Let's play another round of What's That Rash?
May 10, 2018 1:41 PM   Subscribe

A busy and stubborn friend of mine has had a non-itching rash on both legs, below the knee and mostly on the ankles and feet, for about 2 months now. Doctor seen at beginning of rash gave him anti-fungal meds, he used them, but no change. He won't go back to the doctor unless something changes. With his permission and some photos, I'm asking Metafilter for opinions on what it could be.

I know you may or may not be doctors or other trained medical people, and any opinions are personal and not advice. That being said, the Metafilter hivemind is pretty good at this, and there are some people who'd like to know if there's a reasonable possibility that it might be indicative of something serious.

Yes, I know he should go back to the doctor. That's why I'm asking for help. Please don't just say that he needs to see a doctor, unless you can specifically tell me why, or are a doctor and can't be specific but would be alarmed and do something if you had a patient come in with something like this. MeMail is open if there are questions or clarification is needed.

Here are the photos on imgur. If it is not clear from the photos, there's no rash on the tops of his feet or the soles, and it extends further up on the backs of his legs than the front.

For those not into brevity, below is the longer story, with more details and context. To make this simpler, I shall now be calling him Dude.

Dude is not a big fan of doctors, but he isn't stupid. Several people depend on him to fill various emotional and physical needs, and he is often under a lot of stress because of this. He's historically been better at taking care of other people than of himself, though because of this he's learned to be proactive with self-care emotionally. Taking better physical self-care is something he's working on.

Dude is male, a bit over 6 feet and probably 275 pounds. Late 30s to early 40s. Has seasonal and environmental allergies, bad knees, and has had quite a few injuries, but no other known ongoing health issues. Dude is fairly active and always busy. He commutes about 60 miles each way by car at least 3 days a week to a demanding job that doesn't have a very flexible schedule. No smoking of anything, history of occasional bouts of heavy drinking but is not currently drinking at all. No meds that I know of except for OTC antihistamines. Has recently lost some weight using portion control and not drinking. He has a small number of goats and some house cats.

He does have health insurance, but this is the US, so it isn't great and it would be challenging to go to appointments with his regular schedule.

The rash started approximately 8 weeks ago. It doesn't act like common athlete's foot. It doesn't itch or weep, it appears to be more under the skin than on top of it. It started from the outer top of ankle area one side, the other side started within hours of the first, and it spread over the current affected area in less than a week and has not changed since. It has not been transmitted to anyone else. The only difference noticed in the interval was 4 days ago, when after spending about 2 hours in a highly chlorinated hot tub it looked paler, which continued into the next day. That's when I took the photos.

It started at about the same time as a direct exposure of the area to human urine from another person who at the time was thought to have a fungal urinary infection, but it only showed on one lab test and was absent on subsequent tests. The urine did contain Staph, as well as the usual chronic Klebsiella this other person has from a long term urinary catheter installation. I was exposed to urine from the same source in the same way at roughly the same time and did not develop any rash.

The doctor at the walk in clinic who saw Dude's rash right after it started prescribed a single dose of oral Difflucan and topical 2% ketoconazole cream. Both were used as directed. They didn't work, or I wouldn't be asking this question.

Because it doesn't itch, burn, or sting, doesn't seem contagious, and it hasn't gotten any worse, he's mostly ignoring it now. He isn't a sandals and shorts kind of guy, and he doesn't care how it looks. He is airing out his feet more often, changing socks regularly, and washing and moisturizing as part of monitoring them. For the past few days, mostly to humor me, he's been putting an AHA lotion on one foot to see if it makes any visible difference.

So does anyone have any ideas on what it might be? I've been looking at rash photos for days trying to figure this out. It would be nice to know what it is.

More importantly, is it ok to tell the Dude to just go on abiding, or do I need to tell him to proceed calmly but rapidly to the nearest decent hospital and insist that he get tested for something specific because the doctor missed something and he is in immediate danger to himself and possibly endangering others if he doesn't?
posted by monopas to Health & Fitness (12 answers total) 1 user marked this as a favorite
 
I had a rash that looks similar. It was diagnosed as leukocytoclastic vasculitis by a Dermatologist. Have him get a biopsy. Not life threatening but annoying and can be a sign of other issues worth following by a physician.
posted by crunchy potato at 1:46 PM on May 10, 2018 [1 favorite]


Best answer: Schamberg purpura (although that is a bit of a minomer because the lesions are not typically purpuric) aka Schamberg disease.
posted by sudogeek at 2:18 PM on May 10, 2018 [3 favorites]


That's a pretty major league rash; I can scarcely believe the area between ankle bone and Achilles' tendon on the second photo doesn't itch furiously.

