Rash Decisions

Contributed by readers • Edited by Sheldon Jacobson, MD

A 22-year-old man presented to the walk-in clinic of a community health center, complaining of an itchy rash in his groin that he claimed to have had for more than a year. During that time, he had tried several topical medications, including repeated treatments with steroid and antifungal creams, none of which provided any relief. A review of the patient's chart documented multiple visits to the clinic for groin itch during the preceding year. He had been seen by a variety of clinicians, including family practitioners, internists, and a dermatologist. Among the several diagnoses that had been made were tinea curis, lichen simplex chronicus, and eczema.

On physical examination, the patient was a healthy-looking man. He had no other relevant medical history. He reported no allergies and was not taking any medications. The clinician who examined him discovered that he had, in fact, no rash, and asked exactly what was bothering him. The patient pointed to "bumps" that he perceived were present on completely normal-appearing scrotal skin.

In further discussion, the patient revealed that the itching in his groin provoked feelings of anger and frustration. These emotions were so overwhelming that he regularly "broke things," he said, in order to relieve his tension. He described having temper tantrums one to three times a week.

The patient was referred to a psychiatrist, who prescribed an antipsychotic medication. On follow-up two weeks later, the patient happily reported that his symptoms had improved for the first time in the history of his condition.
 

COMMENT

This patient fell victim to two common failings of the medical profession. First, the busy physicians who saw him for his seemingly simple complaint did not review his chart. Thus, they repeatedly misdiagnosed his problem despite ample documentation of previous ineffective treatments. Second, mental illness was never considered in the differential diagnosis—despite the total absence of any physical manifestation of the purported symptom. The obsessive quality of his thinking, coupled with his anger and temper tantrums, were important clues that were missed by multiple physicians. Somatic complaints that have no basis in reality can be the presenting symptom for many psychiatric disorders. In their haste to treat what appeared (by narration, not demonstration) to be a straightforward complaint, these physicians missed the more subtle underlying problem.

Of course, one must consider that there are a number of organic causes of pruritus without a rash, including diabetes mellitus, polycythemia vera, HIV, liver or kidney failure, and most commonly, xerosis (dry skin). These entities should be ruled out before ascribing pruritus to purely emotional factors.