A 40-year-old woman with severe itch and crusted rashes resistant to steroid, cyclosporine 类固醇、环孢霉素治疗无效的顽固湿疹

A 40-year-old woman presented to Tangs Clinical Centre in August 2004 due to persistent itching and oozing erosions on her hands and legs.(Fig.1-A) The rash had occurred 1.5 years earlier, developing later into the weeping and crusting of lesions on her legs. She was administered prednisolone 5mg, hydroxyzine 10mg and betamethasone and fluocinolone cream from September 2003 to March 2004, but the lesions were resistant to response. She was then treated with cyclosporin 100mg, cephalexin 250mg and 0.1% betamethasone & 3% clioquinol cream in April, without success. The eczematous lesions then spread to her arms and fingers.

On examination, the patient was drowsy, body temperature was 37.7°C, pulse rate 100/min and blood pressure 120/88 mmHg. There were erythematous oozing erosions, papules, microvesiculation, scaling and crusting on her legs (Fig.1-A), with similar involvement of the arms and hands: these lesions are extremely pruritic.

Laboratory investigations revealed WBC 10.3 (4.0-10.0), neutrophil 63.0 (40.0-75.0), lymphocyte 25.4 (15.0-41.0), monocyte 5.3 (2.0-10.0), eosinophil 5.3 (0.0-6.0), basophil 1.0 (0.0-1.0), haemoglobin 12.9 (12.0-16.0), haematocrit 37.2 (36.0-46.0), MCV 81.7 (76.0-96.0), MCH 28.3 (27.0-32.0), MCHC 34.7 (32.0-36.0), platelet count 387 (140-440), liver panel and renal panel all were within normal range. Patient was commenced on Tangs Derma-zema capsules 1440mg three times daily. No immunosuppressant therapy was given to the patient henceforth, and his eczematous lesions flared up in month 3 due to the potent immunosuppressants withdrawal effect (Fig.1-B). Thereafter, the patient responded to TANGS treatment very well (Fig.1-C,D,E,F,G,H). The patient achieved an EASI-75 improvement at the end of month 14 of treatment.

Features of Atopic Dermatitis

Major features

  • Pruritus
  • Rash on face and/or extensors in infants and young children
  • Lichenification in flexural areas in older children
  • Tendency toward chronic or chronically relapsing dermatitis
  • Personal or family history of atopic disease: asthma, allergic rhinitis, atopic dermatitis

Other common findings

  • Dryness
  • Dennie-Morgan folds (accentuated lines or grooves below the margin of the lower eyelid)
  • Allergic shiners (darkening beneath the eyes)
  • Facial pallor
  • Pityriasis alba
  • Keratosis pilaris
  • Ichthyosis vulgaris
  • Hyperlinearity of palms and soles
  • White dermatographism (white line appears on skin within 1 minute of being stroked with blunt instrument)
  • Conjunctivitis
  • Keratoconus
  • Anterior subcapsular cataracts
  • Elevated serum immunoglobulin E
  • Immediate skin test reactivity