ABSTRACT
A 59-year-old white female who was previously fit and well, developed gradual tightening and thickening of the skin on her forearms progressing to the abdomen, chest and lower legs associated with restricted movement. She also noticed bruise-like patches on her trunk. There were no systemic symptoms and no history of Raynaud syndrome. Since the beginning of the COVID-19 lockdown, the patient had engaged in increasing amounts of exercise compared with normal;this included yoga once weekly for 75 min, high-intensity interval training for 20 min on alternate days, running three times weekly for 45 min, lifting 2.5 kg weights for the arms every day and regular long walks. Examination showed a 'groove' sign on her forearms and a peau d'orange appearance of the skin with a woody induration and hardness on palpation. Symmetrical and circumferential involvement on the forearms and lower legs and bruise-like indurated patches on the abdomen were noted. Differential diagnoses included eosinophilic fasciitis (EF), morphoea, EF/morphoea overlap, scleroderma, scleromyxoedema and nephrogenic systemic fibrosis. Blood investigations showed an eosinophilia of 1.2 x 109 cells L-1, erythrocyte sedimentation rate of 31 mm h-1, a C-reactive protein of 20 mg L-1 and negative autoimmune and viral serology. She underwent two incisional biopsies down to fascia. The first was taken from the back, which showed an interstitial inflammatory cell infiltrate composed of lymphocytes, plasma cells and very occasional eosinophils. The subcutaneous septa were minimally thickened. The second biopsy taken from the left forearm showed striking thickening of the subcutaneous septa, with an associated inflammatory cell infiltrate, composed predominantly of lymphocytes and plasma cells. This process was deeper and more established than that seen in the biopsy from the trunk. The appearances were clearly those of a sclerosing process of the dermis and subcutis and consistent with eosinophilic fasciitis. Our diagnosis was EF with morphoea overlap and she was treated with oral methotrexate 15 mg weekly and oral prednisolone 50 mg once daily (weight 60 kg), reducing the dose by 5 mg every 2 weeks. An 80% improvement was seen in functionality within 3 months, but the skin remained tight and thickened and therefore the patient was referred for phototherapy [ultraviolet A 1 (UVA1)] as combination therapy. We present a rare case of EF, which appears to have been triggered by intensive exercise. Other causes include insect bites, radiation, infections (Mycoplasma and Borrelia) and paraneoplastic. Haematological associations have been seen, including aplastic anaemia and lymphoma. Treatment options for EF include prednisolone, UVA1/psoralen + UVA, immunosuppressive systemic agents (including ciclosporin and methotrexate), biological agents (including infliximab and rituximab) and physiotherapy.
ABSTRACT
Introduction: An acute increase of dermatologic conditions occurred in National Healthcare System (NHS) health care workers (HCW) during the SARS-CoV2 outbreak. Novel “skin wellbeing” clinics were established to support colleagues. Methods: HCW self-referred to dermatologists during an 8-week period in spring 2020. Clinics were supported by clinical nurse specialists in tandem to a publication of a departmental advice leaflet. Attendees were provided with samples of emollients, dressings, prescriptions and consultations free of charge. Results: A total of 90 electronic medical records were analyzed retrospectively. Parameters included age, sex, ethnicity, diagnosis, previous history, interventions, and investigations. Of 80 new attendances, the commonest complaint was hand dermatitis (57;71%) followed by (PPE) related skin conditions (33;41.3%) and flares of pre-existing skin disease (15;18.8%). A total of 197 separate prescription items were issued. Topical corticosteroid prescriptions were comprised of mild (9), moderate (23), potent (27) and very potent (14) preparations, 4 combined with calcipotriol monohydrate, fusidic acid 2%, miconazole nitrate 2% and clotrimazole 1.0%. Other topical preparations included ketoconazole 2% (1), tacrolimus 0.1% (3), ivermectin 1% (1), azelaic acid 15% (1), adapalene 0.1% (1), adapalene with benzoyl peroxide (1), and combined clindamycin 1% with benzoyl peroxide 5% (8). Oral prescription medications included lymecycline (1) and doxycycline (1). Remaining items included emollients, soap substitutes, cleansing solutions and barrier creams. Discussion: Our study demonstrates a significant burden of occupational dermatologic disease in HCWs as a direct consequence of the pandemic. We discuss measures implemented locally to aid staff recovery and share our experience.