Dermatology concepts are difficult for everyone. It takes a lot of exposure and experience to be able to differentiate. However, this post will attempt to provide a place to return when review is necessary. This lesson will likely take at least 60 minutes to complete, but it may be split up and accomplished over time to make things easier. The post will start with general concepts and then move to easier topics that medics can often manage. The ADTMC protocol for an unknown rash is at the bottom, and there is a video about cellulitis as well. Don’t forget the quiz at the bottom to check learning.
GENERAL CONCEPTS AND DEFINITIONS
After watching these intro videos to the types of lesions, this website from Stanford Medicine is a good thorough review. The website includes pictures and descriptions in greater academic detail, as well as some videos to discuss a good physical exam.
Contact dermatitis is a reaction to a substance. When Soldiers are in the field, this is often from a plant such as poison ivy. My treatment protocol depends on the severity of the reaction. There are reports that talk about washing the oils off of the body with soap and water within 30 minutes from exposure- this can help prevent a lot of the reaction. However, once the rash appears, I typically prescribe a few medications.
For minimal local reaction that is not widespread, I typically give a topical steroid cream. My treatment of choice tends to be Triamcinolone 0.1% cream twice daily for 14 days. There are other creams and gels in this range of potency. Lots of literature suggests even stronger potency, but I find that triamcinolone tends to work fine. It is widely available in DOD pharmacies.
For more widespread lesions (not just one limb) or for more intense spread, I will often add prednisone oral pills. I often do a 9 day taper with the triamcinolone. My cocktail has often been 60 mg for 3 days, 40 mg for 3 days, and 20 mg for 3 days. However, I change this up depending on severity or concern. I may also give a Decadron 4-8 mg IM injection on the first day and then follow it up with my 9 day taper, all while using the triamcinolone cream.
Treatment Regimen for Contact Dermatitis
- Mild: Triamcinolone 0.1% cream used twice daily to affected area for 14 days
- Moderate: Oral Prednisone 60 mg for 3 days, 40 mg for 3 days, and 20 mg for 3 days, and the Triamcinolone 0.1% cream twice daily
- More than Moderate: Decadron 8 mg IM injection on day one, Triamcinolone 0.1% cream twice daily x 14 days, and oral Prednisone tapering cocktail above started the day after the injection.
These regimens have worked for me in the past. However, I give this only as an example and not as what medics should do without guidance. I am not recommending that this necessarily be done for patients in all circumstances, and I am aware that many other providers would disagree with this approach or recommend other approaches to contact dermatitis treatment. Some will use calamine lotion or other lotions, but these really only help with some of the itching and does not resolve the reaction.
My approach to treating heat rash has been to give a low dose hydrocortisone 0.1% cream (over the counter strength) to be used twice daily. I also encourage staying out of the heat as best as possible and changing clothes more often to keep the moisture from staying against the skin. Soldiers often wear gear that causes the moisture to be compressed up against the skin, so I typically recommend that they stay in PT uniforms (shorts and t-shirt) when I can in order to reverse the process. Sometimes I use other creams instead or other approaches, but the Soldier really needs to prevent the rash from continuing by removing the offending behavior for a few days.
Psuedofolliculitis Barbae is essentially razor bumps after shaving. This is also treated with hydrocortisone 0.1% twice daily and allow the Soldier to have a shaving profile. Allowing the hair to grow (not shaving) for a little bit typically resolves this. Most people know what this looks like. However, the short video below does have a few pictures.
- Terbinafine cream applied twice daily for 2 weeks
- Clotrimazole cream applied twice daily for 4 weeks
- Tolnaftate powder applied to the feet twice daily
Cellulitis is a serious condition that should be seen by a provider. There are many causes for rashes, and many are difficult to tease out. The ones above are typically straightforward and can often be managed by medics. However, this protocol below is a helpful protocol from the new ADTMC that details when to refer to a provider.
ADTMC PROTOCOL FOR SKIN COMPLAINT
QUIZ LINK – CHECK LEARNING HERE
All content is intended to be educational only. Medics should operate under the supervision of a medical provider and abide by all local laws while stateside. Medics should only practice at the level credentialed, and only at the level allowed. This content is not intended to treat or give a substitution for any credentialed provider. Content is intended to aid in a deployed prolonged care setting. Take guidance from your leaders. Utilize these posts as preparation and as a supplement to your provider’s direction and teaching.
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This content is the author’s opinion alone and does not necessarily reflect the opinion, official position, or stance of the Department of Defense, or any other branch of the United States Military.