"Itchy red" A case of severe atopic dermatitis, impetiginized

BRIEF HISTORY

This is a case of a 1 year old female who came to the emergency department due to rashes.  The condition started two days prior to admission when the patient was noted to have neck and circumoral erythema that progressed to involve the armpits and inguinal area. This condition was claimed to have happened few hours after consumption of Pasta. The following day the patient was seen itching with notable thickening of rashes. Patient sought consult and was found to have dry erythematous plaque on the neck, circumoral, nasal, armpit and inguinal areas. She was initially diagnosed of having Hypersensitivity reaction secondary to food intake and was given Diphenhydramine IM at 1mkdose. Relief of symptoms was noted and patient was subsequently referred to a Dermatologist who prescribed Cetirizine syrup OD and Hydroxyzine OD. Few hours prior to admission, the patient became irritable and was noted to have symptoms which progressed to involve the eyes, back and trunk. This prompted the mother to bring the patient to the emergency room, hence admitted. She has no allergy to food and drugs. Patient was hospitalized on November 2009 (2 months before the onset of rash) due to acute gastroenteritis and was given Cotrimoxazole for 1 week. History of skin asthma was noted on her elder sister.

PHYSICAL EXAMINATION

Patient was awake, irritable and not in cardio respiratory distress. The vital signs were stable. There was diffuse erythema and wrinkled plaques involving the trunk, back and armpits and erythematous papules and plaques with crusting and excoriation on periorbital, nasal and circumoral area with serous exudate. There was bilateral conjunctivitis with mucopurulent eye discharge and dry cracking lips. The rest of the physical examination was unremarkable.

Fig. 1. Diffuse erythema with wrinkled plaques and desquamation

 on trunk, armpits and neck.

Fig. 2. Erythematous papules and plaque with wrinkling, crusting and excoriation on periorbital area; Bilateral conjuntivitis with mucopurulent eye discharge

Fig. 3. Erythematous papules and plaque with crustingand excoriation

on circumoral and nasal area with serous exudate; Dry cracking lips.

SALIENT FEATURES

1. 1 year and 7 months old
2. Female
3. Afebrile
4. Exposure to Sulfamethoxazole
5. (+) Family history of skin allergy
6. No allergy to food
7. Solitary ulceration on oral mucosa
8. Purulent conjunctivitis
9. Skin lesion:
• Generalized erythema begins on the face then progressed to involved the trunk and extremities
• Pruritic papules and plaques with excoriation and desquamation
• Nikolsky sign (?)

DIFFERENTIAL DIAGNOSIS

1. Acute Exfoliative Dermatoses

1.1. Drug Induced

• Steven's Johnson Syndrome
• Toxix Epidermal Necrolysis

Discussion on SJS and TEN

• Occur at any age
• Frequently affects women
• Fever precedes mucocutaneous lesion by 1-3 days
• Lesions begins within 8 weeks after the onset of drug exposure
• Sulfamethoxazole is a high risk drug
• 90% mucosal involvement and many on more than one site
• Skin lesion:
• Eythematous, dusky red macules; atypical target lesions
• Tender, non-pruritic
• Nikolsky sign (+)

A. Sample picture of patient with SJS/TEN showing extensive erosions and necoris of lips and oral mucosa

B. Sample picture of patient with SJS/TEN showing erythematous dusky red macules with atypical target lesion

2. Infectious Desquamating Eruption

2.1 Erythema multiforme

Discussion on EM

• Occur at any age
• Equal sex distribution
• (-) Fever
• Typically preceded with HSV or mycoplasma infection
• Infrequently related to medication exposure
• Rare mucosal lesions
• Skin lesion:
• Wheal like erythematous papule or plaque
• Typical target lesion with 3 zones
• Initially acral distribution
• Nikolsky sign (-)

Picture C. Sample picture of patient with EM showing target lesion consisting of three zones: a central dusky discoloration or bulla, surrounded by a pale-colored edematous ring encircled by erythema.

2.2. Non bullous impetigo  

Discussion of Non bullous impetigo

• Children of all ages
• Equal sex distribution
• (-) Fever
• Skin lesion
• Pruritic lesion
• Lesions typically begin on the skin of the face
• Erythema and crusting on the nose and circumoral area
• Localized

Picture D. Sample picture of patient with non bullous impetigo showing erythema and crusting on the nose and moustache area which can spread to involve the entire centrofacial region

2.3. Staphylococcal Scalded Skin Syndrome

Discussion on SSSS

• Most common in infants and children
• Equal sex distribution
• Febrile
• Purulent conjunctivitis
• Skin lesion:
• Initially diffuse erythema, scarlantiniform rash
• Superficial tissue paper-like wrinkling of the epidermis progresses to large flaccid bullae in flexural and periorificial surface
• (+) Nikolsky sign

Picture E. Sample picture of patient with SSSS showing indistinct erythema and characteristic crusting with superficial erosions on the face

3. Exfoliative Dermatitis

3.1. Atopic dermatitis

Discussion on AD

• More common during early infancy and childhood
• Equal sex distirbution
• Afebrile
• Rare mucosal involvement
• Commonly associated with family history of atopy
• Skin lesion:
• Pruritic
• Pronounced weeping and crusting of eczematous lesions
• Excoriated papules and crusting in an acute flare of atopic dermatitis
• Labial desquamation and perioral dermatitis

Picture F. Sample picture of itching patient with AD

Picture G. Sample picture of patient with AD showing pronounced weeping and crusting of eczematous lesions

INITIAL DIAGNOSIS:

Staphylococcal scalded skin syndrome VS Atopic dermatitis 

COURSE IN THE WARD

On admission and Day 1

Generalized erythematous papules and plaque with crusting, excoriation and serous exudates

Hypoallergenic diet

IVF D5 0.3 NaCl 500cc for 8 hours
Labs:

• CBC w/ platelet, ESR
• Blood CS

Therapeutics:

• Diphenhydramine 3mkday
• Oxacillin 96mkday
• Ibuprofen q6 PRN
• Miconazole oral gel TID

Day 2

Pruritic diffuse scaling and desquamation with thick rubbery consistency (trunk, back, armpits, inguinal area). Papules/plaques with crusting and excoriation on the face with serous exudates

Referred to Dermatologist

Diphenhydramine discontinued

Therapeutics started:

• 
  
  Cetirizine syrup OD x 10 days
• 
  
  Hydroxyzine syrup BID x 10 days
• 
  
  Hydrocortisone lotion BID
• 
  
  Prednisone syrup 1.2 mkdayx 7 days

Day 3

Clearing of lesions with residual erythema.

Patient still itchy.

Day 4

Significant clearing lesion.

FINAL DIAGNOSIS

Severe Atopic Dermatitis, Impetiginized