HPI: The patient is a massively obese woman who weighed 750 pounds a year before her office visit but at present weighs around 350 pounds. Her weight loss has been achieved by severe calorie restriction (she lives in a care facility). Her skin was clear until a month before the office visit. By history, the dermatitis began on hands and arms, spread to skin folds, postauricular areas and angles of mouth. She has had some diarrhea.
O/E: The patient appeared alert, tired and massively obese. She had a papulosquamous eruption on arms consisting of erythematous patches with fine superficial scale. There was erythema in all examined skin folds with mild serous discharge. She had an erosive postauricular dermatitis and angular cheilitis (see photo). Dental hygiene was good and KOH prep from angle of mouth showed very rare yeast forms.
Clinical Photo:
Lab: Post auricular culture grew Staph aureus (MRSA) and Pseumonas. Serum zinc 0.58 mcg/ml (normal 0.66 - 1.1 mcg/ml)
Biopsy from arm lesion showed orthokeratosis, subcorneal neutrophils, focal hypogranulosis and psoriasiform hyperplasia consitent with psoriasis or given her history acrodermatitis enteropathica.
Diagnosis: The short history of dermatitis here suggests a nutritional etiology may be considered. This woman had no history of skin disease until a month before her office visit. She had been on a very restrictive diet and it is unclear how carefully vitamins and micronutrients had been monitored. The low zinc level may not be the only deficiency she has. Her MRSA should be addressed, but low zinc may have set up a situation where MRSA could thrive in skin folds (an altered skin microbiome).
Questions and Comments: This is a complex case and it is unlikely that sinc supplements will address all of this woman's needs. A nutritionist may help. The angular cheilitis was a clue to "think zinc." Her MRSA needs to be addressed as well as the intertrigo. She is relatively young and healthy. Considering her obesity, a multidisciplinary approach could help her. In the setting of a group home this may not be forthcoming. Patients like this can be marginalized in any health-care setting and present diagnostic and management problems. There are many more questions? What did her hemogram show?
Consider riboflavin deficiency. A trial on B-complex wouldn't hurt
ReplyDeleteI would still treat her with diflucan 200 mg 2 pills weekly for a month for candidiasis and desonide ointment bid
ReplyDeleteAnd also check b12 level too.
May benefit from b12 injection.