Visual Diagnosis: A Child Who Has a Worsening Rash

1. George C. Hescock, MD* 2. Wesley K. Galen, MD* 3. Abraham Gedalia, MD* 4. John L. Ey, MD† 1. LSU Pediatrics/Children’s Hospital, New Orleans, La 2. Clinical Professor of Pediatrics, Oregon Health Science University, Portland, Ore A 3½-year-old African-American boy comes to the dermatologist having a 6-week history of a facial rash that has persisted despite treatment. The previously healthy boy was seen in an emergency department (ED) following a 1- to 2-week history of a nonpruritic rash on his right cheek. The rash had progressed over the previous week despite the use of a topical over-the-counter antifungal medication. One week before the rash appeared, the child experienced low-grade fevers, presumably due to a viral upper respiratory tract infection. A similar rash had appeared on his left cheek 1 year ago following a scratch. That rash finally resolved after several months of frequent application of topical antifungal and antibacterial creams and ointments. The child also has a history of group B streptococcal bacteremia at 2 weeks of age as well as mild intermittent asthma. The physical examination in the ED revealed the child to be well appearing and afebrile, with unremarkable vital signs. His right facial cheek had a 5×3 cm, brightly erythematous plaque with raised borders and some scaling (Fig. 1). The plaque was slightly warm to the touch but lacked significant tenderness. The child was diagnosed as having erysipelas and was discharged with a prescription for oral cephalexin. Figure 1. Erythematous plaque with raised borders and scaling on the right side of the face. One week later, the child returned to the ED complaining that his rash continued to expand despite cephalexin therapy. Again, there was no history of fever or other symptoms, and the plaque was slightly larger (5×5 cm), with other lesions on his face (Fig. 2). Tinea corporis was suspected, the child’s parents were advised to apply clotrimazole-steroid cream to the lesion several times a day until resolution, and he was referred to a pediatric dermatologist. Figure 2. Facial spread of lesions. Three weeks later, …