Physician's Assistant

MRN:

Content:

Presenting Complaint:
Bilateral foot rash with secondary infection

Diagnosis:
Allergic contact dermatitis to bilateral feet with secondary staphylococcal infection

I had the pleasure of meeting Anais Harris, a 21-year-old lady, in our Emergency Department today.

Anais has been experiencing bilateral foot problems since November 2025. The symptoms began with swelling in her legs following a 12-hour shift at work, where she works as a carer in a residential home. She then developed a rash on the tops of both feet which she initially thought was heat-related, as she had started wearing thermal socks with her Crocs at work. She contacted NHS 111 who treated her for cellulitis.

Her GP and our dermatology colleagues (via advice and guidance) felt this was most consistent with allergic contact dermatitis, given the sharp demarcation between normal and abnormal skin following the distribution of her footwear. However, the condition has not improved despite multiple treatment attempts. Previous steroid cream (Mometasone) made the condition worse, causing the skin to become thicker and more irritated. She has had multiple courses of antibiotics including Flucloxacillin and Clarithromycin without sustained improvement. Although she only took the clarithromycin for 2 days before stopping due to foot swelling.

Over the past week, she has developed a papular itchy rash on her bilateral forearms, predominantly around the elbows, which she has been scratching. She reports feeling generally unwell with fatigue but no fevers.

She denies any oral or genital ulcers, eye symptoms, or urine infections. She lives in a house with her partner and his family and has a cat (which she has lived with for several years, predating the onset of symptoms). She has no Mediterranean ancestry.

On examination, there was an erythematous papular rash to bilateral forearms with areas of excoriation on bilateral elbows, but no ulceration or clear vasculitic component. The left anterior tibia showed no discrete swelling despite her complaints, and the recent MRI knee showed no significant pathology to my eye although the report is awaited. Bilateral feet demonstrated erythema in the exact pattern of shoe distribution with clear demarcation between normal and abnormal skin. There was evidence of superficial skin breakdown with islands of skin surrounded by areas of erythema on the soles of the feet, cracking to the web spaces and toes, with thickened skin on the plantar aspect bilaterally.

Investigations:
Blood cultures: Negative
Eosinophil count: Normal
Alkaline phosphatase: 177 U/L (previously 80 U/L in June 2025)
CRP: 15 mg/L
Urea: Normal
AST: Normal
Fibrinogen: 4.5 g/L (remainder of coagulation screen normal)
Full blood count: Normal
Neutrophils: Normal
White cell count: Normal
Venous blood gas: pH 7.4, sodium 129 mmol/L, lactate 0.8 mmol/L
Wound swab (23/01/2026): Moderate growth of Staphylococcus aureus (susceptible to Clarithromycin, Doxycycline, Flucloxacillin and Penicillin)
Knee X-ray (December 2025): Small knee joint effusion, no lipohemarthrosis, no acute bony injury
Knee MRI (February 2026): Awaiting formal radiology report - no obvious infection or significant collection visible on review

Plan:
1. Wound swab of bilateral feet sent to guide antibiotic sensitivities
2. Doxycycline 100mg PO BD for 7 days to treat secondary staphylococcal infection
3. Following treatment of infection, trial topical steroid (patient already has Mometasone supply at home from GP) - advised to persevere despite previous poor response
4. Continue Dermol 500 as soap substitute
5. Additional blood tests sent to exclude systemic vasculitis (autoimmune screen) - results pending
6. Urgent outpatient referral to dermatology for direct clinical review and consideration of patch testing
7. Codeine 30mg PO QDS PRN for analgesia
8. Await formal MRI knee report from radiology
9. Discharge home today with dermatology follow-up
10. GP to follow up blood results and chase dermatology appointment

Summary:

Investigations:

Sdec Sat 21 February 2026 09:55

Field Clipboard (for EPR paste)

Tasks

Feedback