But maybe that's the antihistamines -- which are, after all, blocking an essential part of the immune response -- so I would reduce their use as much as possible for a bit to see if that might help.

And it sounds like topical anti-bacterials haven't been tried yet, so I'd give neosporin cream or whatever else I could get hold of a shot, too.

The way the rash spread to the same part of the other side of the body within a day suggests major immune system involvement to me, so if anti-bacterials help at all, it might be necessary to keep them up for a while.

Also, since hot tub chlorination seemed to help, I'd soak the foot that was directly exposed to the urine in three percent hydrogen peroxide mixed with an equal amount of hot water briefly (~10 min.) once just as an experiment to see what happens.
posted by jamjam at 3:25 PM on May 10, 2018


He should go to a dermatologist. The area it covers and the clear visibility of the rash both pass the threshold of "Go see a doctor about it" for me. That's not a subtle one.
posted by limeonaire at 4:14 PM on May 10, 2018 [2 favorites]


Since you mentioned staph, it can take on many forms including a follicular rash like this one. Since it also has responded positively to chlorinated soaks, it may be the case.
I recently treated a staph infection that doctors were failing in treating, with bleach baths(it sounds worse than it is, bleach baths are actually pretty safe when done correctly. Google it for instructions), a supplement called Monolaurin(it's an antibiotic/antifungal/antimicrobial made from the medicinal part of coconut oil), and topically with essential oils that are widely available and relatively inexpensive like tea tree oil, lavender and geranium. If he's open to trying natural treatments, this should clear up the rash pretty quickly if it is indeed staph related.
posted by OnefortheLast at 4:26 PM on May 10, 2018


I'm not anyone's doctor, but I agree that my first thought was a vasculitis when I saw the photos. I think it's past the walk in clinic stage and warrants a dermatologist's evaluation at this point, but certainly not "imminent danger" territory.
posted by telegraph at 4:57 PM on May 10, 2018 [3 favorites]


Petechiae? Which can be indicative of a lot of issues - some of them rather serious. So, a more thorough doctor’s visit should happen soon.
posted by Sassyfras at 6:04 PM on May 10, 2018 [1 favorite]


I will volunteer that I once thought I had a major rash - turns out the dogs had fleas, and I was delicious... He might want to treat for fleas/mites in the carpets/animals with Revolution.... see if that helps at all if he's having an allergic reaction... it could be that there's something environmental that's getting him. Otherwise, I'm sure the other posters are on the right track.
posted by NorthernAutumn at 6:15 PM on May 10, 2018


For what it's worth, my husband's lower legs look EXACTLY like this (the rash/spots are maybe slightly lighter orange in color, but in exactly the same places) and have for many years. We joke that his freckles melted down his leg.
It looks a lot like the Schamberg purpura linked above. Husband has been living with it, with no problems, for years. I'm not saying don't see a doctor. I'm just saying this appeared on husband one day 7+ years ago and he's still fine.
posted by raspberrE at 6:38 PM on May 10, 2018


Someone close to me had petechiae (looked like this) - learned that it could be down to anemia (which can have a congenital cause, like thalassemia, or a scarier cause) or hypothyroid. Among many other things, no doubt. Another medical person should definitely see this.
posted by cotton dress sock at 10:31 PM on May 10, 2018


Anecdote only: neighbor friend had terrible rashes on her arms, wanted to avoid meds, dropped all refined sugar from her diet. Rash disappeared. YMMV
posted by AnOrigamiLife at 8:37 AM on May 12, 2018


Response by poster: Update!

Thanks to the push of concern from AskMe, my friend made an appointment, and finally saw a dermatologist today.

The dermatologist diagnosed him with something "in the Schamberg family." He was advised to reduce his physical activity level, and there might be some compression hose or socks involved at some point.

I marked sudogeek's answer as "best" because they totally called it, but everyone shares credit for getting him to take this seriously and take care of himself. Thank you, everyone.
posted by monopas at 2:10 PM on June 15, 2018 [1 favorite]


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