What is the best course of action for a patient with a recurrent, itchy, maculopapular rash at the flexural surface of the elbow that spreads to the hands, clears on its own, and has not responded to hydrocortisone (cortisol) treatment?

Management of Recurrent Flexural Maculopapular Rash Unresponsive to Hydrocortisone

This patient most likely has allergic contact dermatitis (ACD) affecting the flexural elbow, and should be referred for patch testing to identify the causative allergen, while switching to a non-steroidal topical immunomodulator such as pimecrolimus cream 1% twice daily until the allergen is identified and avoided. 1, 2

Why Hydrocortisone Failed

• Hydrocortisone is a mild potency (Class VI-VII) topical corticosteroid that may be insufficient for established contact dermatitis, particularly in areas with thicker skin like the elbow 3
• The flexural surface of the elbow is not a sensitive area requiring mild potency steroids (unlike the face or neck), so the use of hydrocortisone was likely underdosing the condition 3
• More importantly, if this is ACD, topical steroids only suppress inflammation temporarily but do not address the underlying allergen exposure, explaining why the rash comes and goes 1

Immediate Management Steps

Switch from hydrocortisone to pimecrolimus cream 1% (Elidel):

• Apply a thin layer twice daily to affected areas only 2
• Pimecrolimus is a topical calcineurin inhibitor that treats inflammatory dermatitis without the skin atrophy risks of prolonged steroid use 2
• Use for short periods; stop when itching, rash, and redness resolve 2
• Avoid sun exposure and do not use occlusive dressings over treated areas 2

If pimecrolimus is not available or contraindicated, escalate to a medium-potency topical steroid (Class IV-V such as triamcinolone 0.1%) rather than continuing ineffective mild-potency hydrocortisone 1, 3

Essential Diagnostic Workup

Refer for patch testing to identify the specific allergen:

• Individuals with recurrent hand/arm dermatitis that spreads and recurs should undergo patch testing to evaluate for clinically relevant causal allergens 1
• Common culprits for flexural elbow ACD include nickel (jewelry, watch bands, belt buckles), fragrances in personal care products, preservatives in lotions, and rubber accelerators in elastic bands 1
• Patch testing is the gold standard for diagnosing ACD and must be performed to guide definitive management through allergen avoidance 1

Document the pattern systematically:

• Note whether the rash spreads centrifugally (from elbow to hands), which suggests contact spread from an allergen source at the elbow 4
• Assess for occupational or hobby-related exposures (sports equipment, protective gear, cleaning products) 1

Definitive Management Algorithm

Once allergen is identified through patch testing:

1. Complete avoidance of the identified allergen is the only definitive treatment 1
2. Continue pimecrolimus or medium-potency topical steroid during flares 1, 2
3. Apply moisturizer liberally to restore skin barrier function; use after applying pimecrolimus 1, 2
4. Consider the "soak and smear" technique: soak affected areas in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks 1

If patch testing is negative or unavailable:

• Consider irritant contact dermatitis (ICD) as the diagnosis 1
• Identify and avoid irritants such as frequent hand washing, harsh soaps, or occupational exposures 1
• Barrier creams and regular moisturizers are equivalent in efficacy for ICD 1

Critical Pitfalls to Avoid

• Do not continue ineffective mild-potency hydrocortisone indefinitely—this delays proper diagnosis and allows continued allergen exposure 1, 3
• Do not assume this is simply "eczema" without investigating for ACD—the flexural elbow location and spreading pattern to hands strongly suggests contact dermatitis 1, 4
• Do not use topical antibiotics (neomycin, bacitracin) or adhesive bandages with preservatives, as these are common contact allergens that can worsen ACD 1
• Avoid applying superglue to fissures or using self-adherent wraps for occlusion, as these contain known allergens 1

When to Escalate Care

Seek dermatology consultation if:

• The rash does not improve after 6 weeks of appropriate topical treatment 2
• Systemic symptoms develop (fever, malaise, lymphadenopathy) 4
• Skin becomes infected (pustules, crusting, warmth) 1
• Phototherapy, systemic immunosuppression, or occupational modification becomes necessary for recalcitrant cases 1