What is the diagnosis and treatment plan for a 56-year-old male patient presenting with two skin lesions, one raised and crusty and the other fading, on both hands, which appeared after incarceration, and is being treated with hypoallergenic soap, Lubriderm (moisturizer) cream, and an Immunoglobulin E (IgE) serum test?

From the Guidelines

The patient's management plan should be enhanced with the addition of a medium-potency topical corticosteroid and consideration of scabies in the differential diagnosis, given the prison setting and timing of lesion appearance. Based on the clinical presentation, this patient likely has a contact dermatitis, which is common in settings where hand hygiene is frequently performed, as noted in the American Contact Dermatitis Society's recommendations for hand hygiene during COVID-19 1. The use of hypoallergenic soap and switching from Eucerin to Lubriderm cream is a good start, as it aligns with the recommendation to switch to less-irritating products 1.

Some key points to consider in the management of this patient include:

• Identifying and avoiding irritants, such as surfactants and detergents, which can exacerbate hand dermatitis 1
• The potential benefits of using barrier creams, such as restorative creams or humectants, although their use is equivalent to regular moisturizers 1
• The consideration of topical steroid-induced damage to the skin barrier when applying a topical steroid 1
• The importance of seeking a dermatology consultation for recalcitrant cases, where phototherapy, systemic therapy, or occupational modification may be necessary 1

Given the prison setting, it is also essential to consider scabies in the differential diagnosis. If there is any suspicion of scabies, prescribing permethrin 5% cream to be applied from neck down, left on for 8-12 hours, then washed off, with a repeat application in 7 days, may be necessary. The IgE serum test is reasonable to rule out allergic etiology. Patient education about avoiding scratching and potential triggers is also crucial to prevent secondary infection and spread. A follow-up at 2-3 weeks may be more appropriate than two months if symptoms persist or worsen.

From the FDA Drug Label

Directions for itching of skin irritation, inflammation, and rashes: adults and children 2 years of age and older: apply to affected area not more than 3 to 4 times daily Purpose Anti-itch

The patient's symptoms of raised and crusty lesions on one hand and fading lesions on the other, which started after entering prison, may be related to skin irritation or allergic reactions.

• The prescription of hypoallergenic soap and Lubriderm cream may help to alleviate the symptoms.
• The decision to discontinue Eucerin cream and order an IgE serum lab suggests a suspicion of an allergic reaction.
• However, the provided drug labels do not directly support the treatment plan for the patient's specific condition 2 2. The hydrocortisone drug labels provide general instructions for itching of skin irritation, inflammation, and rashes, but do not address the patient's specific lesions or treatment plan.

From the Research

Patient Presentation and Treatment

• The patient presents with two lesions, one on each hand, with the right hand lesion being raised and crusty, and the left hand lesion fading.
• The patient reports that the lesions started as soon as he got into prison.
• The treatment plan includes prescribing hypoallergenic soap, discontinuing Eucerin cream, and starting Lubriderm cream.
• An IgE serum lab test will be prescribed, and the patient will be followed up in two months.

Topical Corticosteroids

• Topical corticosteroids are an essential tool for treating inflammatory skin conditions such as psoriasis and atopic dermatitis 3.
• They are classified by strength and the risk of adverse effects, and the risk of adverse effects increases with prolonged use, large area of application, higher potency, occlusion, and application to areas of thinner skin 3.
• Topical corticosteroids can work safely and effectively in patients who are pregnant or lactating, and are available in various formulations such as ointments, creams, lotions, gels, foams, oils, solutions, and shampoos 3.

Treatment of Eczema

• Potent and moderate topical corticosteroids are probably more effective than mild topical corticosteroids, primarily in moderate or severe eczema 4.
• Effectiveness is similar between once daily and twice daily (or more) frequent use of potent topical corticosteroids to treat eczema flare-ups 4.
• Topical corticosteroids weekend (proactive) therapy is probably better than no topical corticosteroids/reactive use to prevent eczema relapse (flare-ups) 4.

Allergy Testing

• Skin testing can provide sufficient evidence to diagnose allergy in patients with a clear history of immediate hypersensitivity to corticosteroids such as anaphylaxis 5.
• Both skin prick and intradermal tests should be used, and there is evidence of cross-reactivity between steroids, so a panel is recommended 5.
• False-positive and false-negative reactions do occur, and challenge remains the only definitive way to demonstrate a safe alternative to use 5.