An 11-month-old girl is brought to the physician with a rash on her abdomen and cheeks that is exacerbated by constant scratching. Her abdomen and cheeks are frequently itchy, red, and scaly. Crusted lesions are present sometimes. The rash has worsened this summer, especially after bathing. There is a family history of chronic, pruritic rashes in paternal cousins and allergy symptoms in the father. Her height and weight are both tracking along the 50th percentiles. Examination shows a blanching, erythematous, scaly rash on her abdomen, back, and face. Physical examination is otherwise normal. Her parents are very concerned about the rash. Which of the following is the most appropriate response?

Question

An 11-month-old girl is brought to the physician with a rash on her abdomen and cheeks that is exacerbated by constant scratching.  Her abdomen and cheeks are frequently itchy, red, and scaly.  Crusted lesions are present sometimes.  The rash has worsened this summer, especially after bathing.  There is a family history of chronic, pruritic rashes in paternal cousins and allergy symptoms in the father.  Her height and weight are both tracking along the 50th percentiles.  Examination shows a blanching, erythematous, scaly rash on her abdomen, back, and face.  Physical examination is otherwise normal.  Her parents are very concerned about the rash.  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be6f_a16a_8f63_19a674b11776_MD0005_00 This clinical scenario is consistent with atopic dermatitis (eczema) and is very common in children. Infants with eczema typically have pruritus, erythema, and scaly/crusted lesions on the trunk, extensor surfaces of the extremities, cheeks, and scalp; diaper areas are usually spared. The pathogenesis involves genetic defects in protein and lipids that normally act to keep the epidermis hydrated and protected. However, disruption of this barrier results in an inflammatory reaction to triggers such as excessive bathing, irritating detergents, and extreme temperatures. Management requires compulsive elimination of triggers and frequent emollients to provide a barrier and restore hydration. If emollients are inadequate, topical steroid creams/ointments may be applied on the body. Low-potency steroids are preferred on the face and skin folds due to risk of skin atrophy. (Choice A) Staphylococcus aureus colonization is associated with atopic dermatitis and may contribute to exacerbation by locally-acting staphylococcal superantigens. Eczema is a risk factor for impetigo (honey-crusted lesions) and cellulitis (focal erythema, warmth, swelling), which require antibiotic treatment. These diagnoses are unlikely based on this patient's examination. (Choice C) Eczema is a clinical diagnosis based on history and physical examination. Although serum IgE levels may be elevated, laboratory testing is not recommended or necessary to confirm the diagnosis. (Choice D) Wiskott-Aldrich syndrome is an X-linked disorder associated with severe eczema, but these patients are immunocompromised and have severe bleeding from thrombocytopenia. Eczema may have a genetic basis based on twin studies, but there is no evidence that the condition alone is inherited in an X-linked pattern. (Choice E) Atopic dermatitis typically clears in nearly 40% of patients by adulthood, but unlike infections, protective antibodies do not play a role in this disease process. Educational objective: Atopic dermatitis in infants typically presents with pruritic, scaly, erythematous lesions on the trunk, cheeks, scalp, and extensor surfaces of the extremities. Diagnosis is made clinically. Avoidance of triggers and compulsive use of emollients are the first-line treatments. Corticosteroids are often indicated to treat exacerbations. References: What's new in the topical treatment of allergic skin diseases (http://www.ncbi.nlm.nih.gov/pubmed/25061854) Evaluation of the child with atopic dermatitis (http://www.ncbi.nlm.nih.gov/pubmed/22093041)

An 11-Month-Old Girl Is Brought to the Physician with a Rash