What is the best course of treatment for a 71-year-old male patient with bilateral lower extremity swelling and redness, and a history of psoriasis, presenting with possible dermatitis and secondary cellulitis?

From the Guidelines

The best course of treatment for this 71-year-old male with bilateral lower extremity swelling, redness, and a history of psoriasis likely involves a dual approach targeting both the dermatitis and secondary cellulitis. Initially, oral antibiotics such as cephalexin 500mg four times daily for 5 days, as recommended by the most recent guidelines 1, would address the cellulitis component. For the underlying dermatitis, which may be psoriatic in nature, a medium-potency topical corticosteroid like triamcinolone 0.1% ointment applied twice daily to affected areas would help reduce inflammation. Some key points to consider in the treatment of cellulitis include:

• Elevation of the affected area to promote gravity drainage of edema and inflammatory substances 1
• Treatment of underlying conditions that may have predisposed to the infection, such as tinea pedis or venous eczema 1
• The use of systemic corticosteroids as an optional adjunct for treatment of uncomplicated cellulitis and erysipelas in selected adult patients 1
• The importance of detecting and treating interdigital maceration, keeping the skin well hydrated with emollients, and reducing any underlying edema to prevent recurrences of cellulitis 1 Leg elevation above heart level when sitting or lying down and compression stockings (20-30 mmHg) during the day can help reduce swelling. The patient should keep the skin clean and moisturized with a fragrance-free emollient like petrolatum-based products applied after bathing. If symptoms don't improve within 48-72 hours of antibiotic therapy, the patient should be reassessed as hospitalization for IV antibiotics may be necessary. This approach addresses both the infectious component with antibiotics and the inflammatory dermatologic condition with corticosteroids, while the physical measures help reduce edema that can complicate healing. The patient's age and potential comorbidities may require dosage adjustments and monitoring for medication side effects. It is also important to consider the patient's history of psoriasis and the potential for systemic treatments, such as methotrexate or cyclosporine, if the condition is severe or unresponsive to topical treatments 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION: Apply a thin layer of clobetasol propionate gel, cream or ointment to the affected skin areas twice daily and rub in gently and completely. Clobetasol propionate gel, cream and ointment are super-high potency topical corticosteroids; therefore, treatment should be limited to 2 consecutive weeks, and amounts greater than 50 g per week should not be used.

The patient's presentation of possible dermatitis with secondary cellulitis, along with a history of psoriasis, may be treated with topical corticosteroids like clobetasol propionate.

• The best course of treatment would be to apply a thin layer of clobetasol propionate gel, cream or ointment to the affected skin areas twice daily.
• Treatment should be limited to 2 consecutive weeks, with no more than 50 g per week.
• It is essential to discontinue therapy when control has been achieved.
• If no improvement is seen within 2 weeks, reassessment of diagnosis may be necessary 2.

From the Research

Treatment Approach

The patient's condition appears to be a combination of psoriasis, possible dermatitis, and secondary cellulitis. To address this, consider the following:

• Topical corticosteroids, such as fluticasone propionate, may be effective in treating the patient's psoriasis and dermatitis, as they have been shown to be safe and well-tolerated 3.
• For the treatment of cellulitis, oral antibiotics such as penicillin, amoxicillin, or cephalexin may be sufficient, as the majority of non-purulent, uncomplicated cases are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus 4.
• The use of dimethylsulfoxide (DMSO) in combination with topical corticosteroids may also be beneficial in treating resistant psoriasis, as it has been shown to be effective in achieving complete clearing in 3-4 weeks 5.
• A two-compound product consisting of calcipotriol and betamethasone dipropionate may be considered for the treatment of psoriasis, as it has been shown to be clinically superior to both monotherapies and reduces side effects 6.

Considerations

When treating the patient, consider the following:

• The patient's age and potential for systemic and local side effects when selecting a treatment regimen 3.
• The possibility of dermal hypoechogenicity, which may be associated with a history of cellulitis in patients with lower extremity lymphedema 7.
• The need for careful evaluation of the patient's skin and subcutaneous tissue to identify potential characteristics that may contribute to recurrent cellulitis 7.

Treatment Options

Based on the patient's presentation, consider the following treatment options:

• Topical corticosteroids, such as fluticasone propionate, for the treatment of psoriasis and dermatitis.
• Oral antibiotics, such as penicillin, amoxicillin, or cephalexin, for the treatment of cellulitis.
• Dimethylsulfoxide (DMSO) in combination with topical corticosteroids for the treatment of resistant psoriasis.
• A two-compound product consisting of calcipotriol and betamethasone dipropionate for the treatment of psoriasis.