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Dr. Nair
Dr. Nair, Dermatologist
Category: Dermatology
Satisfied Customers: 9190
Experience:  MBBS, MD (Dermatology, Venereology & Leprology)
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My question is about a hockey skin disease. I mean a rash

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my question is about a hockey skin disease. I mean a rash which usually appears at spots where shield guards cover skin.
My son got it 3 years ago, when he was 8 years old. He had little rash areas on the front part of his legs. The first doctor said it should be bacteria and prescribed mupirocin (ointment USP, 2%). He also advised to wash hockey gear with bleach regular. It sounded reasonable because a lot of hockey players in our town had this problem before or at the same time including my son's teammates. The medicine worked and Ivan didn't have any rash during the summer time, when he didn't play hockey.
Next season we bought all new gear but our son soon got some rash on his legs and arms anyway. We used mupirocin and washed his gear so the problem seemed manageable.
During the last season (Ivan is 11) everything got worse. At the beginning of the season (October 2009) Ivan got a rash area on his hand (probably because of gloves?). It was growing and getting worse every week. It had bleeding cracks and looked terrible. Also Ivan got a little rash area on his forehead (maybe helmet?). We went to the second doctor in December. The Doctor said it's not a bacteria anymore it's eczema. He prescribed cloderm cream for his hand, legs and arms and something for his face I forgot. It worked, the rash was absolutely gone in two weeks. But it came again to the same spots immediately after we stopped using the medicine. We continued to apply the cream but worried that we shouldn't use steroids for a long time.
So we went to the third doctor soon (January 2010). She prescribed us triamcinolone acetonide cream. It works the same way: if we stop to use it - rash returns immediately or in a several days, even in summer, when he doesn't play hockey. Right now Ivan's hand looks much better - almost smooth skin. But there is a big rash area on his forehead which grows if we don't use the steroid cream. Also some little areas continue to appears on his legs.
We need your advise, please, - what to do now?
Thank you in advance,
Natalia Kulchitsky
Would it be possible for you to take a picture of this rash on the forehead and send me the link after uploading it to picasa, flickr or photobucket?
Customer: replied 7 years ago.
I'v uploaded pictures to picasa:

I noticed that the rash area on his forehead has a shape of a circle. But it hasn't looked like this before. Earlier the rash looked like the rash on his legs - see the pictures, please.
Have taken a look at the picture and I have a few more questions: 1. Has Ivan ever suffered from bronchial asthma or allergic rhinitis (hay fever)? 2. Is there any family history of these? 3. Does Ivan have dry skin?
Customer: replied 7 years ago.
1. When Ivan was 5 he got this diagnose, bronchial asthma, because he suffered from sever cough. About a year later he stopped to cough so I don't think he has asthma. I don't know if he has any allergis but he might have it. We checked his blood for food allergies but all the tests were negative.

2. I am his mom. I had asthma when I was a child. It's absolutly gone when I was about 20 years old. So the doctor said it's in remission.
Ivan's elder brother has a seasonal allergy, he is allergic to dandelions. All the people in our family are allergics to cats.

3. Ivan does not have dry skin.

4. I understand that my son may have an individual reaction to sometghing. But I'd like to reminde you that almost all boys from his hockey team have the same skin problems starting from their legs and it doesn't depend on their family history. Nevertheless not everyone has it as bad as Ivan has.
Ivan seems to have an Atopic Diathesis. This is basically a condition where the body's immune system is hyper reactive to common environmental stimuli (this can include clothing, cosmetics, animal dander etc). His family history is corroborative (bronchial asthma and allergic rhinitis/seasonal allergy). The exact name for his skin rash would be 'Discoid Eczema'. The rash that you described on his hands is also a typical feature. The round patch on his forehead may also have secondary tinea (fungal) infection. A fungal scraping for KOH examination will confirm or refute this. The good news is that Atopic dermatitis starting in childhood is a self-limiting condition, worse in the winters, but ultimately disappearing after a few years. I don't have an explanation for the other boys having the same condition, in all likelihood that may have been a bacterial infection they all had. This is definitely not that. Management includes:
1. Daily use a good moisturizer - at least twice a day
2. Flovent cream (Fluticasone propionate) twice a day till rash disappears, then once at night for 14-28 days after that.
3. Tacrolimus ointment is a more long term option if the rash recurs.
4. Omega three fatty acid capsules - once a day
5. Tab Levocetrizine 5 mg once a day
6. Soap free body wash ( Nivea makes a good one) for bathing - avoid soaps as much as possible
These are prescription drugs. I would recommend seeing your family physician or dermatologist and discussing my recommendations. Hope this helps.
Customer: replied 7 years ago.
Thank you for your reply! Everething seems reasonable in your explanation.
I have a question about your prescription. Why do you think Omega 3 and Tab Lvocetrizine are necessary?
Tab Levocetrizine is for symptomatic relief from itching. It is not an essential part of treatment and need only be taken if the itching is bothering Ivan. Omega three fatty acids are available OTC and are quite wonderful in that they help the skin make an anti-inflammatory lipid that helps in the acute phase by decreasing redness and later when taken as a daily health supplement decreases the chances of the rash coming back recurrently. Would you like me to point you in the direction of some reading material on Atopic Dermatitis?
Customer: replied 7 years ago.
Thank you again!

May be the technology worked wrong but I don't see my last question. You probably didn't get it either.
I asked about moisturizers: which of them you think are good? We have CeraVe, is it fine? What else could you recommend?

Also I'd like to ask you to write the exact concentration of Fluticasone propionate in the creams we should use for Ivan's face and for his arms and legs. (For example, we used ointments with various concentration of Triamcinolone: 0.5%, 0.1% and 0.05%.) I am afraid our phisition might not know it and a dermotologist is not available in our town.
I am also wondering what is the difference between Flovent cream and previous steroids. Is it stronger or just different?

And yes, I'd like to read more about Atopic Dermatitis if you could advise me a good source.

I am sorry my question is so long. But I am greatly appreciate your help. Your answers are excellent!
No your last question did not post. I looked up CeraVe and it seems adequate. Other brands that I like are Jergens Naturals Ultra Hydrating daily moisturizer and Cetaphil moisturizing lotion.
Flovent (Fluticasone propionate) is available in a strength of 0.05%. There is nothing particularly special about the steroid apart from the fact that it is of mid potency, thereby avoiding the side effects of stronger steroids, but still working very well. Tacrolimus ointment is available in a strength of 0.03% and 0.1%. I would recommend starting with 0.03% once Flovent is tapered - continued for 2-4 weeks to prevent a flare.
Here are some excellent resources regarding Atopic Dermatitis - 1. ; 2. ; 3. . Many thanks for the appreciation!
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