Tuesday, March 4, 2008

Blah blah blah steroid cream blah blah blah

I have an inferiority complex around other docs. I'm younger, and less experienced than most. I'm a family doc, and therefore by definition I know a only little about a lot, where most docs know a lot about a little. And all the docs I talk to lately are Hopkins docs (cue church choir "Aaaaahhhh").

So I get a little pleasure from being right.

Henry has the rash from hell. It started over a week ago. I kept bringing it up to the rounding team, as it worsened day by day. And when it started to look impressive, I asked for a steroid cream to help.

Now, I know a little about a lot, but I know nothing about rashes in kids who are severely immunocompromised. Steroids suppress immunity. I wasn't sure if it was a good idea.

Hydrocortisone 1% was suggested, and prescribed. A little itty bitty tube arrived.

Steroid creams are a great example of a place where academic medicine and real medicine don't exactly jive. In residency, we were warned against using anything with any strength for any significant period of time. Everyone got started with 1% hydrocortisone, and maybe, just maybe, if the rash was really bad, you'd start with something higher.

Enter real medicine. My first year of practice I used a lot of hydrocortisone. There's a reason it's over-the-counter. No self-respecting rash gets better on hydrocortisone, at least within a reasonable period of time. (I only use it now on things that would get better with nothing.) I referred a bunch of people to see derm, since I wasn't helping them with my 1% hydrocortisone. And I noticed something: they were pulling out the big guns, the super high-potency creams, for everything.

So I did what they teach you in family medicine residency, that they don't seem to teach you in speciality residency. All things in moderation. I started using medium potency creams to start with on most steroid-responsive rashes, and rarely pulled out the big guns when I thought it necessary. Guess what? Those rashes went away.

Anyway, back to the story. None of the rounding team knew what the rash was. I've hemmed and hawed my way through treating enough rashes to recognize that when I see it. The hydrocortisone was presented like manna from heaven. Hmmm....except it didn't work. His rash has been aggressively worsening.

So the derm docs showed up yesterday. The third-year Hopkins (church choir "Aaaahhh") medical student arrived, and danced circles around me academically. (Honestly, he looked 14. I felt like I should be introducing myself as "Dr. Gump. Dr. Forrest Gump.") The whole team showed, asked a few questions, and kicked around differentials like zinc deficiency and graft versus host disease, which I didn't even know you could get that with an autologous transplant. In the end, they did what all good dermatologists do: they put him on a steroid cream and recommended a biopsy if it's not better in a week.

Did I mention that it was the same steroid cream that I would have put him on a week ago?

"You can name it whatever long fancy latin name you need to, but in the end, you're just going to put a steroid cream on it."

--my senior resident when I was a medical student, on dermatologists


TBTAM said...

GREAT post.

We discovered temovate for lichen sclerosis a few years back in our field, and it changed women's lives. Once the acute treatment phase is over, I have them use it once a week to keep things at bay, instead of having to use a medium strength every day and it just WORKS.

Hope the rash clears and he avoids a biopsy.

Doctor David said...

Here's all I learned from Dermatology during medical school (with apologies to all of my dermatologist friends):
If it's dry, wet it.
If it's wet, dry it.
When in doubt, use steroids.

I hope Henry's rash gets better, and I hope the docs seeing Henry on a daily basis (and as consultants) know enough to treat Family Docs with the respect they deserve.

SOCKS said...

Enjoyable post - sorry it is at your son's expense.

Anonymous said...

I'm a dermatologist and found your blog refreshing--great points! Keep it up and I hope the best for your son. Your sense of humor will get you far!

Lynn said...

I have dealt with specialist (derms) (cue choir... Ahhhhhhhh) for years. I have this ridiculous rash that goes dormant, then rears its ugly headed periodically and puts me in the housebound category, due to its severity.

The "specialist" response is always the same. "You have contact dermatitis." Which means... you're having an allergic reaction, but we don't have a clue what it is.

REALLY?! I would NEVER have known that had they NOT TOLD ME! OK.. I agree I'm a tad bit sarcastic at this point. Let's put aside how horrific I am to look at when I am in the middle of a "flare up". I couldn't care less what I look like. The pain, however, is excruciating.

I have discovered through my own research that I am NOT having an allergic reaction to anything. I have what I think to be Discoid Lupus, which is an autoimmune disorder. I am sterotypical of the disorder and even the pictures look like copies of pictures of me with the flare up, only with someone else face and hands.

When I go to my doctor I will be shocked if this is not my diagnosis. My question being, "Why didn't the "SPECIALIST" find it?" Makes me wonder why I've paid all the money to these doctors, who scratch their heads and inform me that I AM HAVING AN ALLERGIC REACTION. It's all sort of funny to me actually.

YOUR post made me laugh and made me forget the pain I am in right now.THANK YOU!