DIAGNOSING AND TREATING A PAINFUL RASH AT SEA
A Nurse recounts her experience with a tricky diagnosis, 10 days from a possible shore-side evaluation
On 14th October 2017, I was the onboard nurse for a 100M+ motor yacht. We were in transit from Turkey to Dubai, and were just approaching the Suez Canal when I received a call from John while he was on Bridge watch with an officer.
John, a 27-year-old deckhand, complained of an aggressive itch along his neck. I went to his station to conduct an initial assessment.
I was able to identify a red rash, not too dissimilar from contact dermatitis, creeping from his collar line on the right hand side of his neck towards the baseline of his hair at the back of his head. John also mentioned that he felt the itching under his armpits.
The rash was not raised, but was warm to touch (not as warm as infection) and the skin in the area appeared dry and flakey. As it was not possible to examine the axilla (armpit) at this time, I put the patient on a 7-day course of antihistamines and hydrocortisone cream 1%, with explicit instructions to use the hydrocortisone sparingly and for no longer than 1 week (as sometimes the rebound effect can be quite a nuisance with patients), and asked that he come see me for a follow up examination.
Two days later (16th October), John reported that the rash had spread, covering larger areas under both axillae. He was also experiencing “nips of pain” that he described as “tiny people pinching at the skin under his arms” and that the skin felt a little like it was sunburnt. He said the only thing that gave him any relief was taking a shower and the feeling of the water on his skin.
On the 18th of October, still mid-crossing, John’s rash had flared up significantly. His entire right-hand side – from axilla to the waistline of his trousers – had exploded in an angry red rash and dry flakey skin. It dominated the right-hand side of his body, but was also still present under his left axilla and partly tracking down his torso. The rash on the back of his neck had dissipated. Patient vital signs were all stable, no fever present.
It was at this point, due to the itching and now pain, that I no longer suspected contact dermatitis and decided to call MedAire. A kind MedAire nurse took down the case history and put me on the line with one of the MedAire doctors who happened to be an emergency department doctor. We were about 9 hours ahead of Arizona at this point, so it was probably some awful hour of the morning at the MedAire facilities. But, as they’re a 24/7 operation, the doctor and nurse we spoke with were on duty, focused and prepared to clearly explain what they believed to be the cause of John’s symptoms.
As the hydrocortisone cream had not helped my patient and instead, appeared to have caused a flare up, the MedAire doctor explained that my patient was likely suffering from Intertrigo; an inflammatory fungal condition of skin fold. The condition is induced or aggravated by heat, moisture, maceration, friction and lack of air circulation.
The doctor continued that the condition commonly affects the axilla, abdominal folds, neck creases etc. and that it is usually chronic with an onset of itching, burning, pain and stinging – and that the mild lesions may progress to crusting. And, as hydrocortisone can be known to help grow fungus, this may have led to the explosion of the rash on John’s torso.
I had never come across this condition in my practice, and thus would have had a difficult time diagnosing it if not for the support of MedAire.
The doctor and I discussed what antifungal treatments we had available on the vessel. I was lucky enough to have both micronzaole 2% and clotrimatzole cream courtesy of the MedAire Global MedKit. The doctor prescribed a course of clotrimazole cream to be used over the duration of 5-7 days until the patent saw results.
John was also advised to continue to avoid heat and sweating and to wear loose, soft clothing. To help stop aggravation to the skin, John was told to avoid using soap and shower gels while washing, and to keep the skin hydrated using a basic moisturizer such as e45 cream. He was also advised to do his laundry in hot water only, in case the detergents were adding to the irritation of his skin.
Through the advice and assistance of MedAire, I was able to get the patient symptom free within the following week. And, thanks to the secondary diagnosis, I now know how to treat and recognize the condition in the future.
Had MedAire not been involved, I don’t know how long John would have suffered and been misdiagnosed. While there’s always a Google search, trawling the internet using pictures and images for comparisons and “internet doctors” would most likely have yielded an incorrect diagnosis.
Even with an internet diagnosis, I would be wary and reluctant prescribing medications for patient without a doctor’s or nurse practitioner’s consultation or prescription, as this would be working outside the limitations of my knowledge and essentially using “intelligent guesswork” to grasp at the patient’s condition - which is neither good for my practice or the patients wellbeing.
Without MedAire’s assistance, the patient would have had to suffer, with only antihistamines as relief for the duration of the crossing (7+ days), and as he would have continued working in the 35 degree Celsius heat for a few more days, his condition would most likely have gotten worse until we could have him diagnosed shore side.
With the extremely knowledgeable, highly communicative members of their well-trained, multi-disciplinary health care team just on the end of a telephone – I never feel “lost at sea”. Their support and experience allows me to grow and develop as a health care professional and deliver excellent care to my crew and guests.