A 7-year-old boy is brought to the office to follow-up on a flare of atopic dermatitis. Ten days ago, the patient was prescribed a medium-potency topical corticosteroid for 2 eczematous plaques on the left leg that were intensely pruritic. His parents have been appropriately applying the medication twice a day and have also continued to apply topical emollients twice a day as maintenance therapy. Vital signs are normal. Skin examination is shown in the exhibit. Which of the following is the most appropriate next step in managing this patient?

Question

A 7-year-old boy is brought to the office to follow-up on a flare of atopic dermatitis.  Ten days ago, the patient was prescribed a medium-potency topical corticosteroid for 2 eczematous plaques on the left leg that were intensely pruritic.  His parents have been appropriately applying the medication twice a day and have also continued to apply topical emollients twice a day as maintenance therapy.  Vital signs are normal.  Skin examination is shown in the exhibit.  Which of the following is the most appropriate next step in managing this patient?

Quizplus · Accepted Answer

11ec25c8_d63f_e0d7_bc81_05feb361f0cb_MD0003_00 This patient had an acute flare of atopic dermatitis, which was appropriately treated with a topical emollient and corticosteroid. Lack of improvement after appropriate therapy should raise suspicion for an infectious complication. In this case, the patient's weeping, honey-crusted lesions indicate secondary impetigo. Atopic dermatitis is a chronic condition that predisposes patients to microbial infection due to a compromised skin barrier and underlying immune dysfunction. The intense pruritus of an atopic dermatitis flare facilitates entry of pathogens through the defective epidermal barrier due to damage in the skin from scratching. Staphylococcus aureus is the most common pathogen because most patients with atopic dermatitis are colonized with this bacterium. The classic presentation of impetigo includes papules, pustules, or vesicles that break down, causing golden crusting, weeping, or purulence, as seen in this patient. Lesions may be painful or itchy. Treatment of impetigo includes topical mupirocin for localized infection or oral antibiotics (eg, cephalexin) for widespread infection. Ongoing infection perpetuates inflammation, often making atopic dermatitis resistant to conventional therapy without treatment of the superinfection. golden crusting (Choices A and C) Pimecrolimus, a topical calcineurin inhibitor, is second-line therapy for atopic dermatitis and should be considered for flares refractory to topical corticosteroids and without evidence of infection. For severe atopic dermatitis flares, a short course of oral prednisone can be considered but is rarely indicated, particularly in young children, due to systemic side effects (eg, growth suppression, weight gain). This patient's golden-crusted lesions suggest infection, not refractory atopic dermatitis. (Choice D) Irritants/allergens in emollients (eg, fragrances, preservatives) may cause or exacerbate atopic dermatitis flares. However, the presence of golden crusts makes contact dermatitis unlikely; therefore, discontinuation of emollients would likely worsen this patient's underlying atopic dermatitis. (Choice E) Wet wrap therapy uses wet clothing to cover skin treated with emollients or topical corticosteroid to enhance hydration and medication absorption; high-potency corticosteroids are typically avoided due to increased systemic absorption with occlusion. Moreover, this therapy is reserved for widespread or severe atopic dermatitis and is contraindicated with concurrent infection. Educational objective: Atopic dermatitis often has infectious complications (eg, impetigo) that should be considered when standard therapy (eg, topical corticosteroids) for a flare is ineffective. Impetigo classically presents with golden crusts, weeping, or purulence, and treatment involves topical mupirocin or oral antibiotics. References: Atopic dermatitis: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/32412211)

A 7-Year-Old Boy Is Brought to the Office to Follow-Up