Fussy infant presents with worsening red skin
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A 2-month-old male presented virtually to his primary provider with gradually worsening red skin (Figures 1 and 2) and fussiness, which was first noted a few weeks earlier.
The mother was initially advised to use topical, over-the-counter 1% hydrocortisone and ketoconazole twice a week, and changed from feeding breast milk to using soy formula, thinking the condition might be allergy induced. After a couple of weeks, the baby was seen for follow-up, with minimal improvement, along with the new finding of an abrasion caused by chronically rubbing her face on bedding (Figure 3). She was then given topical mupirocin ointment for the abrasion and referred to a dermatologist.
The baby is otherwise healthy, with no fever or other concerns, and was born full term after a normal pregnancy, labor and delivery. He has received his first round of immunizations, and his growth and development are normal for his age. There have been no sick contacts at home or elsewhere, and no one else in the family has any skin problems.
On examination, his vital signs are normal, and the patient appears to be a bit fussy and agitated with scratching. His rash is a generalized erythematous rash, from the crown of his head to his feet, with the head, face and trunk being more involved than the extremities. The mucous membranes of the eyes and mouth are clear, and the abrasion is as shown. On closer inspection of the rash, there are no blisters, vesicles or pustules noted. However, some areas of scattered, somewhat oily desquamation are noted with the erythematous patches, particularly on the head, face and abdomen. He otherwise appears to be a normal, healthy 3-month-old male.
In summary:
1. A young infant with a red rash and oily scaling, primarily of the scalp but with total body involvement to some degree, does not significantly improve with twice-a-week topical therapy.
2. There’s evidence of scratching.
3. The baby is otherwise healthy with no fever.
What’s your diagnosis?
A. First disease
B. Scabies
C. Seborrheic dermatitis
D. Staph scalded skin syndrome
Answer and discussion:
I’m sure most primary care providers will recognize the answer, which is C, seborrheic dermatitis — an inflammatory condition of the skin, mostly of infants, and its cause is uncertain. However, there appears to be an association with several Malassezia species, triggering the inflammatory response. Typically, the onset of the condition occurs in early infancy and tends to improve with age. As seen in the pictures, the baby has the typical, patchy erythema that tends to be worse on the head and face, with flaking skin with an oily or greasy appearance. An old colloquial term for this was/is “cradle cap,” which may still be used in some clinics. The mainstay of therapy includes daily shampooing and removal of the scales. Medicated shampoo for the scalp containing selenium sulfide along with a low-concentration steroid cream (1% hydrocortisone) twice a day for a short time are often very helpful in cooling off the inflammation. The areas of involvement of the rest of the skin can be treated with the same cream until resolution. With the Malassezia connection, it makes sense to employ an antifungal, such as topical ketoconazole cream and/or shampoo. These measures will almost always improve the rash within days during flare-ups. As the baby get older, most common cases of seborrheic dermatitis improve but may flare periodically for years to come.
This patient was also to begin “bleach baths” to decolonize the skin of Staphylococcus aureus, as this has also been associated with flare-ups and in severe cases may invade through broken skin to cause local infections or even bacteremia in severe cases.
First disease is the old 17th century term for rubeola, or measles, which was first described by the great Persian physician Rhazes in the 10th century. Some of you may have seen measles in your practice but most have not due to the effectiveness of the measles immunization. However, as the most contagious viral disease known, there are periodic outbreaks or clusters driven by the unvaccinated from time to time. The key features include a progressively febrile child who “looks sick,” with the “three-Cs” (cough, coryza and conjunctivitis), possible Koplik spots on the oral mucous membranes and the characteristic, morbilliform rash, which begins on the head and face and quickly progresses down the trunk and proximal extremities (Figure 4). Therefore, as noted, there are these characteristic features that distinguish measles from severe eczema, as well as most other diseases.
Scabies is the term given to the cutaneous infestation of the scabies mite Sarcoptes scabiei. The skin findings can be subtle or dramatic, but there usually is no diffuse erythema, as shown in the case presented here, unless there is some associated secondary infection, as shown in Figure 5. The lesions are usually discrete, often resulting in the formation of a pustule or vesicle. Some lesions may reveal a short “track,” where the mite is burrowing. In babies, it is common to see the palms and soles involved (Figure 6). Itching of the patient is universal and usually the chief complaint. Scratching may result in secondary infections. It is fairly common to see other members of the family with lesions. Adults are more prone to having hand involvement, particularly between the fingers. The treatment of choice is usually 5% permethrin cream overnight, then rinsing off the next morning. For severe cases, such as “Norwegian scabies,” a single, small dose of ivermectin (200 µg/kg body weight) is usually effective, although the itching may persist for days to weeks after successful treatment. Some experts recommend applying a second treatment a week after the first to kill mites that may survive in the eggs during the first treatment.
Staph scalded skin syndrome (SSSS) is an S. aureus toxin-mediated illness, and as the name implies, it results in the erythema and blistering of the skin because of injury to the very superficial layers of the skin by the toxin, resembling a burn. The resulting blistering has a very thin covering, which rapidly opens soon after forming (Figure 7). In neonates, this is often referred to as Ritter’s disease, named after the doctor who first described it in 1878 in what was then Czechoslovakia. The patient may be febrile but often is not, depending on the significance of the staph infection producing the toxin. The main, universal complaint is painful skin, which is very fragile in the acute stage. The site of infection may be obvious or relatively hidden. It can often be found in the nose, which is a good place to culture if there is no obvious site of infection otherwise. The patient usually responds fairly quickly to appropriate anti-staph antibiotics, which should include clindamycin to limit toxin production in the 50S ribosome. The resulting damage to the skin is very limited, with no scaring or significant residual marks, due to the superficial nature of the injury.
The patient presented in this case did well with proper use of topical steroids (Figure 8).
Columnist comments:
The Guest Columnist this month, Dr. Joan Eitzen, received her basic nursing education at Pittsburgh Hospital School of Nursing from 1972 to 1975, and her BSN from West Virginia University in 1978. During her 27 years on active duty in the U.S. Army Nurse Corps, she completed numerous leadership courses and earned an MPH at Tulane University, an MSW at the University of Washington and a PhD in health education at the University of Maryland, focusing on women’s health and health promotion. During her active duty years, Dr. Eitzen was stationed at various army hospitals across the U.S., South Korea and Japan. Her nursing experiences include medical-surgical nursing, emergency department nursing, pediatric and neonatal intensive care nursing, and public health. Her last assignment in the Army Nurse Corps was as the deputy commander for nursing (chief nurse) at Walter Reed Army Medical Center in Washington, D.C. She has lived in Colorado Springs with her husband since retirement, where she remains active in the medical arena as a volunteer.
For more information:
Brien is a member of the Infectious Diseases in Children and Infectious Disease News Editorial Boards, and an adjunct professor of pediatric infectious diseases at McLane Children's Hospital, Baylor Scott & White Health, in Temple, Texas. He can be reached at jhbrien@aol.com.