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