Pediatric emergency medicine trisk 310

TABLE 65.1
DIFFERENTIAL DIAGNOSIS OF ECZEMATOUS RASH


Allergy
Atopic dermatitis
Allergic contact dermatitis
Autoeczematization
Drug reaction
Photoallergic reaction
Irritant
Irritant contact dermatitis
Lichen simplex chronicus
Nummular eczema
Asteatotic eczema
Dyshidrotic eczema (pompholyx)
Intertrigo
Frictional lichenoid dermatitis
Immunologic
Wiskott–Aldrich syndrome
Hyperimmunoglobulin E syndrome
Omenn syndrome
Severe combined immunodeficiency
Graft-versus-host disease
Agammaglobulinemia
Immune dysregulation, polyendocrinopathy, enteropathy, X-linked
(IPEX)
Infectious
Seborrheic dermatitis
Dermatophyte infection
Scabies

Molluscum contagiosum
Pityriasis rosea
Human immunodeficiency virus
Oncologic


Histiocytosis (Letterer–Siwe)
Cutaneous T-cell lymphoma
Leukemia and lymphoma
Nutritional
Acrodermatitis enteropathica
Pellagra
Kwashiorkor
Other
Psoriasis
Erythroderma a
Netherton syndrome
Ichthyosis
a Potentially

acute life-threatening condition.

Nummular Eczema
Nummular eczema presents as coin-shaped plaques that are erythematous
and may contain tiny vesicles, crusts, and excoriations. Lesions often occur
on the hands, arms, and legs ( Fig. 65.2 ). They may be single or multiple
and are often symmetric. Nummular eczema can be related to dry skin and
atopy. Differential diagnosis includes dermatophyte infection, impetigo, and
contact dermatitis (such as nickel in belt buckles or school chairs or desks).

TABLE 65.2
AMERICAN ACADEMY OF DERMATOLOGY CONSENSUS
CONFERENCE FEATURES OF ATOPIC DERMATITIS
Essential features (must be present)
Pruritus
Eczematous skin changes with chronic or recurring history, typical
morphology, and distribution
• Face, neck, extensor involvement in infants and children
• Flexural lesions in any age group
• Sparing of groin and axillary regions
Important features (seen in most cases, support the diagnosis)
Early age at diagnosis
Personal or family history of atopy
Immunoglobulin E reactivity
Associated features
Atypical vascular responses (e.g., facial pallor, white dermographism,
delayed blanch response)
Keratosis pilaris/hyperlinear palms/ichthyosis/pityriasis alba
Ocular/periorbital changes
Other regional findings (e.g., perioral changes/periauricular lesions)
Perifollicular accentuation/lichenification/prurigo lesions
Adapted from Eichenfield LF, Hanifin JM, Luger TA, et al. Consensus conference on pediatric atopic
dermatitis. J Am Acad Dermatol 2003;49(6):1088–1095. Copyright © 2003 with permission from the
American Academy of Dermatology.

Acute management of nummular eczema involves ruling out any
coexistent superinfection with a bacterial culture from any eroded, crusted,
pustular, or painful lesions, and treatment with potent topical steroids.
Maintenance strategies include using daily petrolatum-based barrier

ointments and intermittent potent topical steroid use (e.g., twice weekly) for
prevention.