Chronic Lower Extremity Dermatitis in Young Adult Male

Case at a Glance

A 22-year-old Caucasian male presents with a chronic, intermittent rash affecting bilateral lower extremities, persisting for several months despite initial treatment attempts.

Patient's Story

The patient reports a recurring rash primarily affecting his ankles and extending up both legs that has been present for several months. The rash appears and resolves in a seemingly random pattern. The lesions are most prominent around the ankle region, particularly in areas where socks make contact with the skin, presenting as clustered patches. Smaller erythematous papules extend proximally along both legs. The patient describes mild to moderate pruritus, with occasional episodes of more intense itching leading to excoriation. He denies any systemic symptoms or recent changes in activities or exposures. Current medications include sertraline (Zoloft) for depression and famotidine (Pepcid) for acid reflux.

Initial Assessment

The patient initially presented to his primary care physician with the described rash. Physical examination revealed erythematous, papular lesions with some areas of clustering around the ankles bilaterally, with scattered similar lesions extending up both lower extremities. The distribution pattern suggested possible contact dermatitis or other inflammatory dermatosis.

The Diagnostic Journey

Initial treatment with topical corticosteroids and antifungal preparations yielded no improvement. The patient was referred to dermatology for specialized evaluation. A punch biopsy was performed, which revealed ulcerated epidermis with underlying inflammatory changes, but lacked specific diagnostic features. The histopathology was reported as 'ulcerated skin' without definitive diagnosis. Environmental factors were considered, including potential contact allergens such as laundry detergents, but elimination of suspected triggers did not result in improvement.

Final Diagnosis

The case remains under investigation. Differential diagnoses under consideration include vasculitis, various forms of capillaritis (pigmented purpuric dermatoses), contact dermatitis, and other inflammatory skin conditions. The consulting dermatologist noted that the clinical presentation and initial biopsy results were non-specific.

Treatment Plan

Given the non-diagnostic initial biopsy and lack of response to conventional treatments, the dermatologist recommended consideration of additional skin biopsies from different areas of involvement to obtain more specific diagnostic information. Further evaluation may include additional laboratory studies and possibly patch testing depending on clinical suspicion.

Outcome and Follow-up

The patient continues to experience intermittent flares of the rash. Additional diagnostic workup is planned to establish a definitive diagnosis and guide targeted therapy. Close dermatologic follow-up has been arranged to monitor progression and response to any future interventions.