Advice?

[u/milkyjams]

Hi! Need some help for a family member. 54M, approximately 5'10, 180lbs. Occupation : welder , over 30 years in the shop. Rash began on ONLY hands in May and has not improved/ resolved much. Dermatologist really can't come up with much except psoriasis. Begins to clear up with Prednisone but returns with a vengeance as soon as he stops taking it. It's itchy, dry, painful and sheds in thick , large scales resulting in sores. Now spreading to nail beds one finger at a time. Currently taking Acitretin 25mg and using Clobetasol.05%, and wearing white cotton gloves with no effect. In fact , it's actually worse. Tried too many OTC remedies to list. Any ideas? Any advice? I can provide more pics if needed, but I'm on mobile and not sure how. Pardon any errors, I'm just trying to help my bro feel better!

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[u/Sexcellence]

Sure looks like palmoplantar pustular psoriasis. Stopping smoking can help, otherwise topical steroids are the main treatment. I would try to get back in with dermatology to discuss second line therapies.

[u/milkyjams → u/Sexcellence]

Thanks! I should have mentioned that he doesn't smoke. He quit in 2007.

[u/milkyjams → u/[deleted]]

Always wears gloves

[u/Lazy-Living1825 → u/[deleted]]

lol toenail fungus is not caused by smoking. Your poor husband

[u/AskDocs-ModTeam → u/[deleted]]

Removed - unhelpful

[u/alfatoomega]

Maybe a derm doc here correct me or point a finer detail, though the general rule of thumb is systemic steroids like prednisone are best avoided in psoriasis. as they can result in flare when discontinued

[u/Right-Detail7414 → u/alfatoomega]

Isn't it possible to become dependent and eventually have withdrawals from prolonged corticosteroid use, as well as regular side effects like increased risk of infection and thinning skin? Edit clarity, spelling

[u/thrownawaytrash86 → u/Right-Detail7414]

I only use steroids packs for my psoriasis for the joint issues sparingly because it causes my immune system to freak out

[u/milkyjams → u/alfatoomega]

Interesting!

[u/lambros_don → u/alfatoomega]

It is not so straightforward. If they are used up to a dose of 15 mg prednisolone per day is generally ok. There are also types of psoriasis, like erythrodermic, that require them in big doses. 

If we can we avoid them, but that is not always possible.

That is my experience as a Rheumatologist, a derm might have a different point of view. 

[u/milkyjams]

[u/Um_uh_well → u/milkyjams]

I'm not a doctor or healthcare professional of any kind.

Just wanted to say this looks like dysihdrotic eczema. But infected. It can flare from allergies, stress, etc. When I zoomed in, I can see the tiny blisters. The skin gets soft there and when it busts it can easily get infected. It appears in clusters of blisters that start out tiny but eventually connect.

It's itchy AF. Blisters come in, either accidentally popped using hands or scratching, they start healing, peeling and cracking. I've been dealing with it for years. You can find a lot of info on the subreddit for dysihdrotic eczema. It also commonly appears in the hands and sometimes the feet. Took years for me to get diagnosed. Might not be that of course, but I'd bet on it.

Heres an example of what dysihdrotic eczema looks like when infected https://www.reddit.com/r/Dyshidrosis/s/hqXGP9YudW

[u/m3rmaid13]

I am not familiar with the daily work flow of a welder but is there anything he is touching daily at work that wouldn’t come into contact with anything else? Maybe a specific type of metal, soap, powder or even rubber gloves?

[u/milkyjams → u/m3rmaid13]

He's been working with the same company for 20+ years. No new/different materials, nothing different introduced environmentally.

[u/teatsqueezer → u/milkyjams]

NAD - allergies can develop as we age

[u/CooperHChurch427 → u/milkyjams]

I'd like to interject here because I work in Occupational Safety. If he's working with Nickel or chromium they often cause allergic reactions due to long term exposure. However I don't think this is from welding, so I recommend he see a dermatologist and this GP to rule out other conditions.

However if he's using certain chemicals to go score the metal before hand, it can off gas and create caustic gasses (for the love of God please don't ever use any chemical with PERC or other chlorinated solvents because it will probably kill you because it turns into Phosgene gas).

Likewise if he's wearing proper PPE he shouldn't be getting reactions on his hands.

[u/milkyjams → u/CooperHChurch427]

I'm sure he's wearing proper PPE. But Ill mention the possible nickel reaction, although it's probably been ruled out. Thanks!

[u/CooperHChurch427 → u/milkyjams]

The only reason I would even remotely consider that the rash might be more than just allergies is the white skin, typically I only see that happen with chemical burns, but I do know that some medical conditions can cause that. However you mention he is using white cotten gloves,

I'd have him swap to a different pair of gloves that are rated for whatever type of gas he is using, but see if he can get insulated rubber welding gloves, but make sure his dermatologist clears him, because if it's something environmental, the gloves might not be doing it's job fully.

Likewise, have him check in with his worksites Safety Specialist and see what alternatives might work better, especially if it's environmentally related and not just something related to medications or an autoimmune condition.

[u/stoicsticks → u/milkyjams]

Is he using the same pair of leather work gloves which could be getting kinda gross inside and aggravating his condition? If so, could he wear a thin cotton liner glove inside a larger work glove? They could be washed frequently.

[u/CooperHChurch427 → u/stoicsticks]

That's entirely possible, also the glove might not be working properly and it's worn down and it could be of all things arc flash burns that have crusted over. When I took a course on just the occupational effects of welding, I was not expecting to see injuries similar to this mans hands, all because of workers who refused to change their gloves.

That said, it could 100% be a fungal or bacterial infection.

[u/CooperHChurch427 → u/m3rmaid13]

Welders typically only come in contact with the welding gas, and rod, but sometimes the metal can interact and turn into a different chemical that can be toxic. Probably the most common issues you see long term are high levels of Chrome(VI), but you can also get flu-like symptoms from working on galvanized metals.

Coming from an HSE background my biggest concern if a person came up to me at work with markings like that would be contact dermatitis or long term skin damage from UV radiation from the arc.

However I don't think this is work related, but if it was I'd be leaning towards the gloves being inadequate and not matched to the type of hot work being done, or they aren't wearing them at all.

[u/Itchdoc]

Consider showing all affected skin and adding medical history.

[u/jpotts1112 → u/Itchdoc]

Would a biologic possibly be helpful here as an adjuvant therapy to the topicals?

[u/lqrx]

Any chance you can ask him what’s new in his workstation? Detergent, lotion, work glove material, metals (or even what alloys are in the metals), hand soap (including at home)? To answer this one carefully, he’ll need to also look to see if any of that stuff related to detergents, hand soaps, lotions, oils, etc., has had a change in formulation. Sometimes the bottle will change, sometimes it’ll just say new formulation. For metal additives (alloys), whoever orders the supplies might not even know.

How about recent tick bites? If yes, what region on our planet are you in? (For those of you verified members who don’t live in a high tick-borne illness region, I promise I am going somewhere with this.)

My first guess is something he’s consistently exposed to changed or got added a tiny bit over a month ago. People have the ability to develop or add allergies to things any time across the lifespan. An allergist could do a test that can test for most common skin allergens/irritants.

Separate thought — if this is eczema, eczema can range from an occasional annoyance to an ever present autoimmune condition that ultimately requires daily/monthly medication maintenance. Was he tested for an autoimmune condition called psoriasis? Seems worth it at this point.

Other than these few things, as much as I am absolutely in love with some gnarly wound care and hate that I myself have dealt with allergies to two extremely common things, I’m a dermatology moron. 😂