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A 5-year-old male with 4-month history of rash on cheek
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A 5-year-old male presented to a dermatology clinic with a 4-month history of rash on the left cheek. The parents reported that they initially noted small bumps on his cheek that gradually expanded into a larger shape. They also noted some lightening of the background skin. The patient denied itch from the area and was otherwise well.
At home, he was treated first with hydrocortisone 1% cream for 1 month and most recently had been using plain emollient daily, with no visible improvement. The parents noted that he was not on any prescription medications.
On exam, the patient was well-appearing. On the left cheek, there was a curvilinear, V-shaped, hypopigmented patch, within which were numerous 1-mm papules and patchy erythema.
Source: Aditi Murthy, MD
Can you spot the rash?
Contact dermatitis
Lichen striatus
Atopic dermatitis
Perioroficial dermatitis
Epidermal nevus
Case Discussion
Lichen striatus (B) is a well-described inflammatory dermatosis seen in children, which typically occurs within lines of embryological skin development called Blaschko’s lines. The rash consists of a linear arrangement of small erythematous papules with an erythematous or hypopigmented background, a feature more often noted in darker skin types. Biopsy can differentiate between other types of linear eruptions in children but is not necessary for diagnosis. The cause of lichen striatus is unknown, although viral infections have been proposed as a trigger. Treatment is not necessary because the eruption resolves on its own within months to years, and the condition tends to have a poor response to topical steroids.
Contact dermatitis can occur on any site that has been exposed to a culprit allergen. It often presents with geometric shapes that serve as a clue to an outside etiology. Unlike in our patient, contact dermatitis is usually pruritic and should respond well to topical corticosteroids. In this particular case, the distinctive curvilinear shape argues against an external cause of the rash.
Atopic dermatitis (eczema) commonly presents on the face, especially in infants. In slightly older children, such as our patient, flexural areas would also be more prone to involvement. The rash typically consists of ill-defined, scaly, erythematous patches accompanied by significant pruritus. Topical corticosteroids and emollients are mainstays of therapy.
Perioroficial (perioral) dermatitis is a reasonable consideration in the differential of a papular eruption on the face of the child. Typically, the eruption is more symmetric on the face and consists of erythematous papules and occasionally pustules that favor both periorbital and perioral skin. This rash can be triggered by overuse of topical steroids in some cases, and first-line treatments include topical calcineurin inhibitors or topical antibiotics. In more severe cases, oral macrolide antibiotics have been used with success.
Given the curvilinear shape, an epidermal nevus could be considered in this case; however, the lesion is usually present at birth. Epidermal nevi form in the lines of Blaschko and are caused usually by mosaic activating mutations in the affected keratinocytes. These nevi are typically asymptomatic, and treatment (if desired) would be surgical excision.
- References:
- Paller AS, et al. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 5th ed. Elsevier; London; 2016.
- Patrizi A, et al. Pediatr Dermatol. 2004; doi: 10.1111/j.0736-8046.2004.21302.
- For more information:
- Aditi Murthy, MD, is a pediatric dermatology fellow at The Children’s Hospital of Philadelphia. She can be reached at MurthyA1@email.chop.edu.
- Marissa J. Perman, MD, is an attending physician at The Children’s Hospital of Philadelphia.
Disclosures: Murthy and Perman report no relevant financial disclosures.