What are the treatment options for macules and patches on the skin?

Treatment of Macules and Patches

For macules and patches covering less than 10% body surface area (BSA), initiate topical corticosteroids with oral antihistamines as first-line therapy, reserving systemic treatment for more extensive involvement. 1

Initial Assessment and Grading

The treatment approach depends critically on the extent of BSA involvement and associated symptoms:

• Grade 1 (<10% BSA): Macules/patches with or without symptoms like pruritus, burning, or tightness 1
• Grade 2 (10-30% BSA): Similar presentation but limiting instrumental activities of daily living 1
• Grade 3 (>30% BSA): Limiting self-care activities of daily living 1

Treatment Algorithm by Grade

Grade 1 Management (<10% BSA)

Topical corticosteroids are the cornerstone of treatment:

• For body lesions: Class I topical corticosteroids (clobetasol propionate, halobetasol propionate, or betamethasone dipropionate cream/ointment) 1
• For facial lesions: Class V/VI corticosteroids (aclometasone, desonide, or hydrocortisone 2.5% cream) to minimize side effects 1
• FDA-approved hydrocortisone: Apply to affected areas not more than 3-4 times daily 2

Oral antihistamines for symptomatic relief:

• Non-sedating options: Cetirizine or loratadine 10 mg daily 1
• Sedating option (especially for nighttime pruritus): Hydroxyzine 10-25 mg four times daily or at bedtime 1

Continue treatment without interruption at this grade 1

Grade 2 Management (10-30% BSA)

• Continue the same topical and oral regimen as Grade 1 1
• Obtain non-urgent dermatology referral for specialist evaluation 1
• Do not interrupt ongoing therapy unless specifically directed 1

Grade 3 Management (>30% BSA)

This requires immediate escalation:

• Hold any ongoing immunotherapy if applicable 1
• Obtain same-day dermatology consultation 1
• Rule out systemic involvement: Order CBC with differential and comprehensive metabolic panel 1

Systemic corticosteroids become necessary:

• Prednisone 0.5-1 mg/kg/day (or equivalent methylprednisolone dose) 1
• Continue until rash resolves to Grade 1 or less 1
• Then initiate 4-6 week steroid taper 1

Maintain oral antihistamines as above 1

Special Considerations for Pruritus Management

When pruritus is the predominant symptom:

Mild/Localized Pruritus

• Emollients: Use cream or ointment-based, fragrance-free products 1
• Topical corticosteroids: Same regimen as above (Class I for body, Class V/VI for face) 1
• Oral antihistamines: As previously described 1

Moderate Pruritus (Grade 2)

• Dermatology referral indicated 1
• Escalate to oral corticosteroids: Prednisone 0.5-1 mg/kg/day tapered over 2 weeks 1

Severe Pruritus (Grade 3)

• Add GABA agonists: Pregabalin or gabapentin 100-300 mg three times daily 1
• Oral corticosteroids: Prednisone 0.5-1 mg/kg/day tapered over 2 weeks 1
• Dermatology referral mandatory 1

Supportive Skin Care

For congenital or chronic macules/patches:

• Bland emollients: Thick creams or ointments with minimal fragrances or preservatives for chronic management 1
• Bathing: Use water alone or nonsoap cleansers 2-3 times weekly, followed by emollient application 1
• For eczematous changes: Add low- to mid-potency topical corticosteroids twice daily as needed for acute flares 1

Critical Pitfalls to Avoid

• Never use topical corticosteroids as monotherapy for fungal infections, as they can worsen the condition 3
• Do not delay dermatology consultation when BSA exceeds 30% or symptoms are severe 1
• Avoid premature discontinuation of treatment in Grade 1-2 cases 1
• Add PCP prophylaxis if immunosuppression exceeding 3 weeks is expected (>30 mg prednisone equivalent/day) 1
• Start proton pump inhibitor for GI prophylaxis when systemic corticosteroids are initiated 1