Clinical case – from scales in the groin to erythroderma
Mr X, an 82-year-old Caucasian male, with a background history of plaque psoriasis, moderate-severe Alzheimer’s dementia and deafness with bilateral hearing aids, presented alone in general practice, with itching in the groin for the preceding seven days. He was a poor historian and a limited skin history was available.
On examination there were bilateral erythematous patches with scaling in the groin. His GP treated this as tinea cruris, with the patient given topical miconazole nitrate 2% cream to use twice daily. His psoriasis was stable and he was prescribed cetraben ointment to moisturise the skin twice a day.
The following week, he presented to the surgery reception asking to be seen, despite not having an appointment booked. He was given an appointment later in the week with a different GP. Mr X stated that the rash in the groin was still present and was weeping. However, he was not able to state which cream he had been using or how often, due to his dementia.
A swab was taken from the groin and he was prescribed clotrimazole 1% cream to use twice daily and asked to come back in two weeks, but he did not attend the follow up appointment.
One month later, unfortunately his psoriasis flared, with scaly plaques on the torso and upper limbs and he was prescribed betamethasone valerate 0.1% cream. The groin rash still had not resolved at this point. Although the swab showed no significant growth, interpretation was difficult as it was taken after treatment was commenced. On the basis that fungal infections in the groin are a common diagnosis in primary care, especially in older adults who may struggle with personal care, the patient was advised to persist with the topical clotrimazole.
Following another four weeks, Mr X’s wife called the GP surgery for an urgent home visit review as he was now confused and ‘shedding dead skin’. When I attended the home visit, he was lying in bed and not been out of the house for the preceding week. By this point he had developed erythroderma and he had approximately 80% coverage of psoriasis and was haemodynamically compromised with hypotension and tachycardia.
He was immediately discussed with the local dermatology team, but due to limited local acute dermatology services, he was admitted to the acute medical team and then had to wait until the next day to be transferred to a neighbouring dermatology unit 20 miles away. Unfortunately, Mr X died 48 hours after admission to the dermatology ward.
Skin disease in dementia - challenges of the case
A holistic approach is required when managing vulnerable older adults, taking into account their frailty, cognitive impairment, multimorbidity and ability for self-care.
In the case of Mr X, at each encounter with his GP, multiple new challenges emerged, ranging from gaining an accurate history for clinical review, making the correct diagnosis, to recognising social concerns.
Mr X had advanced dementia and his medication compliance could not be determined. Being prescribed two different creams for different indications could have confused him. He was not able to inform the GP how often he was using the antifungal or steroid ointments or where he was applying the treatments. Harm could have occurred if he had mistakenly used the topical steroid instead of the antifungal, which would exacerbate the fungal infection. Using cetraben on the fungal rash would lead to undertreatment. This also meant that reviewing the response to a treatment trial was very difficult.
Despite his dementia, the patient always presented to his GP alone. The GP had made telephone contact with his wife to reinforce the treatment plan. No safeguarding concerns of neglect had been raised before. His wife was aware of the skin rash, stating how it was ‘driving them both mad’ and the repeated consultations with the GP. However, it later transpired she was not actively helping him with his skin treatment regime. Without the help of a third party, it was difficult to ensure Mr X remembered or understood his skin regime correctly.
Mr X would attend the GP surgery with no pre-booked appointment, asking for a same day review of his groin rash. Unfortunately, GP surgeries are often overbooked with appointments, seeing patients who turn up with no appointments is not feasible, except in emergencies. His dementia became a barrier for him to access services; he could neither use the online booking system nor phone for an appointment due to his hearing impairment. Even when he was given a follow-up appointment, he was not able to remember when to attend. Seeing different GPs, with a lack of continuity was another challenge for both the patient and the GP.
This case highlights the vulnerability of dementia patients, who need relatives or carers to safeguard their care needs, and an appointment system adapted to
Appreciating the link between acute and chronic skin disease
Tinea cruris is a common presentation encountered, but often mismanaged and neglected. Perhaps this is due to the perception that skin disease is often seen as ‘not serious’, with a lack of empathy from clinicians,1 whilst skin rashes are often hastily reviewed in 10-minute GP appointments with multiple patient presentations. This will prolong the symptoms the patient experiences and lead to multiple courses of treatment, including oral antifungals, which can lead to side effects.
