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

Next!

This time last year, I felt great.  It was wonderful to finally feel good again. 

Things fell apart when I tried to reduce my number of meds.  Discontinuing ssz was a huge mistake, so I added it back in.  Next I discontinued the hcq.  The difference wasn’t as dramatic as it had been with ssz, but it definitely made a difference.  Sometimes I wonder if we should have just added it back instead of switching to biologic #2.

After a year spent singing the praises of Enbrel, I’ve been fairly silent about my second biologic.  Reason being, it didn’t work.  It’s a med that works very well for many people, so I don’t want to denigrate it unfairly.  In my treatment plan, though, it’s history.

Given my druthers, my rheumatologist would have written prescriptions to return to what was working a year ago.  She, obviously, knows all sorts of things I don’t, and thought it better to try a different biologic (maybe because just a couple months ago she had to argue with my insurer that biologic #1 wasn’t working).

I’ve now received my first dose of Cimzia of the cool looking syringe.  I’ll post a picture if my insurance company ever gets around to processing my pre-auth.  They took their own sweet time with the last one, and it drives me crazy that think they know better than my doctor what treatment is appropriate. (/rant)

I feel better already – likely due to the 20mg prednisone that I’ll have the pleasure of tapering off in a couple months.  On the plus side, there’s no need to finance a steroid injection in my shoulder.  The pred has already helped dramatically.

I have no desire to work my way through every single biologic on the market.  Let’s hope this one works better than the last.

Ch-ch-ch-Changes

For nearly a year now, I’ve been injecting Enbrel weekly.  It was pretty scary in the beginning, but I like Enbrel.  I like how it makes me feel so much better.  I like how easy it is to use.  I like the once-a-week schedule so that it’s easy to remember and incorporate into a routine.  I like that it works.

My inflammatory markers look good.  Ten years ago, my response to the meds would be considered a success story.  Now, my rheumatologist tells me, the standards are higher.  She’s treating me, not my lab reports, and thinks I might do better on Humira.  I shouldn’t have new bursitis, I shouldn’t have enthesitis, my feet shouldn’t hurt all the time if these meds were doing their job 100%.  So, effective immediately, I’ve moved on to my second biologic.

I just got off the phone from trying to activate my new Humira card.  All the literature – yes, I actually read this stuff – says that the card is good for twelve months.

  • “This card is valid for 12 months from the date of first use, after which the patient has the option to reenroll (sic) in the program.”
  • “The program pays:  Months 1-12: Up to $500 each month”
  • “Easy to renew after 12 months”

After providing all my information, the voice on the other end of the phone concluded the conversation by saying that this card is good for twelve fills.

“No, you mean twelve months, right?  That’s what your literature says.” 

We went back and forth, her insisting that it’s only good for twelve fills, and me wondering why they won’t cover that last fill of the year when their written materials say that they’ll help out for a full twelve months.

A Humira prescription gets me a box of two injections to be given every-other-week, which should make one box last four weeks.  Divide fifty-two weeks of the year by four weeks per box, and it’s obvious that it takes thirteen fills to get through a year.  This is basic math that my eight-year-old understands; it should not be an impossible concept for an adult to grasp.

Some people will point out that I should be grateful that they’re picking up a portion of the cost.  And I am.  Really.  Extremely grateful.  I just happen to think it’s deceitful to tell people that the card is good for a year if it isn’t. (/rant)

I got my first Humira injection today.  I now have a headache – my first in over a year.  I hope that’s bad coincidental timing, and not a problem that I’ll have with the new med.  Since I’d heard that Humira stings much more than Enbrel, I was a bit concerned.  That turned out not to be true – at least for me.  It was about the same.  With any luck, that will continue.

And now, given that it’s only a week until Christmas, I should probably start my Christmas shopping.
Or baking.  Or packing for our trip.
Have a Merry Christmas!