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:
I agree with yous diagnosis and as a ddx I supposed a Acrodermatitis Enteropathica.Does patient have a history of refractory diarrhea, failure to thrive, alopecia? That gradually appeared shortly after weaning from breast milk. Does patient have a history of siblings or other family members with similar symptoms in infancy?
ReplyDeleteHelge Riemann of Brunswick, Maine wrote: "If the problem persists despite treatment I would biopsy to rule out a Langerhans cell histiocytosis."
ReplyDeleteThe differential diagnosis for this eruption would include seborrheic dermatitis, contact dermatitis, atopic dermatitis, psoriasis, candidiasis, and Langerhans cell histiocytosis. A trial of topical steroids is worthwhile before a biopsy is planned.
ReplyDeleteI would expect a 9-week-old infant to manifest fleshier thighs and a rounder belly. Perhaps there is an underlying nutritional deficiency in this child.
ReplyDeleteI first thought of seborrheic dermatitis, given the salmon-colored appearance of the eruption; perhaps an early manifestation of Leiner's or Letterer-Siwe Disease.
I've also seen severe contact allergic dermatitis secondary to disposable diaper brands present like this, although that would not explain umbilical involvement.
Agree that psoriasis is most likely given sharp demarcation and umbilical involvement- there may be some clinical overlap with seborrheic dermatitis that explains the neck fold involvement. Sometimes there is superimposed allergic or irritant contact dermatitis as well from the many topicals that distraught parents have been applying so would make sure they stop everything other than what is prescribed. I'd do a KOH just for good measure. Triamcinolone ointment twice daily for 2 weeks is our usual initial treatment for napkin psoriasis.
ReplyDeletei agree with psoriasis. i think it's best if you perform a biopsy prior to any therapy.
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