Case Studies

Case 4 - A child with a dry itchy rash

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This 6-year-old girl presented with a history of a progressive dry itchy rash on her arms, legs and neck since the age of 3 months. Apart from a history of mild asthma well controlled on salbutamol inhalers as required, she was well. Both her parents gave a history of hay fever and her older brother had a history of asthma.

• (a) Describe what you see in the clinical images?

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  Dry erythematous lichenified skin on the forearms and lower limbs with involvement of the flexures.

• (b) What is the most likely diagnosis?

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  Atopic dermatitis.

• (c) What is the aetiology underlying this skin disease?

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  The aetiology of atopic dermatitis is multi-factorial with genetic and environmental influences, epidermal barrier defects, penetration of exogenous agents into the skin and activation of the immune response.

• (d) Is her family history relevant to her skin disease?

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  Yes. Atopic diseases include atopic dermatitis, asthma and hay fever. Children with atopic dermatitis often have a personal or family history of first-degree relatives affected by atopic disease.

• (e) What are the potential complications of this disease?

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  Bacterial infection, often with Staphylococcus aureus causing impetigo, herpes simplex viral infection (eczema herpeticum), erythroderma and allergic contact dermatitis.

• (f) What topical treatments would you consider for this child?

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  Regular moisturising to break the itch–scratch cycle, topical corticosteroids of different potency depending on body site to control acute flares and topical calcineurin inhibitors to maintain remission.

• (g) What other treatments would you consider, if the rash is not responding to topical treatment alone?

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  Treat super-added infections with oral antibiotics and/or antiviral treatment, use of bandaging of limbs over moisturisers, zinc or topical corticosteroids, phototherapy, short course of oral prednisolone, systemic immunosuppressants (e.g. azathioprine, ciclosporin).