What is the next step for a patient with inflamed follicles and erythema in the groin and axillary (arm pit) region that responds to ketoconazole (Ketoconazole)/hydrocortisone (HC) cream but does not resolve?

From the Guidelines

The next step for a patient with inflamed follicles with erythema in the groin and armpit regions that partially responds to but is not resolved by ketoconazole/HC cream would be to prescribe a more potent topical corticosteroid, such as betamethasone valerate 0.1% or clobetasone butyrate 0.05%, in combination with an antimicrobial agent, as listed in the expert consensus guidelines 1. This approach is based on the patient's partial response to the initial treatment, suggesting that a more potent topical corticosteroid may be necessary to reduce inflammation. The guidelines provide a list of suitable topical corticosteroid and antimicrobial combination preparations, including BetnovateÒ (betometasone valerate 0.1%) and EumovateÒ (clobetasone butyrate 0.05%) 1. Some key points to consider when selecting a topical corticosteroid include:

• The potency of the corticosteroid, with more potent options such as betamethasone valerate 0.1% or clobetasol propionate 0.05% being reserved for more severe cases 1
• The combination of the corticosteroid with an antimicrobial agent, such as ketoconazole or fusidic acid, to address potential fungal or bacterial infections 1
• The formulation of the preparation, with creams being preferred for weeping skin and ointments being preferred for dry skin 1 It is also important to advise the patient on proper hygiene and skin care practices, such as using aqueous emollients and soap substitutes, and avoiding normal soaps that can dehydrate the skin 1. If the patient's condition does not improve with the more potent topical corticosteroid and antimicrobial combination, further evaluation and consideration of other treatment options, such as oral antifungal therapy or dermatology referral, may be necessary.

From the FDA Drug Label

DOSAGE & ADMINISTRATION SECTION ... If a patient shows no clinical improvement after the treatment period, the diagnosis should be redetermined. The next step is to redetermine the diagnosis since the patient does not resolve with ketoconazole/HC cream treatment, as the patient's condition has not shown clinical improvement after the treatment period 2.

• The patient's symptoms of inflamed follicles with erythema in the groin and arm pit region may indicate a different condition that requires a different treatment approach.
• Re-evaluation of the patient's condition is necessary to determine the best course of action.

From the Research

Possible Causes of Inflamed Follicles

• The patient's symptoms may be related to Demodex-associated inflammatory skin conditions, as discussed in 3.
• Seborrheic dermatitis is another possible cause, characterized by scaling, erythema, and itching, often occurring in the scalp, face, chest, back, axilla, and groin, as described in 4.

Treatment Options

• For Demodex-associated inflammatory skin conditions, treatment options may include permethrin, crotamiton, benzyl benzoate, and oral metronidazole, as mentioned in 3.
• Since the patient has responded to ketoconazole/HC cream, but the condition has not resolved, consideration may be given to alternative antifungal agents or combination therapies, as discussed in 5 and 6.
• Topical corticosteroids may also be considered, taking into account the potential risks and benefits, as outlined in 7.

Next Steps

• Further evaluation may be necessary to determine the underlying cause of the patient's symptoms and to guide treatment decisions.
• Consideration may be given to alternative treatments, such as those mentioned in 3 and 7, to address the patient's ongoing symptoms.