trying a different type such as ketoconazole as not all fungal infections are senstitve to terbinafine e.g. tinea versicolour (although this fungus doesn't usually occur on the feet).

Not much help I know, but after 7 years and multiple failed attempts at the usually successful treatments by numerous practitioners I guess looking into the more unlikely and unusual causes may be worth a shot.

Regards,

David Kelly

 

Apologies; I was thinking of Griseofulvin (which has to be taken for a minmum of 8 weeks for TP) as this is the only oral antifungal which is licensed for children in the UK.

I`ll keep quiet now, hope you manage to get some skin scrapings for Differential/Definative diagnosis.

Cheers,:drinks
Bel

 

Thanks everyone. I personally don't think it's a marine organism. The water here doesn't support much marine life anyway - too ucky. He's been in the see loads of times since without worsening the problem.

Probably allergy testing is the way to go and to do some culture analysis. The only problem is that we just don't have the facilities to test these allergies here in North Cyprus, he'd have to go off island to do it.

Thanks for all your input. If I ever get a proper diagnosis, I'll be sure to share it with you all.

Leah x

 

OK, I have a weird suggestion but it is supported in Dockerty's cutaneous diseases of the lower extremity, and I cured myself of eczema/dishydrosis using this naturopathic protocol. You are not supposed to do it until you finish growing....14 maybe, maybe not.
10,000IU of vit A and a zinc tablet daily. For 90 days. (I took 40,ooo IU, but I weigh 84kilos)
It worked for me, and nobody knows what exactly causes dishydrosis.

 

everyone has already posted my thoughts on first line treatment, but if thats not working how about Condys Crystals.

 

This looks very like the problem my daughter-in-law had but she had not been in the sea. Cause is still unkown. Her dermatis could not put a name to it but tried severil treatments with no effect. In desperation I gave her some Crystacide to try, within two days the results where amazing, treatment continued untill all signes of infection had gone. It is now 14 months later and the infection has not returned.
Crystacide is based on Hydrogen Peroxide effective agains many types of bacteria and some fungi and viruses. Well worth a try.

 

Hi
Looking at the photo. it looks like ringworm especially if the dog has been licking his feet. T.circinata and T.corporis is usually transmitted from cats and dogs and as his skin has already been compromised by steroid use he is more susceptable to infection.
Regards
Deborah

 

You and me both, Deborah :drinks




.

 

Yes, but as stated before, did not respond to oral or topical antifungals. Fungus has been ruled out.

 

Hi Leah,

I`m not being bloody minded here, really....but you can`t rule out tinea infection 100% without a differential/definative diagnosis by microscopy and culture of a skin sample. I appreciate that it is quite difficut to obtain a sufficient amount from the dorsum, perhaps a dermatologist would be in a position to do so?

Pts with chronic TP will sometimes not respond effectively to first line tx. Did you personally monitor the pt whilst they were undergoing the course of oral terbinafine? If not, can you take the pts word for it that there was no improvement at all during that time? Is the pt in a position to differentiate between skin damage caused by overuse of topical steroids (i.e. thin and shiny with rubour) and tinea? Perhaps reinfection occured as the source (i.e. canine) had not been removed?

There are many variables associated with infection and reinfection of tinea, which are not always apparent to us pods.

Anyway, i do hope you manage to get to the bottom of this condition and thanks for sharing the photos with us:drinks


Cheers,
Bel

 

Just a question regarding the dog licks: Does the dog seem focused on the lesions themselves or just the feet in general? We are all aware of a dogs highly developed sense of smell and I recall a specific case I had wherein the patient's dog alerted her to the presence of an occult abscess by his relentless desire to smell the "callus" (overlying the abscess).

 

Just a point on ruling out tinea from using oral lamisil. Normally I would agree with you that six weeks should be enough to clear a skin infection. However I have come across a nail infection which did not seem to respond to terbinafine. It was picked up in the far east (singapore I think) and took over six months of oral lamisil treatment alongside topical treatment before it cleared.

It may be worth switching anti-fungals to see if it responds better to something else, but scrapings are well worth doing.

 

Bit out of left field but does he apply anything to his his ingorwn nails (i.e. iodine)?

 

Just for interest some photographs of ringworm:http://www.medicinenet.com/ringworm_pictures_slideshow/article.htm

Another good site for Dermy pictures: http://www.skinatlas.com/contents.htm

Just a thought. Is he still wearing the same trainers? Possibly reinfecting himself with existing nasty in his footwear?

Interested to know how he gets on.

Regards,

Mandy.

 

May be a nummular eczema, contact dermatitis but unlikely a dermatophytosis. Best bet is to biopsy the lesion and send the tisse to an experienced dermatohistopathologist. Use a 3.0 - 4.0 punch biopsy at the margin of the lesion.