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This hypersensitivity reaction may be secondary to medications, infection, collagen-vascular disorders, or an occult malignancy. When it is localized to the skin, prognosis is excellent. 

Cutaneous Leukocytoclastic Vasculitis

A 13-year-old girl with known eczema presents with a vesicular rash on her palms that appeared after swimming in the ocean. Skin is tender; vesicles ooze clear liquid. Treated with triamcinolone w/o effect. Watch real-time examination on video.

A. Acute palmoplantar eczema (dyshidrotic eczema)

VIDEO: The child's hands are chronically dry but the skin has recently begun to crack; vesicular rash appeared after an ocean swim. Dx?

Clinical Topics

A 13-year-old Girl with a Vesicular Rash on Palms 

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma.

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma. The violaceous color and configuration of the skin lesions suggests which of the following? 

Hard Purple Nodules: Your Dx?

Guidance for PCPs: Streamlining Menopause Care

The following transcript has been edited for clarity, style, and length.

For our practitioners watching today, thank you for taking the time to view this discussion. There’s a lot of complex information here, and our goal is to clarify it as much as possible. A common challenge is streamlining these conversations with patients, as spending hours with each patient isn’t practical. Lisa, what strategies would you suggest for busy practitioners to streamline these discussions?

For my colleagues in internal medicine, family medicine, and primary care, I’d first like to emphasize the importance of asking your midlife patients about vasomotor symptoms. The menopause transition is a critical time to assess cardiovascular risk and focus on long-term health and wellness. Women experiencing vasomotor symptoms are at increased cardiovascular risk, so it’s much more than a lifestyle issue.

Remember that the U.S. Preventive Services Task Force is clear: hormone therapy isn’t indicated for primary prevention. However, that’s different from addressing the symptomatic menopausal patient in front of you who may not be sleeping, is experiencing sexual dysfunction, and is generally miserable.

I suggest a “red, yellow, green” approach to categorize patients:

 These are women who are symptomatic with moderate to severe vasomotor symptoms, are close to menopause (within 10 years of their final menstrual period), and have no significant cardiovascular risk factors, clotting history, or elevated breast cancer risk. For example, the 52-year-old sitting in front of you who is miserable but otherwise healthy—she’s a great candidate for menopausal hormone therapy.

 These are women with clear contraindications to hormone therapy, such as a history of breast cancer, thromboembolic events, high cardiovascular risk, or prior cardiovascular events like a stroke. For these patients, focus on non-hormonal options, such as 

, along with other off-label non-hormonal treatments.

 These are the intermediate cases. These women may have some risk factors that require a more nuanced discussion and consideration of patient preferences. If this isn’t your area of expertise, consider referring these patients to a provider specializing in menopausal medicine.

Using this framework can help streamline your approach and build confidence in using FDA-approved non-hormonal options for patients who cannot or will not use hormone therapy.

Exactly. For those “yellow category” patients who don’t have clear indications for or against hormone therapy, it’s essential to connect with specialists in your area for guidance. If you’re unsure who those people are, I strongly recommend visiting 

, the website of the Menopause Society. They provide a directory of certified menopause practitioners who are well-versed in this area and can assist with patient care.

And if you’re looking to deepen your knowledge, I encourage you to join the Menopause Society. Attend our annual meeting or the Menopause 101 course to learn more and enhance your ability to support these patients.

Yes, becoming a member of the Menopause Society is an excellent way to stay current and build expertise in this critical area of patient care.

. We hope you’ve found this discussion valuable!

Panelists discuss strategies for simplifying complex information for primary care physicians (PCPs), provide tips on how PCPs can effectively communicate evidence-based treatment options to patients, and outline actionable points and key takeaways to enhance patient care in managing menopause symptoms.

Nonestrogen Treatments for Menopause

 For women who cannot or choose not to take estrogen therapy—whether due to anxiety, personal preference, or medical contraindications—there are alternatives available. Some of these options include medications traditionally used off-label for managing hot flashes. For instance, low-dose antidepressants, including SSRIs and SNRIs, gabapentin, and even certain bladder anticholinergics, have shown varying degrees of effectiveness.

However, these medications often come with side effects that can exacerbate existing menopausal symptoms. For example, SSRIs may cause weight gain and reduced libido, which are common complaints from menopausal women. Gabapentin can lead to bloating or fatigue, and anticholinergics may worsen dry mouth and constipation. These side effects often make such treatments less desirable.

This is where a newer category of medications, NK3 and NK1 receptor antagonists, stands out. They are specifically effective for hot flashes and, importantly, do not come with the common side effects of older medications. Another remarkable attribute of these drugs is how quickly they work—patients often notice improvement within one to two weeks. This rapid response can help sustain patient morale and compliance, offering a welcome alternative to traditional off-label treatments.

 I’d like to add to that by encouraging everyone to consult the 2023 non-hormonal position statement from the Menopause Society. This document thoroughly reviews the now two FDA-approved non-hormonal treatments for hot flashes, including elinzanetant, and evaluates the off-label use of other medications. It also provides an overview of lifestyle modifications, mind-body approaches like cognitive behavioral therapy, and the plethora of over-the-counter supplements marketed for menopausal symptoms.

Post-Women’s Health Initiative (WHI), we saw a significant shift away from hormone therapy. Many women turned to supplements and non-hormonal options, including SSRIs, which primary care providers often recommend for hot flashes. However, the data supporting these supplements is limited, and the Menopause Society ultimately does not recommend them due to a lack of robust evidence.

That said, many patients still want to try supplements, especially if they’re pursuing a more natural approach. While I generally don’t oppose patients experimenting with supplements, I’m cautious when it comes to those with complex medical histories or who are on medications like tamoxifen, aromatase inhibitors, or multiple blood pressure drugs. In such cases, potential drug interactions are a significant concern.

 We haven’t even touched on compounded hormones yet, which is a contentious topic. After the WHI results in July 2002, many women stopped using FDA-approved hormone therapies and turned to compounding pharmacies for alternatives. While these compounded products often relieved hot flashes, they are unregulated, lack standardized dosing, and do not come with the necessary safety warnings. This makes them less safe, particularly for patients with other medical conditions.

Panelists discuss alternative therapies for women who are not candidates for or choose not to use hormonal therapy, review nonhormonal treatment options recommended by the North American Menopause Society, and explore the growing importance of Level I evidence and consensus opinions in creating a more holistic view of available therapies, both hormonal and nonhormonal.

Alina L. Popa, MD

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