Pictorial case study

The case

A five-year-old girl was brought to the surgery by her mother.

The mother was concerned that the child's itchy, erythematous rash was getting worse and more weepy, despite regular application of aqueous cream.

The girl had the rash over her face, trunk and limbs. She was fretful and the scratching was causing sleep disturbance. Her elder sister had asthma and her mother had hay fever and eczema. What are the diagnosis, management and differential diagnoses?

Diagnosis and management

The child had infective exacerbation of atopic eczema. She was prescribed emollients, flucloxacillin and antihistamines. A few months later she was referred to the dermatologist to consider an immunomodulator because her eczema was not well controlled on topical steroids with and without antibiotics. Usually a bacterial infection can be acquired on top of the eczema, but sometimes a herpes virus infection or molluscum contagiosum can occur.

The tendency to asthma, eczema, urticaria and hay fever is largely genetic.

Atopy is characterised by an overactive immune response to environmental factors. Atopic eczema affects three per cent of pre-school children.

Mild to moderate atopic eczema can be managed with emollient. Topical steroids should be used to reduce itch and inflammation.

Possible different diagnoses

- Infantile seborrhoeic dermatitis.
- Impetigo.
- Eczema herpeticum.
Differential diagnosis
Infantile seborrhoeic dermatitis
- Generally occurs in infants a few months old.
- The lesions are well defined, with yellowish, greasy scales.
- The scalp, face, nappy area, trunk and axillae are typically affected.
- Itching is mild. The child is usually not bothered by the rash.
- The rash clears in a few weeks.

Contributed by Dr Vasa Gnanapragasam, a GP in Sutton, Surrey.

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