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Dr. Nair
Dr. Nair, Dermatologist
Category: Dermatology
Satisfied Customers: 9190
Experience:  MBBS, MD (Dermatology, Venereology & Leprology)
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Why do I have a red and intensely itchy rash on shin and ankle?

Resolved Question:

I have a red, intensely itchy rash on the shin of my left leg and the outside ankle and shin of my right leg. Has been there about 4 years. Have been to several doctors without success. Cortisone creams make it worse. I have used Clobetesal several times but it doesn't help at all. Another doctor prescribed a stronger cream than Clobetesal but it got worse. Bendaryl cream usually works better at controlling the itch than anything else. It is always there, but at times it has flare ups where it gets worse - usually when I have been unusually active or stressed. But it has raised areas that are red and extremely itchy. I try not to scratch but catch myself doing just that at times. Is there any hope of some treatment to relieve this. It is not only itchy but sometimes painful and super red/painful.

Submitted: 5 years ago.
Category: Dermatology
Expert:  Dr. Nair replied 5 years ago.


Would it be possible to take a photograph of the affected area at your convenience?

Customer: replied 5 years ago.

Here is a picture of right leg. Will send another picture of left leg.

Customer: replied 5 years ago.

Left leg.

Expert:  Dr. Nair replied 5 years ago.

Thank you for the photographs. Tell me have these plaques ever been biopsied? If so do you have the report handy?

Customer: replied 5 years ago.

They have been biopsied. I do not have a report but Dr.'s office told me the biopsy report was fine.

Expert:  Dr. Nair replied 5 years ago.

Thank you for the information. By fine your doctors probably meant that skin cancer has been ruled out because otherwise there is no way a biopsy from one of your red, scaly plaques could be the same as normal skin.
I think you most likely have Psoriasis. The second possibility would be Lichen Planus Hypertrophicus and third Lichen Simplex Chronicus. Infections with certain bacteria can also look like this - e.g Lupus Vulgaris, TBVC and Leishmaniasis but these do not itch and are quite rare in the US.
Psoriasis is a predominantly a condition affecting the skin, scalp, nails, and joints. Any one or all may be involved. Normal skin has checks and measures which regulate its orderly formation. For multiple reasons this control is lost in Psoriasis and the skin turnover time reduces from 30 days to 3-4 days. The new skin that is made this fast is thicker than the surrounding skin and weaker, resulting in scaling. There are many variants of Psoriasis with the commonest one being chronic plaque psoriasis. Here are links providing more detailed information on the subject:
Treatment options are dictated by how severe and widespread or resistant the Psoriasis is - 50% or more body surface area involvement with Psoriasis is best treated with Methotrexate as is resistant Psoriasis not responding to topical measures. This is a tablet and taken once a week. A test dose of 2.5 mg is given followed by 7.5 mg per week. The dose can be titrated upwards till 30 mg per week depending on response. Results are normally remarkable and once the disease has been under control for 3-6 months Methotrexate can be tapered off slowly. Results can then be maintained by creams such as Halobetasol or Betamethasone and Daivobet ointment. Coal tar based creams can also be used.
Another option for extensive or resistant Psoriasis is Acitretin but this is much more expensive that Methotrexate and needs to be taken daily. PUVA and NBUVB are light therapies effective in the condition.
As far as over the counter products go here is what I normally recommend for patients:
1. Cortizone cream + Mg 217 sal-acid ointment twice a day (morning & evening) over all affected areas. Mix these two creams in equal proportion before applying.
2. Triton Mg 217 intensive strength medicated tar ointment: apply over skin lesions once at night. Wash off in the morning. Can stain clothing so appropriate precautions should be taken.
3. Balnetar Therapeutic Tar Bath: Add to tub of water as directed on the bottle - lie in tub for 15-20 minutes. If this is not possible then use soapworks coal tar soap bar and leave lather on for 5 minutes. Product does not smell very good and will stain clothing but is effective.
4. Omega-3 fatty acid capsules - 2 in the morning & 2 at night after meals.
5. Cap Lumitene 30 mg twice a day.
6. Olive oil or Neutrogena body oil massage to affected areas once a day. This is optional.
Tab Claritin or Zyrtec 10 mg twice a day will help with the itching.
NOTE: All of these are usually available over the counter & online at . Treatment will need to be continued for 2-3 months for maximum benefit.
Hope this information is useful, please feel free to ask if you have any queries. Regards.

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Customer: replied 5 years ago.

Is the Methotrexate prescription? How do I get that?

The Betamethasone is the other cream I have used that I didn't have any success with.

Thank you for your help.

Expert:  Dr. Nair replied 5 years ago.

You're most welcome.
Yes Methotrexate is prescription only. It anyway needs to be taken under a Doctor's supervision so I would recommend discussing it with your GP or Dermatologist.

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