Dermatology
Question 139 of 180
A 20 month old boy is brought to the Emergency Department by his mother. He has a past medical history of eczema which is normally well controlled. Over the previous 2 days he has developed a new rash around his mouth. He is off his food and is febrile. What is the most likely causative agent for this child's presentation?
Answer:
Disseminated herpes simplex virus infection (eczema herpeticum) presents with widespread lesions that may coalesce into large, denuded, bleeding areas that can extend over the entire body, occasionally complicated by secondary infection with staphylococcal or streptococcal species. Fever, lymphadenopathy, and malaise are common with eczema herpeticum. It is a medical emergency, especially in children under two years of age, and requires urgent referral for diagnosis and management. It can have serious sequelae, such as eye or meningeal involvement resulting in scarring.Eczema
Dermatology
Last Updated: 12th February 2021
Atopic eczema (also known as atopic dermatitis) is a chronic, itchy, inflammatory skin condition that affects people of all ages, although it presents most frequently in childhood. It is typically an episodic disease of flares (exacerbations, which may occur as frequently as two or three times each month) and remissions; in severe cases, disease activity may be continuous. About 70% of people with atopic eczema have a positive family history of atopic disease (atopic eczema, asthma, and/or hay fever).
Clinical features
The distribution and appearance of the rash will be influenced by the person's age and the duration of the rash.
- In adults, there is generalised dryness and itching, particularly with exposure to irritants. Eczema on the hands may be the primary manifestation.
- In children and adults with long-standing disease, eczema is often localised to the flexure of the limbs, such as the bends of the elbows or behind the knees.
- In infants, eczema primarily involves the face, the scalp, and the extensor surfaces of the limbs. The nappy area is usually spared.
- Acute eczema (flares) varies in appearance, from poorly demarcated redness to fluid in the skin (vesicles), scaling, or crusting of the skin.
- Chronic eczema is characterised by thickened (lichenified) skin resulting from repeated scratching.
Categorise eczema as:
- Clear — if there is normal skin and no evidence of active eczema
- Mild — if there are areas of dry skin, and infrequent itching (with or without small areas of redness)
- Moderate — if there are areas of dry skin, frequent itching, and redness (with or without excoriation and localised skin thickening)
- Severe — if there are widespread areas of dry skin, incessant itching, and redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking, and alteration of pigmentation).
- Infected — if eczema is weeping, crusted, or there are pustules, with fever or malaise.
Differential diagnosis
Differential diagnoses of atopic eczema include:
- Psoriasis — less itchy, well-circumscribed, reddish, flat-topped plaques with silvery scales; typically symmetrical
- Allergic contact dermatitis — eczematous rash, at any site related to a topical allergen, in a person of any age
- Seborrhoeic dermatitis — red, sharply marginated lesions with greasy scales; usually confined to areas with sebaceous gland activity (for example ears, beard area, eyebrows, scalp, and nasolabial folds)
- Fungal infection — annular patch or plaque with slightly raised, sometimes scaly, border, and central clearing
- Scabies or other infestations — should be suspected when there is recent onset of an itchy rash in family
Management
- Mild eczema flare
- Prescribe generous amounts of emollients, and advise frequent and liberal use.
- Consider prescribing a mild topical corticosteroid (such as hydrocortisone 1%) for areas of red skin. Treatment should be continued for 48 hours after the flare has been controlled.
- Moderate eczema flare
- Prescribe a generous amount of emollients, and advise frequent and liberal use.
- If the skin is inflamed, prescribe a moderately potent topical corticosteroid (for example betamethasone valerate 0.025% or clobetasone butyrate 0.05%) to be used on inflamed areas. Treatment should be continued for 48 hours after the flare has been controlled.
- For delicate areas of skin (such as the face and flexures), consider starting with a mild potency topical corticosteroid (such as hydrocortisone 1%) and increase to a moderate potency corticosteroid only if necessary. Aim for a maximum of 5 days' use.
- Occlusive dressings or dry bandages may be of benefit; however, treatment should only be started by a healthcare professional trained in their use.
- If there is severe itch or urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine, loratadine, or fexofenadine).
- Severe eczema flare
- Prescribe a generous amount of emollients and advise frequent and liberal use.
- If the skin is inflamed, prescribe a potent topical corticosteroid (for example betamethasone valerate 0.1%) to be used on inflamed areas.
- For delicate areas of skin such as the face and flexures, use a moderate potency corticosteroid (such as betamethasone valerate 0.025% or clobetasone butyrate 0.05%). Aim for a maximum of 5 days' use.
- Occlusive dressings or dry bandages may be of benefit; however, treatment should only be started by a healthcare professional trained in their use.
- If there is severe itch or urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine, loratadine, or fexofenadine).
- If itching is severe and affecting sleep, consider prescribing a short course (maximum or two weeks) of a sedating antihistamine (such as chlorphenamine).
- If there is severe, extensive eczema causing psychological distress, consider prescribing a short course of an oral corticosteroid in adults. There are no data from controlled trials, but 30 mg prednisolone taken in the morning for 1 week should be sufficient.
- Infected eczema
- If there are extensive areas of infected eczema, swab the skin and prescribe an oral antibiotic. Flucloxacillin is the first-line choice. Prescribe erythromycin if the person has an allergy to penicillin or if there is known resistance to flucloxacillin. If the infection responds poorly to the first-line antibiotic, prescribe an alternative antibiotic, if necessary, according to the swab results, or seek specialist advice.
- If there are localised areas of infection, consider prescribing a topical antibiotic. Creams or ointments containing antibiotics can be used as separate products or combined with a corticosteroid. Avoid using combined corticosteroid/antibiotic preparations on a regular basis as this will increase the risk of antibiotic resistance. Advise that topical antibiotics should be used for no longer than 2 weeks.
- Episodes of infected eczema usually coexist with a flare and will require concomitant treatment at the appropriate treatment step.
- Refer to a specialist if eczema herpeticum (widespread herpes simplex virus) is suspected.
Complications
- Infection
- Bacterial infection with Staphylococcus aureus may present as typical impetigo or as worsening of eczema (with increased redness, oozing, and crusting of the skin).
- Herpes simplex infection, indicated by grouped vesicles and punched-out erosions, may occur. Disseminated herpes simplex virus infection (eczema herpeticum) presents with widespread lesions that may coalesce into large, denuded, bleeding areas that can extend over the entire body, occasionally complicated by secondary infection with staphylococcal or streptococcal species. Fever, lymphadenopathy, and malaise are common with eczema herpeticum. It is a medical emergency, especially in children under two years of age, and requires urgent referral for diagnosis and management. It can have serious sequelae, such as eye or meningeal involvement resulting in scarring.
- Superficial fungal infections are more common in people with atopic eczema.
- Psychosocial problems
- Atopic eczema causes considerable distress, and depression has been reported in both teenagers and adults with atopic eczema.
- Preschool children with atopic eczema have higher rates of behavioural problems, fearfulness, and dependency on their parents, than unaffected children.
- School children with atopic eczema have problems including time away from school, impaired performance, social restrictions, teasing, and bullying.
- Atopic eczema can be associated with poor self-image and self-confidence that can impair social development. Among children with moderate-to-severe eczema attending outpatient departments, psychological problems are double that of school children without eczema.
- Sleep disturbance is a major problem for people with atopic eczema and their families.
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
