100 Cases in Dermatology

Rachael Morris-Jones, Ann-Marie Powell, Emma Benton

• Publisher: CRC Press
• Year: 2011
• ISBN:
  9780429586101
• Edition: 1
• Topic: Medicine
• Subtopic: Dermatology

A 23-year-old African Caribbean woman presents in the emergency department with an acute onset facial rash. During initial assessment she complains of a two week history of general malaise, fatigue, fever, and weight loss. You have been assigned her examination...100 Cases in Dermatology presents 100 scenarios with a dermatological manifestation co

CASE 1: AN ITCHY, SLOW-GROWING INFANT

History

A 26-week-old baby boy attends your clinic with his mother. He has developed a generalized dry, red, itchy rash over the past seven weeks. His mother has been applying a regular emollient diligently and using a bath emollient. She reports that he is waking more and more frequently at night and appears to be troubled by his skin. She is worried about weaning him. He is currently breast-fed and his mother has an unrestricted diet. He has been offered a bottle of formula milk, but took only 60 mL before vomiting and developing a rash. He also developed a rash when his father kissed him, immediately after eating an egg mayonnaise sandwich.

He is the first baby of his parents; his mother had asthma in childhood and his father is allergic to shellfish. There are no pets at home. His father is a smoker. The baby was born at term by normal vaginal delivery and is vaccinated to date.

Examination

His height has reached a plateau over the past eight weeks and now rests on the 9th centile for his age. He is alert and happy, although he rubs his legs vigorously when undressed. He has generally dry skin, with widespread low-grade erythema and raised, poorly defined patches of active eczema; there are widespread excoriations (Fig. 1.1) and no clinical evidence of impetiginization. He has low-grade generalized shotty lymphadenopathy. The rest of his examination is normal.

Figure 1.1

INVESTIGATIONS

Skin prick tests
Allergen	Resulting wheal	Interpretation
Positive control	5 mm	Functioning assay
Negative control	0 mm
Egg white	11 mm	Highly likely to be allergic
Egg yolk	4 mm	Possibly allergic
Cow’s milk protein	8 mm	Highly likely to be allergic
Soya	7 mm	Highly likely to be allergic
Wheat	0 mm	Not allergic
Salmon	2 mm	Not allergic
Cod	1 mm	Not allergic
Peanut	9 mm	Highly likely to be allergic

Questions

• What is this eruption?

• What associated condition does he present with?

• What dietary recommendations will you make for the baby (and mother)?

ANSWER 1

This eruption is eczema. The history his mother gives makes an associated food allergy probable – likely to egg and cow’s milk protein (CMP). This, in combination with a positive family history of food allergy and asthma, means we can classify his skin condition as atopic eczema. His mother is correct to be anxious about weaning him.

It would be appropriate for this baby to be investigated for associated food allergy. Food allergy is more likely in babies presenting with eczema from a young age, and it is possible that food allergy may be contributing to the activity of his eczema and vice versa. The first line investigation should be skin prick test (SPT) to the common weaning food protein allergens (CMP, egg, soya, wheat, and fish). Peanut is commonly added to this initial panel.

The history suggests that this baby is likely to be allergic to egg and CMP, and this has been confirmed by SPT. It would be worth restricting his mother’s intake of these proteins if she intends to continue breast-feeding as this may improve eczema control. If his mother wishes to stop breast-feeding, the most appropriate alternative at his age would be an amino acid formula. The incidence of coexisting CMP and soya allergy is high and the positive SPT would suggest this baby is currently allergic to both. CMP and egg are nutritionally important and ensuring a balanced diet while restricting both can be challenging; specialist dietetic advice is important. Low-grade exposure to allergenic proteins through maternal milk might be contributing to skin signs and his static growth parameters.

Regular use of topical emollients and avoidance of detergents are essential for maintaining the skin barrier function of infants with eczema. It is unlikely, however, that emollients and dietary restriction alone will suffice in the management of his eczema. His parents should be introduced to the practical aspects of topical therapy and a ‘step-up, step-down’ approach to the management of flares. They should be taught to identify flares early and initiate effective therapy quickly.

The association of early-onset eczema and egg allergy is associated with a three-fold increased risk of asthma in later childhood. This is an important opportunity to discuss the potential contribution paternal smoking would have on increasing that risk. Reassuringly, both egg and CMP allergy are frequently outgrown, although peanut allergy is more likely to persist.