Pragmatically, when topical treatments are prescribed in the community on first presentation, skin scrapings are rarely done. However, when alternative diagnoses are possible, such as psoriasis in this case, it will help to confirm an organism and enable the correct treatment is initiated.2
This case highlights the importance of managing acute skin conditions in a timely manner, particularly in patients with chronic skin conditions. Suboptimal treatment of an innocuous fungal infection can then cause an acute flare in the underlying chronic skin disease. This then makes management more difficult as multiple treatments may then be needed at the same time. Caution needs to be raised when steroids are prescribed in those with co-existing tinea infections, as using steroids on patches of tinea can result in tinea incognito.
The consultation model in vulnerable older adults
Healthcare professionals (HCP) need to be able to identify patients with cognitive impairment who are struggling to engage with the consultation. Once identified, an alert should be placed in the patient’s record to raise awareness. This will then allow the consultation and management plan be adapted for vulnerable adults, such as those with advanced dementia. For example, relatives or carers should be involved in the management plan (with patients’ consent or in the best interest for those who lack capacity).
A pragmatic approach minimising the number and frequency of treatments prescribed should be used. This can help improve patient understanding and adherence of the treatment regime. For patients with ongoing management needs, a clear follow-up plan needs to be determined, which may be in the community. If they do not attend follow-up appointments, then the reason for this needs to be established rather than discharging the patient.
A generic skin care plan, similar to the asthma and diabetes action plans used during acute attacks, could be developed and provided to vulnerable adults and their carers, so that they are aware of clinical features that should prompt urgent review. In this case, a care plan may have enabled Mr X to be seen when his psoriasis first flared.
Dermatologists will also need to feel confident with identifying cognitive impairment in patients who are undiagnosed and involve other services as required. Involving dermatology speciality nurses, psychiatry liaison specialists and social workers in older adult specific multi-disciplinary dermatology clinics may be required in future.
The need to increase confidence in diagnosing dermatoses
In an ageing population, more acute and chronic dermatological presentations will be seen in both primary and secondary care.3 Therefore, it is important to investigate any dermatology presentation as you would with any other presenting complaint, such as chest pain, in a general medical setting.
However, many HCPs do not feel confident diagnosing skin conditions, both acute and chronic, or appreciate how rapidly clinical features can deteriorate.4 This illustrates a lack of dermatology teaching in undergraduate and postgraduate training.
Furthermore, with a reduction in dermatology training posts and acute dermatology services in the UK,5 non-dermatologists will see more dermatoses. Acute skin conditions such as erythroderma are now often being managed initially by acute internal medicine, under the guidance of dermatology. Further education on skin disease, especially dermatology emergencies is required.
This case unfortunately had an unwanted outcome, but the lessons that can be learnt will help improve our patient care in older adults with skin disease.
This article was the joint winning entry for the British Society for Geriatric Dermatology Kligman Essay Competition 2020.
For more articles on skin conditions go to our dermatology section
Dr Mitesh Patel, City and West Birmingham NHS Trust
- Kownacki S. Skin diseases in primary care: what should GPs be doing? Br J Gen Pract 2014; 64(625): 380–81
- Ely JW, Rosenfeld S, Seabury Stone M. Diagnosis and management of tinea infections. Am Fam Physician 2014; 90(10): 702-10
- Schofield JK, Fleming D, Grindlay D, Williams H. Skin conditions are the commonest new reason people present to general practitioners in England and Wales. Br J Dermatol 2011; 165(5): 1044-50
- Rübsam ML, Esch M, Baum E, Bösner S. Diagnosing skin disease in primary care: a qualitative study of GPs’ approaches. Fam Pract 2015; 32(5): 591-95
- Eedy D. Dermatology: a specialty in crisis. Clin Med (Lond) 2015; 15(6): 509–10