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SOUTHERN DERMATOLOGY & SKIN CANCER CENTER

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THE DERMATOLOGY & SKIN CANCER CENTER

Gregory J. Wilmoth, MD
Eric D. Challgren, MD
Margaret B. Boyse, MD
Laura D. Briley, MD
Tracey Cloninger, PA-C

4201 Lake Boone Trail, #200
Raleigh, NC 27607
Telephone: (919) 782-2152

 

THE SKIN RENEWAL CENTER AT SOUTHERN DERMATOLOGY

4201 Lake Boone Trail, #207

Raleigh, NC 27607
Telephone: (919) 863-0073

A Rash Is Always a Symptom of Something

Jeffrey, a 60-year-old patient of Dr. Laura Briley’s at Southern Dermatology in Raleigh, came in with a common complaint that turned out to have an uncommon cause.  Jeffrey, it turned out, had a specific form of Lupus. But in the beginning, as Dr. Briley explains, Jeffrey had a rash.

“Rashes are an incredibly common reason for coming in to see a dermatologist,” she notes. “Rashes are obvious and disturbing to everyone. Whether they’re itchy, not itchy, scaly, dry, red, or oozing—when you have a rash you know something is wrong.”

Often, the cause of a rash is easily fixable, self-limiting, and benign. Figuring out that cause however, so that one knows what to fix, can be a puzzling challenge. “Delineating the origin or causative factor behind a rash is largely about listening to the patient’s story,” explains Dr. Briley. “It’s important to hear the details I can’t learn from a physical exam. So there needs to be an in-depth conversation: How long has the rash been there? When did it start? Under what circumstances did it first appear? Are there exacerbating factors that make it worse or better? What does it feel like?

Environmental Factors

Then there are the environmental factors, Dr. Briley continues. “Have they changed anything at home like laundry detergent or soap; or have they gotten new towels or clothes they perhaps forgot to wash before wearing. Travel also is a big one. Often someone might say, ‘No, I haven’t changed anything.’ Then I’ll ask if they have traveled lately, and they’ll say ‘well, yes.’ It’s funny how easy it is to overlook something as simple as having slept on hotel sheets—which are laundered in cheap detergent—or having used the hotel soap.”

More Than a Rash

So, like many, Jeffrey’s rash was what brought him in to see the doctor, however in his rare case it was ultimately his rash that perhaps saved his life.

“Jeffrey’s rash was all over his body—face, arms, torso—and it wasn’t itchy,” notes Dr. Briley, “but it was bright red.  This had been going on for about four months, and he’d been given all kinds of steroid creams, but without any explanation about the cause of his condition and without any improvement.”

In addition to his rash, Jeffrey had also become quite ill in that four-month span. “Understanding what’s going on with a person’s health in general, even if their presenting complaint is only a rash, is a really important part of the diagnostic process,” Dr. Briley says. “Jeffrey, over the last four months, had experienced a sudden health decline. He’d lost a lot of weight, had a massive work-up for heart disease, and his kidneys were failing. His nephrologist was about to put him on dialysis. Now, this was a previously healthy 60-year-old man with little more than slightly elevated blood pressure—so this was a dramatic life change in a very short time.

“The other thing about this rash was that it didn’t really bother him all that much. A lot of times people come in with a rash that is just so irritating that it’s almost an emergency for them to come in and be seen. Jeffrey’s huge rash however, wasn’t irritating at all. It was just there.”

No Simple Test

“Rashes in general are particularly challenging because there isn’t a simple test to figure them out,” Dr. Briley explains. “For example, when someone comes in with a strange spot or a new mole, I can typically look at it and have a pretty good idea if it’s likely to be skin cancer or not. With something suspicious for cancer, the history behind it and how the patient feels about it aren’t so relevant. Basal cell carcinoma looks a certain way—most of the time. And if I’m unsure, or if it looks fairly normal but the patient tells me it’s been itching or bleeding, then I can biopsy it and get a definitive answer in about a week.”

Dr. Briley ultimately decided to run a rather large and detailed laboratory panel on Jeffrey to cover all the bases. She had started to suspect that lupus or perhaps an autoimmune disease was at play given the full picture of Jeffrey’s health. “Luckily,” she says, “I didn’t just do a screening exam for lupus. I did a comprehensive panel that tested all of his antibodies.”

This was fortunate because the typical markers for lupus were not elevated. Jeffrey did, however, have a specific type of systemic lupus that was attacking his kidneys. “There was just one marker for his specific disease that would have been missed on a routine screening,” notes Dr. Briley, “and we may never have figured it out without testing all his antibodies.”

Dr. Briley talked to Jeffrey’s nephrologist and was able to get him started on immunosuppressants before he ever had to go on dialysis. His kidney function improved, and he started to gain back the weight he’d lost.  Jeffrey began to feel like a normal person again, all thanks to a mysterious rash. And, of course, to Dr. Briley.

Hives: Another Diagnostic Difficulty

Hives, medically termed urticaria, are another common problem most often experienced by people having an allergic reaction. Food allergies, medication allergies, or an environmental exposure can all cause this raised, red, incredibly itchy type of rash.

“Chronic hives are one of the most challenging things I deal with,” Dr. Briley says. “Usually, someone will come in with hives that started after taking a new antibiotic, or coinciding with a lot of stress—something that has gotten the immune system to attack the skin for one reason or another. Typically I can put them on an antihistamine, and the body works itself out in a week or two.

“With chronic hives however, someone will come in and tell me they have itched every day of their life for years. This is a much more difficult problem to solve.”

Dr. Briley explains that what makes chronic hives more of a challenge is that whatever the initial event was that produced the hives, it’s long gone—often after many years—so discovering the cause is much less likely. “We end up doing an extensive work-up during the diagnostic process: Do they have thyroid disease? Do they have lupus?  But sometimes all we can come up with is that the body just got stuck producing the chemicals that force the hives to keep happening,” she says. “It’s really a very challenging thing to have to live with.

“Luckily,” says Dr. Briley, “today there is a new medication that alters thinking and outcomes. People used to have to live on Benadryl just to get through the day—which is a problem because it makes you really drowsy. Now there is a new medication called Xolair. It’s given by a monthly injection, and it’s amazing,” Dr. Briley says smiling. “I have patients who have itched for 10 years or more, and this just fixes it. These patients, who would come into my office sobbing from constant discomfort, are now able to get their lives back. It’s nice to have a treatment to offer them that really works.”