KEY POINTS

• Atopic eczema frequently presents within the first year of life and early onset is associated with ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgements
• Glossary
• 1: An itchy, slow-growing infant
• 2: An agitated atopic child
• 3: An acute monomorphic eruption in a systemically unwell atopic child
• 4: A recurrent, unsightly facial eruption in a stressed but well young adult
• 5: Blistered hands and feet in an athletic man
• 6: Chronic erythematous pruritic eruption on the lower legs
• 7: An itchy localized eruption
• 8: An eczematous eruption complicating venous ulcers
• 9: A transient pruritic eruption exacerbated by heat
• 10: A toddler with brown patches which urticate
• 11: Acute soft tissue swelling associated with systemic symptoms
• 12: Chronic scaly plaques on the knees
• 13: Widespread scaly eruption appears after a sore throat
• 14: A patient presents acutely unwell with all his skin red and hot
• 15: An itchy eruption appearing on the chest and arms after sun exposure
• 16: Acute-onset linear blistering on the legs
• 17: Chronic blistering eruption on the dorsal hands
• 18: Sun-induced skin pain, redness and scarring in a child
• 19: Sudden-onset widespread rash
• 20: Recurrent annular erythematous lesions reactivating at identical skin sites
• 21: Painful lip lesion associated with a localized blistering rash and sore mouth
• 22: Painful eroded mucous membranes and skin lesions
• 23: Acute-onset extensive blistering and skin necrosis with mucous membrane involvement
• 24: Fever, epilepsy and a widespread skin eruption with marked facial oedema
• 25: Acute-onset multiple pustules on a background of erythematous skin
• 26: Acute non-blanching cutaneous eruption associated with a sore throat
• 27: An itchy papular eruption on the ankles
• 28: A generalized itchy blistering eruption in an elderly woman
• 29: Sudden onset of erosions, blisters and fragile skin following gradually worsening mouth ulcers
• 30: An itchy, vesicular extensor eruption associated with malabsorption
• 31: An itchy blistering eruption recurring in a second pregnancy
• 32: Extremely itchy stretch marks in the third trimester
• 33: Asymptomatic sclerotic white plaques on the trunk
• 34: Insidious onset of tightening of the skin over the limbs
• 35: Acute facial rash, fever and joint pains in a young woman
• 36: Annular erythematous rash of sudden onset
• 37: Hair loss, scarring rash and photosensitivity
• 38: An erythematous rash and muscle weakness
• 39: Widespread maculopapular eruption on the trunk and face with flu-like symptoms
• 40: Slow asymptomatic depigmentation of the skin
• 41: A young adult with high blood pressure, irregular pigmentation and skin lumps
• 42: An overweight teenager with thickened skin around her neck
• 43: A dramatic and painful ulcer in a young patient with no evidence of infection
• 44: Slow-onset asymptomatic lesions on the shins of a diabetic patient
• 45: Slowly progressive swelling and discolouration over the shins
• 46: Asymptomatic annular lesions on the limbs
• 47: An asymptomatic papular and annular eruption
• 48: Ulcer over the gaiter area on a background of aching legs
• 49: Slow-onset, unilateral, painless leg swelling
• 50: An infirm elderly man with arterial disease and an ulcerated heel
• 51: Non-healing foot ulcer in a diabetic patient
• 52: A regressing vascular lesion in a pre-school child
• 53: A livid red birthmark on a newborn child
• 54: Slow development of a scaly plaque on a finger
• 55: A slow-growing ulcerated non-healing nodule on the face
• 56: Multiple basal cell carcinomas in a young patient
• 57: An ulcerating lesion on the scalp, enlarging over 4 months
• 58: A rapidly growing lesion on the dorsum of the hand
• 59: A longstanding flesh-coloured nodule on the face
• 60: Multiple, slightly atypical looking naevi on the trunk
• 61: An enlarging pigmented macule on the face of an elderly man
• 62: A unilateral rash around the nipple
• 63: A changing pigmented lesion on the leg
• 64: A pigmented nodule on the back
• 65: Longstanding erythematous scaly patches
• 66: A slow-growing plum-coloured skin nodule
• 67: Papular and pustular eruption on the face with scarring
• 68: A red face with papules and pustules
• 69: Sudden-onset facial crusting and blistering in a child
• 70: An erythematous painful face
• 71: A hot, swollen leg
• 72: Painful areas of superficially eroded skin in the flexures of a child
• 73: Asymptomatic erythematous scaly patches on the palms and soles
• 74: Acute-onset blister on the lip with facial swelling and pain
• 75: A localized, painful, blistering eruption
• 76: Multiple flesh-coloured papules on the face
• 77: Multiple hyperkeratotic papules and nodules on the fingers
• 78: Sudden-onset maculopapular rash with conjunctivitis and malaise
• 79: Crops of blisters becoming widespread in a child with gastrointestinal upset
• 80: Multiple cutaneous boils appearing over 12 months
• 81: Chronic, sore, macerated skin in the finger webs
• 82: Asymptomatic purple skin lesions appearing on the limbs and trunk
• 83: Widespread itchy eruption preventing sleep
• 84: Painless erythematous lesion on the nose grows over four months
• 85: Scaling of the scalp with occipital lymphadenopathy in a child
• 86: A pruritic annular rash and family involvement
• 87: Progressive scaling of the palms and dystrophy of the fingernails
• 88: Patchy asymptomatic hair loss over the scalp
• 89: Frontal hair loss in a woman
• 90: Excessive facial hair in a young woman
• 91: Multiple skin lesions develop in a renal transplant recipient
• 92: Stiffness of the skin developing after bone marrow transplantation
• 93: Streaky skin changes in a toddler and a maternal history of miscarriage
• 94: A young adult with seizures and markedly photo-damaged skin
• 95: A young man seeking genetic counselling advice regarding his dry skin condition
• 96: Recurrent blisters on the extremities associated with minor pressure/friction
• 97: An increasing number of asymptomatic facial lesions in a young boy
• 98: Macroglossia, fatigue and back pain in an elderly woman
• 99: Subacute pruritic erythematous eruption in an elderly patient with weight loss
• 100: A young girl with unusual scars and unexplained injuries
• Index