It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”
Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.
Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”
If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.
For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.
Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.
“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”
Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.
Be mindful of the rapid onset of purpuric lesionscon the skin.
They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”
13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.
Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”
As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.