Makindo Medical Notes

Introduction: Chronic rash in a child can result from a variety of underlying causes such as atopic dermatitis (eczema), psoriasis, allergic reactions, infections, or genetic conditions. The approach to managing a chronic rash depends on accurate diagnosis, symptom control, and addressing underlying causes.

Detailed History

• Duration: How long has the rash been present?
• Onset: Gradual or sudden?
• Pattern: Does it come and go, or is it persistent?
• Triggers: Exposure to allergens (e.g., foods, soaps, chemicals), temperature changes, or stress?
• Family History: Any family history of eczema, asthma, hay fever, or autoimmune conditions?
• Symptoms: Itchiness, pain, discharge, or any other associated symptoms such as fever?

Physical Examination

• Examine the rash for location, extent, pattern, and morphology (e.g., papular, vesicular, scaly).
• Assess the distribution: Is it localized or generalized?
• Note any associated findings: Crusting, weeping, excoriations, or lichenification.
• Look for systemic signs of infection, such as fever or lymphadenopathy.

Differential Diagnosis

• Atopic Dermatitis (Eczema): Commonly seen in children with a personal or family history of atopy (asthma, allergies).
• Psoriasis: Well-demarcated, scaly plaques, often found on the scalp, elbows, and knees.
• Contact Dermatitis: Reaction to an irritant or allergen.
• Fungal Infections (e.g., Tinea): Annular lesions with raised borders, may involve the scalp (tinea capitis) or body (tinea corporis).
• Impetigo: Superficial bacterial infection, often with honey-colored crusts.
• Scabies: Itchy rash, often in web spaces of fingers, wrists, and groin.

Investigations (if needed)

• Skin swab: For bacterial or viral culture if infection is suspected (e.g., impetigo).
• Skin scraping: For fungal testing (KOH prep) in suspected tinea.
• Patch testing: To identify allergens in suspected contact dermatitis.
• Biopsy: In persistent or unclear cases to rule out other dermatological conditions (e.g., psoriasis, dermatitis herpetiformis).

Management Strategies

• Moisturizers: Regular use of emollients to hydrate and repair the skin barrier (e.g., petroleum jelly, creams).
• Avoid Triggers: Identify and avoid potential triggers (e.g., soaps, allergens, temperature extremes).
• Topical Steroids: Prescribe mild-to-moderate strength steroids (e.g., hydrocortisone, clobetasone) for inflammation control in eczema or psoriasis.
• Antihistamines: For managing itching (especially in atopic dermatitis).

Condition-Specific Treatment

• Atopic Dermatitis (Eczema):
  • Emollients and moisturizers for daily use.
  • Topical steroids for flare-ups.
  • Topical calcineurin inhibitors (e.g., tacrolimus) in steroid-resistant cases.
  • Education on skin care and avoiding triggers.
• Psoriasis:
  • Topical steroids combined with vitamin D analogs (e.g., calcipotriol).
  • Phototherapy in moderate-to-severe cases.
  • Referral to dermatology for systemic treatment in severe cases (e.g., methotrexate, biologics).
• Contact Dermatitis:
  • Identify and avoid the causative allergen or irritant.
  • Topical steroids for inflammation.
  • Patch testing to confirm allergens.
• Fungal Infections (Tinea):
  • Topical antifungal agents (e.g., clotrimazole, terbinafine) for localized infection.
  • Oral antifungal treatment (e.g., griseofulvin) for scalp or widespread involvement.
  • Keep affected areas dry and clean.
• Impetigo:
  • Topical antibiotics (e.g., fusidic acid, mupirocin).
  • Oral antibiotics (e.g., flucloxacillin) in more severe cases.
  • Good hygiene practices to prevent spread.
• Scabies:
  • Topical scabicides (e.g., permethrin cream) applied to the entire body.
  • Treat all close contacts to prevent reinfection.
  • Oral ivermectin in resistant cases.

6. Referral

• Dermatology referral: For persistent, recurrent, or unclear rashes that do not respond to standard treatments.
• Infectious disease consultation: In cases of chronic infections or when systemic involvement is suspected.

7. Parent/Guardian Education

• Provide guidance on daily skin care routines (use of emollients, proper bathing practices).
• Educate about the nature of chronic skin conditions and the importance of adherence to treatment.
• Advise on managing triggers, diet, and the potential need for long-term care in cases like atopic dermatitis or psoriasis.