A 5-year-old girl who is well known to your practice attends with her mother


A 5-year-old girl who is well known to your practice attends with her mother. She has been
troubled by worsening pruritus over the last six weeks. She has missed more than ten days of
school in the last month. Her mother reports that she wakes frequently at night and is lethargic
and moody during the day. Her bed sheets are covered in flecks of blood in the morning.
The girl is known to be allergic to egg, fish and peanut, and has begun to develop the
symptoms of seasonal allergic rhinoconjunctivitis within the last couple of months. She has
a positive family history of atopy, both parents are allergic to animals and her older brother
has asthma. Her younger brother has been sent home from nursery with impetigo recently.
Her treatments include an emollient as soap and leave-on preparation and various
strengths of topical steroids ranging from very mild to moderately potent depending on
site and eczema severity. On questioning, however, mother
reports that her daughter’s skin is so sore that she is refusing
to bathe or apply her topical treatment.
A full examination reveals a fractious child; she is unable to
stop scratching her skin once undressed. She is slim, with her
height at the 25th centile and weight at the 4th centile for
her age. She has widespread, mildly tender, shotty lymphadenopathy
(cervical, axillary and groin). Her skin is generally
mildly erythrodermic and extensively excoriated, particularly
her limbs (Fig. 2.1), neck and lower back. The excoriations
are covered with haemorrhagic crust and yellowish exudates

What is the primary diagnosis?
• What secondary complications are exacerbating her pruritus?
• How would you manage this patient?

The primary diagnosis is atopic eczema associated with a positive family history of atopy
as well as manifestations of IgE-mediated (immediate-type) hypersensitivity (food allergy
and allergic rhinoconjunctivitis). This is clearly a moderate to severe flare of her eczema.
The severity of eczema can be ‘scored’ by various validated subjective (e.g. CDLQI – children’s
dermatology life quality index) and objective scoring systems. Crudely, however,
the impact on sleep and school attendance as well as the clinical severity of her eczema
demonstrated in the photograph denotes severe eczema with significant functional
There may be several factors contributing to the current flare. It is likely that there is an
element of secondary infection with Staphylococcus aureus or impetiginization of this
child’s eczema. The extensive yellow crusting of her excoriations, her tender lymphadenopathy,
and the fact that her brother has impetigo, suggest colonization of the patient
and potentially other family members. Difficulty in adhering to a bathing regime is likely
to contribute. Other potential factors which worsen pruritus include iron deficiency. She
is also vitamin D deficient, presumably due to her dietary restriction (egg and fish are the
main dietary sources of vitamin D).
It is important to gain control of this child’s eczema rapidly. Swabs should be taken for
microbiology culture and sensitivity testing both from the patient and her immediate
family members. As there appear to be at least two members of the family affected by
Staphylococcus aureus it would be worthwhile considering Staphylococcus eradication
protocol for the entire family (i.e. antiseptic washes and antibacterial nasal ointment).
The patient might benefit from a 5–10-day course of antibiotic with good Staphylococcus
aureus coverage (first line: flucloxacillin; second line: erythromycin or co-amoxiclav).
The extensive use of a moderately potent topical corticosteroid ointment for 2–4 weeks
may be required before weaning back to weak preparations or calcineurin inhibitors as
maintenance therapy.