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
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. In Conclusion History is the most important element in unraveling the diagnosis of skin disorders. Studying pictures of rashes and lesions is helpful for recognition of various disorders. However, many skin conditions can have the same features. For example, fine scaling rashes can include tinea pedis, seborrheic keratosis, stucco keratosis, pityriasis alba, psoriasis, lichen planus and cutaneous drug reactions, just to name a few. Considerations in a differential diagnosis should include the characteristics of the rash (symmetry, primary/secondary lesions), color, location and history. In this case, a preadolescent girl with a past medical history of allergic rhinitis and environmental allergies presented with a symmetrical, pruitic skin disorder with xerosis on her heels. Tinea pedis and xerosis are relatively rare in very young children. Dr. Fishco is board-certified in foot surgery and reconstructive rearfoot and ankle surgery by the American Board of Podiatric Surgery. He is in private practice in Phoenix. He is also a faculty member of the Podiatry Institute. For related articles, see “What You Should Know About Atopic Dermatitis” in the September 2005 issue of Podiatry Today. Also check out the archives at www.podiatrytoday.com.