Well: Think Like a Doctor: The 18-Year Rash

Think Like a Doctor

Solve a medical mystery with Dr. Lisa Sanders.

The Challenge: Can you figure out what can cause a rash that lasts 18 years?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to take on a difficult case and offer their own solution to a diagnostic riddle. This week, you'll find the case of a 40-year-old woman who had a rash on her hands that wouldn't go away. Can you help figure out what's causing it, and how she can clear it up? I will provide you with the same information her doctors had to see if you can figure out the cause of this mysterious rash.

The first reader to offer the correct diagnosis gets a signed copy of my book, "Every Patient Tells a Story," and the satisfaction of solving a case that stumped a dozen doctors.

The Patient's Story

"It's been like this for 18 years," the woman answered quietly. She held out her hands for the dermatologist to see.

"That's a long time," Dr. David Grekin murmured sympathetically as he took her hands into his own and carefully examined the red, rough, cracked skin that had come to dominate the woman's daily life.

As well as she could remember, the problem had started out as an ordinary little rash – first she got tiny little bumps that looked like they might be filled with a clear liquid. They itched, she sometimes scratched and then the skin turned shiny and hard. It was eczema, she was told by her first dermatologist, and that made sense: she had hay fever and skin that seemed to react to everything. And her mother had eczema, though not this severely.

That doctor had given her a prescription for a strong steroid cream – the first of many. She used the cream and her skin improved, but the rash never really went away. Even when she was using the topical steroid her hands were often itchy, red and chapped.

From Bad to Worse

Then, a few years ago, not long after she'd bought her first house in a small town just north of her office, the rash seemed to worsen, a lot. When she curled her fingers, the skin at the knuckles would crack and bleed. Brushing her teeth would tear open the tender flesh over the joints. Washing her hair was a nightmare as the fine strands knifed through the cuts on her hands and fingers. Housework was frustrating, with whatever she was cleaning ending up smudged with blood. Washing dishes, folding clothes or making the bed would open the cuts embedded in the creases over the joints.

The woman started wearing medical gloves during household chores. Sometimes the gloves filled up with so much blood from her cracked hands that she had to change them, lest the blood seep out the top and soil whatever she was working on.

At work, she used adhesive bandages, which she bought in wholesale quantities, to cover the barely healing cuts. Many days she had one on every finger.

Looking for Help

People she hardly knew would comment on her hands. "That looks painful" was something she heard all the time, often followed by the suggestion that she should really see someone about her rash.

She certainly tried, seeking out highly recommended doctors in Milwaukee, the biggest city near her home. In all, she'd been to nearly a dozen dermatologists and allergists. All agreed that she had eczema. All recommended steroid creams and emollients. One doctor suggested that she put the cream on her fingers and sleep in gloves to improve the penetration into her skin. That helped, but the rash persisted.

Another recommended petroleum jelly each night under her gloves. Again, helpful, but the rash remained. A third suggested one of the new powerful immune-suppressing creams along with a steroid cream. The label had a long list of scary potential side effects – she didn't care. Still, it didn't work better than the other creams she tried.

Was it something she was allergic to? She changed her soap frequently and tried every lotion on the market. She sampled the full range of laundry and dish detergents. None of that seemed to matter.

She eliminated foods: No gluten. No dairy. No meat. She was a vegan for a while. None of it helped. When her last dermatologist started talking about ultraviolet radiation, a treatment used on patients with psoriasis, she looked around once more. Surely there was someone who could help her with her rash.

A Neighborhood Doctor

At this point, she had been to all the new hot doctors, all the ones written up in the local magazines, all the ones her friends swore by. So, this time she looked for someone close. She often had to see these doctors several times a year and figured she should at least make the visits more convenient. That's how she came to the office of Dr. Grekin.

It was late afternoon when she arrived at Dr. Grekin's office. The nurse took her to a bland examining room and asked her a series of questions. She didn't smoke or drink. The only medicines she used were an antihistamine and the cream for her rash. And other than the hay fever she had no allergies. She worked in an office; she didn't have pets.

A few minutes later Dr. Grekin walked in and introduced himself. He was older than many of the doctors she'd seen, in his mid-60's. His hair was white and he had a warm, unhurried manner. She liked him immediately and with a little encouragement the whole story came out.

A New Perspective

Dr. Grekin had reviewed the patient's records before going in to see her. Although he had never met her, she'd been seen by other doctors in his practice group. The first note was from over a decade earlier. Her most recent visit was a year ago. All the doctors she saw seemed to agree – this was some type of eczema.

You can see the note from the first doctor in the practice and the most recent one reviewed by the doctor here. Dr. Grekin told me that the notes in between don't offer any additional information or insight.

A Peculiar Rash

Most eczema can be managed with the judicious use of steroid cream and moisturizers and by avoiding known triggers. When patients ended up in Dr. Grekin's office worried about their eczema, it was usually because of a misunderstanding about the chronic nature of the rash. Eczema will return when the triggers are present, but using the cream again will usually get it under control. Still, there was always the possibility that something else was going on.

The patient was a pleasant, young-looking woman, and when she told her story, Dr. Grekin realized that whatever was making her rash persist, it wasn't because she was ignoring doctors' recommendations. She was very clear about what she had done, how often she was doing it and how poorly it worked.

The rash, Dr. Grekin noted, was limited to the back of the hands. One oddity stood out immediately: the rash spared the ends of the fingers. From wrist to midway down the finger the skin was red, raw and irritated-looking. Some of the skin was shiny and thin; other areas were thickened and dull. None of the skin on that part of the hand looked normal. Each knuckle was lined with deep cracks. Some appeared to have bled recently. The entire length of the pinky on each hand was red. And yet the skin on the tips of the first three fingers — from just beyond the middle joint to the nails — looked completely normal. She had no rashes anywhere else on her body.

"Is your rash always like this?" Dr. Grekin asked – red on the back of the hand, on the knuckles and the first part of the finger but nowhere else?

Always, she assured him.

Do you wear gloves with the fingertips cut off? he asked. Never, she replied with a question in her voice.

Solving the Mystery

Dr. Grekin was quiet for a few moments, then announced, "I don't think you have eczema." He pulled over a bright light and looked hard at her fingers. "Nope, not eczema," he repeated.

Do you know what this patient has? Dr. Grekin did.

Post your answers in the Comments section. I'll post the answer tomorrow.

Rules and Regulations: Post your questions and diagnosis in the comments section. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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