A 4-month-old boy is brought to the office by his father due to a severe diaper rash that has been present for 4 days and is progressively worsening. His mother has been applying over-the-counter barrier cream to the rash with each diaper change but has seen no improvement. The child attends day care, and the day care attendant advised that the rash be evaluated to "make sure it is not contagious to other children." The patient was recently admitted to the hospital for pneumonia, requiring parenteral antibiotics and intravenous fluids. He was discharged a week ago and still has a mild cough but is otherwise playful with normal appetite. The patient was born at 38 weeks gestation without complications. Weight and height are at the 65th percentile. Temperature is 36.7 C (98 F). Physical examination shows a well-appearing, interactive infant. Skin examination shows multiple erythematous, confluent, papular lesions in the diaper area, including the genitalia, buttocks, perineum, and genitocrural folds. There are also several isolated, bright-red papules with scaling beyond the diaper area on the inner thighs. There are no lesions on the chest, abdomen, or extremities. The lungs are clear to auscultation. Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 4-month-old boy is brought to the office by his father due to a severe diaper rash that has been present for 4 days and is progressively worsening.  His mother has been applying over-the-counter barrier cream to the rash with each diaper change but has seen no improvement.  The child attends day care, and the day care attendant advised that the rash be evaluated to "make sure it is not contagious to other children."  The patient was recently admitted to the hospital for pneumonia, requiring parenteral antibiotics and intravenous fluids.  He was discharged a week ago and still has a mild cough but is otherwise playful with normal appetite.  The patient was born at 38 weeks gestation without complications.  Weight and height are at the 65th percentile.  Temperature is 36.7 C (98 F).  Physical examination shows a well-appearing, interactive infant.  Skin examination shows multiple erythematous, confluent, papular lesions in the diaper area, including the genitalia, buttocks, perineum, and genitocrural folds.  There are also several isolated, bright-red papules with scaling beyond the diaper area on the inner thighs.  There are no lesions on the chest, abdomen, or extremities.  The lungs are clear to auscultation.  Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be74_3553_8f63_43f12d90035d_MD0005_00 This child is presenting with candidal diaper dermatitis, which occurs most commonly in young infants. Moisture and/or skin breakdown coupled with skin colonization by yeast (eg, Candida albicans) from the gastrointestinal tract predisposes children to infection. Children who have recently received antibiotics are at higher risk for candidal infection, as the antibiotic-mediated decrease in normal bacterial flora favors yeast production. Clinical features include "beefy" red papules and plaques in the diaper area, accompanied by satellite lesions (erythematous papules separate from the main rash). Diaper rashes from candidal infections involve the skin folds, distinguishing it from the skin-fold sparing seen in irritant/contact diaper dermatitis. Diagnosis is clinical. Treatment of candidal rashes involves a topical antifungal such as nystatin or clotrimazole. "beefy" red papules and plaques (Choice B) Powder (eg, cornstarch, talcum) should be avoided in the prevention or treatment of diaper dermatitis due to the risk of aspiration. (Choice C) Although topical corticosteroids can temporarily decrease inflammation, they are typically not used in the treatment of candidal infections. Use of high-potency corticosteroids should be particularly avoided in the diaper area due to the risk of systemic absorption and adrenal suppression. (Choice D) Mupirocin can be used for a suspected bacterial superinfection, which typically presents with pustules or honey-crusted drainage. Mupirocin is not effective in the treatment of candidal infections. (Choice E) Zinc oxide creams and petrolatum ointment are beneficial for irritant diaper dermatitis and can be used as adjuvant therapies in yeast infections. However, antifungal therapy is first-line treatment for a candidal infection. Educational objective: Candidal diaper dermatitis presents with "beefy" red plaques, satellite papules, and involvement of the genitocrural folds. First-line therapy is a topical antimycotic agent (eg, nystatin, clotrimazole). References: Prevention, treatment and parent education for diaper dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/26264797)

A 4-Month-Old Boy Is Brought to the Office by His