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Facial pruritus, erythema in an 11-year-old male
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An 11-year-old male presents with the chief complaint of “poison ivy on his face.” The child had been hiking with his grandparents the day before, and had seen some poison ivy, but did not recall touching any. That evening, his face began to swell with some erythema. By the next morning, the rash had worsened, with intense pruritus, more swelling and erythema and some blisters. However, he did not complain of pain. He was taken to his primary provider’s office, where he received an injection of steroids, a prescription for oral and topical steroids and oral Benadryl.
James H. Brien
By that evening, he and was taken to the local ER, where he was diagnosed with staphylococcal cellulitis, because it looked just like it did once before when he had culture-positive staphylococcal cellulitis coincident with poison ivy. Therefore, a lesion was swabbed for culture, and he was given a dose of an unknown injectable antibiotic (probably clindamycin) and transferred for admission.
His past medical history was that of a healthy male, and as noted above, had a history of severe poison ivy dermatitis in the past that included cellulitis with a positive staphylococcal culture. His immunizations are up to date, and there has been no injury to the face.
Examination revealed normal vital signs and was positive for large patches of weeping erythema, with swelling and scattered vesicles on his face (Figure 1). Additionally, there are similar, less severe patches of erythema on the anterior and posterior neck (Figures 2 and 3) and groin. The rest of his exam was normal. No lab tests were done at the hospital.
Examination revealed normal vital signs and was positive for large patches of weeping erythema, with swelling and scattered vesicles on his face (Figure 1).
Images: Brien JH
Additionally, there are similar, less severe patches of erythema on the anterior and posterior neck (Figures 2 and 3) and groin.
Case Discussion
This is the typical history and appearance of a highly sensitive child with poison ivy dermatitis (B). Secondary bacterial infections are very uncommon, despite how it might appear. After reviewing the patient’s past record, I found that the Staphylococcus recovered with the previous episode a year earlier was actually coagulase-negative Staphylococcus, which, as we know, is a common skin organism not known to cause cellulitis. This time, the same culture technique (topical swab) from the same ER had no growth. This seems like a good time to point out that growing an organism off the surface of the skin or a suspicious patch of skin does not constitute a reliable specimen, but more likely the organisms with which the skin is colonized. Additionally, this patient had no fever or pain; just intense itching.
The cause is urushiol, the oily substance in the sap of the Toxicodendron radicans (Figure 4), sometimes referred to as Rhus toxicodendron, but usually known as “poison ivy.” In previously sensitized people, re-exposure to it can provoke an intense inflammatory reaction, often within hours. Sometimes it is a simple patch or a linear inflammatory lesion as shown in Figure 5, but it is all dependent on the degree of sensitivity and how the urushiol is spread over the skin. If it is on the hands, it will reveal where the hands have recently been, including the face and neck.
The cause is urushiol, the oily substance in the sap of the Toxicodendron radicans (Figure 4). Sometimes it is a simple patch or a linear inflammatory lesion as shown in Figure 5.
Cellulitis will usually have diffuse, painful swelling and smooth erythema (Figure 6). This will clear fairly quickly with only anti-inflammatory therapy with intravenous or oral steroids and topical cool compresses, as shown in Figure 7.
This will clear fairly quickly with only anti-inflammatory therapy with intravenous or oral steroids and topical cool compresses, as shown in Figure 8. The erythema obviously does not involve the shaded areas of skin, like the anterior neck and axillae (Figure 9).
At the risk of provoking some controversy, I suppose it is possible for poison ivy dermatitis to become secondarily infected with Staphylococcus aureus, especially with lots of scratching, but in my experience, it must be fairly uncommon. Cellulitis will usually have diffuse, painful swelling and smooth erythema (Figure 6), often with an obvious port-of-entry. I have seen many cases of severe poison ivy dermatitis, but never treated one with an antimicrobial. However, I have stopped antibiotics in all referred to me, usually on the same day.
Eczema herpeticum is the result of Herpes simplex invading damaged skin due to eczema or atopic dermatitis (Figure 10).
In severe cases, poison ivy dermatitis can have edematous, markedly erythematous, blistering lesions, oozing yellowish serosanguinous material, giving the impression of severe impetigo and possible cellulitis. However, this will clear fairly quickly with only anti-inflammatory therapy with intravenous or oral steroids and topical cool compresses, as shown in Figures 7 and 8, which were taken 4 days apart of a patient admitted for IV antimicrobial therapy, but who was treated only with steroids and topical comfort care. In this age of antimicrobial stewardship, without a history of pain, possible fever and outdoor exposure, I would suggest holding off on antibiotics. However, don’t get too dogmatic: If a patient is suspected of having a bacterial infection, especially about the face, by all means, give antibiotics until the diagnosis is clear.
Sunburn is usually not a diagnostic dilemma. The erythema obviously does not involve the shaded areas of skin, like the anterior neck and axillae (Figure 9).
Eczema herpeticum is the result of Herpes simplex invading damaged skin due to eczema or atopic dermatitis (Figure 10). It can result in a severe, disseminated infection, with potentially life-threatening consequences. Infants are usually admitted for IV acyclovir to get control of the infection, while older children can usually be treated as outpatients with oral acyclovir, but it is always a judgment call.
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James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.