Hot Seat Case # 107 Denouement: 6 month old Male with recalcitrant rash

Posted on: February 22, 2018, by :

Amie Cahill MD,  Children’s National Medical Center

Case: 6mo previously healthy male born term UTD on immunizations presents with a 1 month history of persistent and worsening scalp and diaper rash recalcitrant to the following interventions: OTC hydrocortisone 1% cream, nystatin, ketoconazole cream on body, mineral oil on scalp. Patient had been seen by pediatrician twice who referred them back for a second ED visit after no improvement with ketoconazole cream from the first ED visit. No history of fevers and complete ROS otherwise negative aside from rash.

Here’s How You Answered Our Questions:

The “other” answers were a an outpatient referral to dermatology instead of labs.

Discussion:

As ED physicians, rashes are the bane of our existence. While we say most are viral exanthems, this is an instance where that is clearly not the case. The major point of debate for this case was whether this child required inpatient vs. outpatient management. And as expected, answers varied all over the place within both groups. Dr. Isbey stated that her threshold to admit this patient was low given multiple visits to providers (ED and PMD) with multiple treatment options (creams/ointments) without improvement. Others, including Dr. Button felt that tying dermatology into the case from the ED is most beneficial in determining disposition as they have the expertise in this arena. Despite this rash appearing unusual to us, this may not be the case for them and may give us more reassurance for discharge when a solid plan can be made.

Denouement:

Labs were obtained and resulted as:
CBC: WBC 16.1   Hct 12.7  Hgb 37.1   Plt 455  Diff: Segs 28%    L 59% M 8%  ANC  4508
CMP: Na 142 K 5.2 Cl 107 Bicarb 24 BUN 4 Cr 0.24 Glu 92  ALT 399 AST 38 ALT 33
Ferritin 122

Patient was continued on the 1% ketoconazole cream and told to either extend application to scalp or use selenium sulfide shampoo on scalp 2-3x weekly. Hydrocortisone 1% was re-added to regimen, as was nystatin. Photos were shown to Dermatology, and the family was given follow up information and instructions for dermatology clinic.

The patient was seen 1 week later in Dermatology clinic with no improvement..  He was started on a moderate potency triamcinolone steroid cream to diaper region and scalp and Keflex due to brightly erythematous appearance of GU rash and concern for possible bacterial superinfection. The family was told to return in 1 week with plans to biopsy for suspicion of LCH if no improvement.

After one week of triamcinolone and Keflex, the patient had significantly improved. Dermatology diagnosed it as sebopsoriasis with napkin dermatitis.

Although this case ultimately was not LCH, below is a link to a case report from the Dermatopathology journal of a 12month old with chronic diaper rash, scalp rash, and an oral ulcer all recalcitrant to treatment, proven by biopsy to be LCH. This and other similar case reports reinforce that LCH should pop up on a clinician’s differential diagnosis in cases of chronic, recalcitrant scalp and diaper seborrheic dermatitis as skin findings can be the sole presenting sign. Of note, as was this case in this article, local petechiae often accompanies either the scalp or diaper dermatitis when LCH is the cause.

Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803736/

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

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