Enough

Like the boomerang generation of kids who leave home, then return, my rash has made an unwelcome return and shows no inclination of departing.

It took five long months of steroid cream to vanquished my rash the first time.  The dermatologist didn’t even look to verify that the rash had disappeared.  He took my word for it, and just nodded his head as he instructed me to taper off the topical steroid.  Tapering oral prednisone I understand.  20mg, 18mg, 15mg, 12mg, 10mg, 8 mg, 5mg, 4mg…  It’s not so clear how one tapers a topical medicine that’s applied “sparingly.”  Maybe every-other-day instead of daily?  The doctor wasn’t clear, and I didn’t think to ask until too late.

In the beginning, this rash was mildly annoying.  Now that it’s back, it’s more than annoying.  It hurts.  If I wear shoes, with every step it feels like coarse sandpaper scraping raw patches on my feet.  If I go barefoot, my slacks rub back and forth across the rash on top of my feet.  If I wear capris or skirts to keep fabric off my legs, people stare at these hideous red blotches.

Back to the dermatologist I should go, I suppose, but I have lost all inclination to make appointments to see doctors.  It is wearying.

  • phone to make appointment, wait 2-3 weeks to be seen
  • rearrange my schedule
  • make arrangements for my kids while I’m at the doctor
  • drive an hour for a 15 minute appointment, then another hour home
  • go to pharmacy to fill yet another prescription
  • return for follow-up appointment to check whether treatment was effective (more driving, more childcare, more schedule rearranging)

I’m starting to wonder if the benefit is worth the time & money expended, and I’m starting to understand why some doctors aren’t too enthusiastic about treating patients with chronic conditions.  If you break a bone, the doctor can set it and it will (usually) heal.  If you catch a cold, it will go away in a few weeks.  Even if you get pneumonia, you either get well, or die; it doesn’t drag on for years and year and years.

It’s the dragging on and on and on that gets me.  There should be a limit to the number of medical issues every person has to deal with.  I’d like to say, “I’m sorry, but my quota has been filled, that diagnosis will have to go to someone else.”  I’ve had enough.

Nummular Dermatitis & TNF-Inhibitors

Nummular dermatitis (aka discoid eczema) has an incidence of 2 in 1000 people, mostly men in the age range of 55-65.  However, treatment with a TNF-inhibitor is also a risk factor.

Like many medical terms, the name nummular dermatitis  comes from Latin roots:

  • nummular – from nummus - coin
  • dermis – a layer of skin
  • itis – inflammation

So, nummular dermatitis is coin-shaped inflamed patches of skin.  This rash can itch and burn, even to the extent that it disrupts sleep.  Some people, however, are fortunate enough to skip the unpleasant sensations that typically accompany this unsightly rash (sometimes there are advantages to peripheral neuropathy).

This rash is not contagious.

Appearance

Nummular dermatitis begins as a group of blisters or tiny red dots.  It quickly becomes a round or oval-shaped patch of red (sometimes pink or brown) skin.  Multiple patches are possible; they can be as small as two millimeters, or as large as four inches.  The rash usually appears on the extremities (arms, legs, feet, hands) or torso.  Thankfully, it is rare for patches to appear on the face.

  

Diagnosis

This rash is unique in appearance and can often be diagnosed based on a visual examination.  Usually no expensive tests are needed, but occasionally the rash will look like ringworm, in which case a doctor might need to take a sample to make an accurate diagnosis.

Causes

There are no known causes of nummular dermatitis, however a Dutch study of RA patients done in 2005 showed that 25% of RA patients on TNF-inhibitors needed referral to a dermatologist, vs. 13% of RA patients who had never taken a TNF-inhibitor.  Fortunately, only a small number had nummular dermatitis.  Of note, hepatitic C patients treated with a TNF-inhibitor have an increased risk of nummular dermatitis.  It will be interesting to see the results of follow-up studies now that TNF-inhibitor use is more common in the treatment of RA.

Treatment

Home treatments aren’t enough to deal with nummular dermatitis. Without adequate treatment, this rash can stick around indefinitely. Even with medical treatment, the rash can take months to resolve – some sources say it sometimes takes a full year for the rash to go away.

The goal of treatment is to:

  • reduce inflammation
  • repair the skin
  • rehydrate the skin
  • if infected, treat the infection

Credit:  http://s252.photobucket.com/albums/hh18/Jane-emma18/?action=view&current=Gumby.jpg&newest=1To reduce inflammation, prescription-strength steroid cream or ointment can be rubbed into the rash two-three times daily.  Unless you are Gumby, if your rash is on your back, you will need assistance with the application.  Oral steroids can be used when topical steroids are ineffective (this also eliminates the need for an assistant).

