“I am worried, Doc. I got eczema. It’s a problem. It hurt. Sometime it’ll get infected and I been to the hospital to get my eczema treated. They had to use IV antibiotics and everything. One time, it formed an abscess and they cut it open. Took forever to heal. I’m worried to death about this eczema. It could happen anytime. It ain’t only in one place. Sometimes it’s small and it go away. Sometime it gets worse and hurt and it stays. Maybe it’s an allergy or something. Whadda you think, Doc?”
I examine the lady. There are marks on her neck, arms, hands, tibia, and feet. None of the lesions are acutely infected but resolving inflammation of varying age overlies each punctate lesion. The diagnosis is clear, but most clear on her neck. The skin is thickened in the submandibular triangle with scarring from long-term and repeated episodes of significant irritation. The hyperpigmentation extends from each lesion and follows the veins. These are track marks.
I ask the lady if she smokes cigarettes to which she responds, “Yeah, maybe a pack a day. Ok, maybe a pack-and-a-half.” I ask if she drinks alcohol to which admits. These are warm-up questions. I ask whether she uses needle drugs to which she answers, “No, no. I don’t do that. I would not never do that.”
Sadly, it is a familiar response to me. Surprisingly, more people answer this question with honesty than not. Either way, I understand. In a few minutes, the lady will understand as well.
Completing a physical exam including heart, lungs, abdomen, and nervous system, helps her to sense that her well-being is carefully assessed. I find more than track marks to address, but they must wait for another day.
The time has come to answer her question and to reveal my thoughts. “There are a few things that cause eczema. Sometimes, eczema is caused by an over-reaction of the immune system that attacks part of the skin. Sometimes, eczema is caused by a reaction to an irritating substance like certain perfumes, lotions, or needle drugs.” To the mention of needle drugs, she makes eye contact searching for the condemnation, which is absent. The truth hovers without criticism, judgement, or rejection. Now, she understands.
I continue, “The best way to avoid this problem is to avoid the substance irritating the skin.” I hand her a topical antibiotic. “This should help prevent an infection and promote healing. But, if you continue to expose your skin to the irritant, this antibiotic will not help. In fact, your heart valves may eventually become infected. Of course, that could mean death.”
Her eyes reveal understanding and her smile shines appreciation.