CASE
Many a worried parent has brought his or her infant to a dermatology specialist with a florid rash that worsens despite everything that is done to treat it. Such was the case of this 7-month-old boy whose body was almost completely covered with a rash. The parents had brought a large bag filled with the many products and prescriptions they had tried on the child, often several on any given day, including tea tree oil, hand lotion, glycerine, and ammonium lactate lotion. The last made the child's condition so much worse that he was taken to the emergency department in the middle of the night and was given prednisolone syrup, which calmed things down for the few days he was on it.
History The rashes had begun at about 1 month of age, about the same time the child had begun having problems with his ears. An older sibling had had similar problems and still had a rash of some sort more often than not. These conditions were very similar to ones that had been experienced by their mother at that age.
Examination This was one of the most miserable children this examiner had ever seen; he was writhing during the examination and trying to scratch but not having much success. The patient's face (Figure 1), scalp, chest, arms, and legs were covered with a dry, scaly rash that also had focal areas of excoriation and redness. His skin in general was quite dry, even in uninvolved areas. Factoring in the examination findings as well as the family history of atopy, atopic dermatitis (AD) was clearly the condition we were dealing with.
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DISCUSSION
The correct answer is extensive patient education; an extremely useful measure because ongoing care based on an understanding of the issues involved will, arguably, be more important than almost any other step. A referral to an allergist may be ad visable at some point, but more to evaluate the overall atopic state and associated reactive airway disease than for the acute skin problem. “Caine”-based sprays are notorious for causing acute contact dermatitis and are not especially helpful in treating pruritus. Most dermatology clinicians advise daily bathing for patients with AD using the correct products to bathe and moisturize the patient's skin.
Comment Opinions vary regarding the cause of atopic dermatitis, but all agree that its incidence is increasing. Eighty-five percent of patients develop AD in the first year of life and 95% in the first 5 years of life. Despite being utterly common, its appearance, especially when acute and severe, still baffles and confuses parents and clinicians. The situation is typified by this case, in which so many products were being used on any given day that one would never know which products helped and which products made things worse. For example, ammonium lactate lotion, a perfectly good moisturizer for adults, is far too harsh for such a young child.
Education, at length and in detail, goes a long way toward easing parents' minds about the causes of and remedies for AD. The condition is likely to improve with age, and permanent scarring is not expected. Daily skin care is mandatory, including daily bathing with mild cleansers (such as Cetaphil or Dove liquid body wash) followed by the generous application of petroleum jelly or other pure, unscented and noncolored product.
I make sure the parents know that, no matter how well they follow my instructions, fl ares will occur but will generally be manageable. JAAPA
Joe Monroe practices at the Dawkins Dermatology Clinic, Oklahoma City, and is the department editor for Dermatology Digest The author has indicated no relationships to disclose relating to the content of this article.