To increase absorption, the steroid cream/ointment should be applied to wet skin – particularly after a shower or twenty-minute soak.  Following application of the topical medicine, a good moisturizer should be applied to wet skin.  Some people recommend covering the medicated areas (ie with plastic wrap) for an hour to hold in the moisture.  Gently pat yourself dry; do not rub with a towel and remove the steroid cream & moisturizer.

Another treatment option – when topical steroids fail – is light therapy (UVB).

Although home treatments alone can’t cure nummular dermatitis, there are a few things you can do.  Take good care of your skin and be sure to moisturize it well.  Also, avoid potential flare-triggers.

A few of the things that sometimes cause flare-ups of this condition are:

  • frequent use of detergents or harsh soaps
  • hot tub usage
  • extreme temperatures (very hot or very cold)
  • extremes in humidity (or lack thereof)
  • rough wool clothing
  • skin injury (ie cut, burn, or insect bite)
  • some medications  (examples include accutane, neomycin, and TNF-inhibitors)
  • sensitivity or allergy to rubber, nickel, cobalt, formaldehyde, or mercury

This means that if your routine is to take a long, hot shower first thing in the morning before dressing in a nice warm, wool sweater and cozy wool socks, you might need to modify your routine.  Make it a shorter lukewarm shower, apply a good moisturizer to your skin, then dress is loose cotton clothing.  If your workout routine later includes spending twenty minutes in a steam room, followed by half an hour soaking/stretching in a hot tub, followed by an hour in a swimming pool, ten minutes in the dry sauna, and then another hot shower, you’re intentionally doing five of the eight things you need to avoid.

See a doctor for accurate diagnosis and treatment if you suspect nummular dermatitis.

Vocabulary for Reading Medical Literature about Nummular Dermatitis

erythematous – red
papules – bumps
vesicles – very small blisters
pruritic – itchy
xerosis – abnormal dryness

References

Arthritis Research & Therapy
Medscape
Skinsight
American Academy of Dermatology
DermNet NZ
British Association of Dermatologists

It’s the Little Things

Rich aroma scents the air.  Tomato sauce, enhanced by fresh herbs, has everyone’s mouth watering in anticipation.  Eager to eat, my kids volunteer to set the table.  Fresh-baked French bread is served on a wooden cutting board, along with a large container of garlic butter.  Everything is ready except for the spaghetti noodles, and they’re almost done.

I carefully lift the lid from the pasta pot, but my shoulder catches, my arm jerks ever so slightly, and the steam takes the wrong path in its escape from the pot.

Ouch!  A 2″x3″ steam burn is truly a curse-worthy event!  A little cold water (indirect) helped briefly.  My first thought was, “Oh good, it hurts.  Really bad burns don’t hurt.”  (It turns out that this is a myth.)  My next thought was, “Didn’t one of those meds I take include burns in the list of reason to phone the doctor?” 

Every pill bottle came out of the cupboard and I scanned all the little info sheets.  Nope.  I must be thinking of something else.  Good.  I’ll just treat it with tlc.

Aloe is great for burns.  Fortunately, I have some.  I sliced open a couple leaves, placed them carefully so that the burn was covered, and bound them on with vet-wrap. 

Before going to bed, I changed to fresh leaves.  The next morning in the shower I decided that the pain of hot water on my arm was much worse than the stigma of being unwashed.

I bound more aloe onto the burn and left it alone until bedtime.  A few days of morning and evening dressing changes helped.  After a while I skipped the new aloe at bedtime, and in the morning decided to give the burn some air (since it no longer hurt).  The tlc worked.  I was shocked that the burn never blistered.

Aloe is good, but I still expected blisters.  Instead, the skin looks… well…  Have you ever gotten glue on your skin and let it dry instead of washing it off promptly (not that adults would do this, but perhaps you remember when you were a kid)?  After a while it looks tough and wrinkly, sort of like an old farmer’s hands appear after years of working in the weather.  You can scratch the glue and start peeling it off.

Well, that’s what my burn looks like now.  Tough and wrinkly, except where it’s starting to peel away. I’m keeping a pretty close eye on it, since from my recent reading about burns, perhaps I should have checked in with my doctor.  I just don’t see why it’s necessary to run to the doctor about every little thing that happens.