1. What essential questions does one still need to ask to help make the diagnosis?
2. What is the tentative diagnosis?
3. Can you list at least three differential diagnoses?
4. What features of this condition differentiate it from other conditions in your differential?
5. What is the suitable treatment of this condition?
When A Pediatric Patient Has Severe Itching On Her Heels
Atopic eczema usually develops in childhood. The face is a common initial location of presentation in younger children. Older children will usually have the rash on the flexor surfaces of the arms and legs. When the extremities are involved, it is usually symmetrical. Xerosis of skin is usually associated with atopic eczema. Atopic eczema is known as the “itch that rashes” rather than the rash that itches.
Atopy is defined as a tendency to develop certain allergy-related diseases such as asthma, hay fever and eczema. One can perform the atopy patch test to make the diagnosis of atopy by introducing a known allergen to the skin to stimulate an IgE-mediated reaction. Treatment of atopic eczema involves using topical steroid agents for acute flare-ups and using hydrating creams daily for maintenance.
Tinea pedis is a fungal infection located on the skin of feet and this is caused by dermatophytes. While tinea pedis is very common in adolescents and older patients, it is uncommon in pre-adolescents. It is uncommon to have the fungal infection on the hands due to environmental reasons. The clinical presentation of tinea pedis may be a wet blistering rash in the acute state or it can be a dry scaling rash.
Generally, tinea pedis is asymmetrical with only one foot involved or one foot worse than the other. Web spaces are frequently involved in the acute variety and the periphery of the foot has scaling in chronic conditions. Treatment includes antifungal medications and prevention with hygiene recommendations of maintaining a dry and clean environment for feet in the shoes.
Key Insights On Diagnosis And Treatment
This patient was diagnosed with atopic eczema. A frank discussion with her mother involved describing the disease process and that this may be a chronic problem. Therefore, even though the initial treatment of implementing a topical steroid medication is fairly straightforward, effective treatment is more involved.
First, discuss the allergic component of the disease. Oftentimes when the allergy component is worse (i.e. exacerbation of asthma or allergic rhinitis), then the dermatologic component of eczema may be worse.
Proceed to review bathing tips. Recommendations include bathing every day, using mild cleansers such as cetaphil or soaps that are fragrance-free. Other measures include trying to discourage scratching which activates the itch-scratch-itch cycle.
When it comes to selecting an appropriate topical steroid medication, mid-level to high potency agents are preferred. Over the counter preparations and low potency steroids do not fare well for treatment of atopic eczema. I will generally use triamcinolone 0.1% ointment (Kenalog, Taro). Ointments are stronger than creams and are made from oils, versus creams, which are oil mixed with water. Ointments are better than creams for dry scaling skin.
Discuss the proper usage of topical steroid agents. Application should be a thin coating of medication versus leaving clumps of medication on the skin. Washing hands after handling the medication is important. I will prescribe a small quantity of medication (15 g) so the patient uses the medication sparingly and appropriately.
Generally, treatment with the topical steroid will be for two weeks and once the rash is resolved, the patient can subsequently use maintenance creams. Recommendations for maintenance include using a hydrating cream such as eucerin. One should apply it by first pat drying the affected area (never rub skin with a towel) and then rub the cream into the skin within two minutes of getting out of the bath. The patient can use the topical steroid again during acute exacerbations.