He was referred to a Dermatologist about 3 months ago and a course of Prednisolone and Advantan cream were precribed for "Eczema"but he has had only minor relief. He is on Lipitor, Atacand, Metoprolol and Aspirin for IHD for several years. He has had no history of Eczema, Asthma or Hayfever. He has had no history of similar rash in the past. No other singinificant medical history.

What do you think about this man's rash. How can I treat him ? I would appreciate your opinion.

My approach would be this. Thorough history, especially regarding what was happening around the time the rash started, drug history expecially which oral meds he started and at what time in relation to the start of the rash. Hobbies, interests, changes of employment and housing. Did he get a new pet or other animal. Full general exam to exclude systemic illness. Blood screening with rast general screen, inflammatory markers, immunoglobulins, iron studies, LFT, UEC, etc. Biopsy an active area which has not been excoriated. Swab for MCS as he probably has staph colonisation.
My first approach at medication would be antihistamines such as 25-50mg phenergan at night, fexofenadine during the day, and lots and lots of menthol with camphor in sorbolene cream.
I have a few patients like this... their histology tends to come back as "spongiotic dermatitis". I seldom find a cause, and most end up on oral steroids. But the main issue appears to be his itching and scratching. Helping him with that will probably improve his quality of life a lot in the short term (Submitted By: Dr Chris Kear)

You have to look at his drugs. The beta blocker will be making this worse. Stop it if possible. Lipitor will be drying his skin as well. Moisturizer, strong topical steroids for a while to get it under control and then consider UVB light therapy. If not available consider azathioprine 50-100 mgs daily to get better overall control rather than oral steroids. Or use oral steroids at first plus Azathioprine because it takes 3 weeks to really kick in. Check this methyl transferase enzyme level first. If low stay on 50 mgs azathioprine. (Submitted By: Dr Ian McColl)