Atypical Diaper Dermatitis

Abstract: 9 week old infant with recalcitrant diaper dermatitis.

HPI: This child has had a dermatitis which began in the napkin area at ~ 1 month of age. He has been treated with topical Nystatin, clotrimazole cream, Aquaphor and Maalox. No response. New lesions have appeared around umbilicus and neck. His paternal grandfather may have psoriasis.

O/E: There is a sharply demarcated erythematous dermatitis in the pubic, perineal and perirectal area. The umbilicus is involved and there are a few patches in the neck folds. The child is otherwise healthy in appearance.

Clinical Photos:



Diagnosis: I am suspicious of psoriasis or a psoriasiform diaper dermatitis here. This is so well-demarcated and the umbilical lesion may be a clue. I have started him on triamcinalone 0.1% ointment after bath and will reevaluate in a week.

Questions: What alternative diagnoses would you suggest? What may I be missing? Would biopsy be helpful?

References:

Photo after 7 days of TAC 0.1% ointment:

Abstract: 80 yo man with scalp erosions following micrographic surgery.

HPI: The patient is an otherwise healthy 80 yo man who underwent Mohs surgery on November 16, 2011 for a basal cell carcinoma of the mid-parietal area of the scalp. The large defect needed a complex closure. Within a few days there was some evidence of inflammation and a wound culture grew out staph aureus sensitive to methicillin but resistant to penicillin, clincamycin and erythromycin. He was treated with cephalexin and seemed to do well, but presented on January 19, 2012 with thick crusts along a portion of the scar (unfortunately not photographed). He feels well otherwise.

O/E: 1/19/2012. There were thick honey-colored crusts in a linear distribution over ~ 1/2 of the "S" closure. The crusts were lifted off with a number 15 blade and the base was covered with creamy pus which was cultured and cleansed. The base was glistening granulation tissue, in some areas eroded in others raised.

Clinical Photo after very gentle debridement

Culture Report: Pending

Diagnosis: Erosions secondary to subacute infection. Role of subcuticular sutures may be key. Possible erosive pustular dermatosis of the scalp secondary to inadequately treated infected Mohs wound.

Plan: At this time will wait for culture report and then treat with an appropriate antibiotic. I will debride the hypergranulation tissue and consider using a topical steroid as recommended for erosive pustular dermatosis of the scalp.

Your Comments will be appreciated.



2/22/12 Healed after Keflex 500 mg b.i.d. x 2 weeks and H2O2 cleansing

Puzzling Purpura

Abstract: 11 yo with three week history of localized purpura

HPI: This is a healthy, stable 11 year old who has had two episodes of purpura on the upper arms. Mildly pruritic. Her pediatrician reported the family to social services. She's on no meds.

O/E: There are purpuric bruises on both upper arms. The remainder of the cutaneous examination if unremarkable.

Laboratory: All hematologic studies are normal

Pathology: A biopsy was performed. Results pending

Impression: Puzzling Purpura. Her pediatricians were concerned about child-abuse and referred her to social services. Their report found no evidence of this. It is likely that this is due to some kind of intentional or unintentional trauma. See a similar case "Diagnostic Challenge" presented by Dr. Amanda Oakley in 2007. I am also considering Gardner-Diamond syndrome (whatever that really is). Further reading raises the question of a purpuric contact dermatitis from azo and other clothing dyes.

Question: What are your thoughts?
One Week Follow-up:

Note: Cleared completely after one week. This argues for factitial disease (as our readers' felt)









Reference:
1. Rasmussen JE. Puzzling purpuras in children and young adults. J Am Acad Dermatol. 1982 Jan;6(1):67-72.
2. Meeder R, Bannister S. Gardner-Diamond syndrome: Difficulties in the management of patients with unexplained medical symptoms. Paediatr Child Health. 2006 Sep;11(7):416-9. Available full text.