Two-month-old with diffuse erythema: A case report

Introduction

Diffuse erythema in infants presents a formidable diagnostic challenge because of overlapping clinical features among infectious, inflammatory, and genetic dermatologic conditions. The diagnosis is further complicated when multiple processes occur concurrently, such as a primary dermatosis with secondary bacterial and/or fungal infections. Among the differential diagnoses, inverse psoriasis, which is characterized by well-demarcated, erythematous lesions in intertriginous areas, can be particularly difficult to diagnose. In young infants, timely recognition and treatment are essential to prevent morbidity, yet the rarity of inverse psoriasis in this age group may delay definitive diagnoses. We describe the case of a 2-month-old female with acute, rapidly progressive erythema involving multiple body regions, highlighting the need for a broad differential diagnosis, early multidisciplinary collaboration, and heightened awareness of atypical presentations in this age group.

Case report

We present a case of a 2-month-old white female patient with a history of persistent seborrheic dermatitis of the scalp and chronic diaper dermatitis who developed an extensive erythematous rash within 24 h. According to the mother, the rash appeared 6 days after receiving her 2-month routine vaccines. On initial presentation, the patient had acutely progressing generalized erythema of the face, scalp, neck folds, portions of the abdomen, and inguinal region with severe yellow, greasy scales on the scalp that had spread to include the eyebrows and cheeks (Figure 1(a) and (b)). Two days prior, a “blister-like” eruption appeared on the right cheek and had since scabbed over.

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Figure 1.

(a, b) Presentations of erythroderma in patient. (A) Yellow, greasy scales of scalp, cheeks, and eyebrows on erythematous background. (b) Erythroderma of neck folds with satellite lesions. All images represent initial presentation on admission.

Mother reported decreased oral intake over the previous 24 h but denied fever, decreased urine output, bloody stools, or purulent discharge. The patient was born at 37 weeks of gestation via vaginal delivery to a mother who was Group B Streptococcus negative. The patient’s newborn stay was uncomplicated, and the state newborn screen was negative. There was no family or household history of methicillin-resistant Staphylococcus aureus or herpes simplex virus (HSV).

Initial workup in the emergency department was significant for leukocytosis 14.3, hemoglobin 10.6, hematocrit 31.4, platelet count 638,000, and a negative respiratory pathogen panel. Inflammatory markers included C-reactive protein 0.7 mg/dL and procalcitonin 0.08 ng/mL. A peripheral blood culture was collected and was later positive for Staphylococcus epidermidis at 18 h. Abdominal X-ray revealed gaseous distention consistent with non-obstructive ileus.

Upon admission to the pediatric floor, HSV/varicella-zoster virus (VZV) PCR swabs of the skin and eyelids were collected. The patient was empirically started on Cephalexin, Valacyclovir, and oral Fluconazole. This regimen was chosen to provide empiric coverage for bacterial staphylococcal/Streptococcus skin infection, HSV/VZV, and fungal diaper dermatitis, respectively. Treatment also consisted of oil and a desquamating comb for seborrheic dermatitis, with appearing scales.

Dermatology was then consulted and agreed that the neck rash was most consistent with a staphylococcal/Streptococcus skin infection and agreed with HSV antiviral coverage until proven negative based on the presence of satellite lesions. Dermatology also felt that the skin findings could ultimately be due to underlying inverse psoriasis, given the psoriasiform nature and location of the lesions. Because of this, a short-term course of Mometasone with transition to Tacrolimus 0.03% BID was the treatment of choice. Triamcinolone was used instead of Mometasone due to facility availability. Pediatric Infectious Disease was then consulted for recommendations concerning possible eczema herpeticum versus staphylococcal/streptococcal scalded skin syndrome (SSSS). On day 2, HSV/VZV PCR swabs of the skin and eyelids were negative.

Within 48 h, the patient’s rash dramatically improved. The only complication during the patient’s admission was a single episode of tachypnea and increased work of breathing, which required 3 h of oxygen support.

The patient was discharged home on Cephalexin, Clindamycin, Fluconazole, Triamcinolone 0.1% topical ointment, and Nystatin 100,000 units/g topical cream. Patient was also referred to outpatient Pediatric Dermatology for additional workup regarding a possible immune-mediated process of inverse psoriasis, potentially benefiting from short-term topical Mometasone and transition to Tacrolimus following infection clearance.

Discussion

This case provides a unique presentation of multiple causes of erythroderma in a 2-month-old and the importance of a multifaceted clinical workup. Because erythroderma can coincide with a variety of unique etiologies, it is important to compare clinical presentations. In this case, there was a high clinical suspicion for seborrheic dermatitis, SSSS, eczema herpeticum, inverse psoriasis, and diaper dermatitis.

With the crusting lesions on an erythematous base spanning the face and trunk, the top differential diagnosis was initially eczema herpeticum. However, cutaneous findings of eczema herpeticum are typically pustules and punched-out erosions. Workup requires an HSV PCR analysis of skin scraping of the affected areas, as well as the mucous membranes of the eyes, which was negative in our case. ² Empiric treatment includes Acyclovir or Valacyclovir.

After eczema herpeticum was ruled out, pediatric infectious disease and dermatology suspected seborrheic dermatitis. This rash classically presents with greasy-looking, yellow scales in areas with numerous sebaceous glands, including the scalp and face, which was consistent with our patient. ⁴ In more severe cases, erythroderma can be present, resulting in erythematous patches underlying the scales and plaques. This manifestation can be difficult to differentiate from psoriasis and needs expert opinion from a dermatologist. ⁴

Because this presentation of erythroderma included the scalp, neck folds, and groin instead of extensor surfaces, inverse psoriasis was also suspected. ⁵ Short-term Mometasone (3–4 days) with transition to Tacrolimus 0.03% BID was the treatment of choice, but Triamcinolone use still resulted in clinical improvement.

Although inverse psoriasis is associated with the prominent areas of erythroderma in this case, erythema in the neck folds and inguinal regions raised suspicion for SSSS. ³ This disease process often begins as a flaccid bulla, which then can crust over, as it did in our case. ² Because of the nature and potential correlation between blister and rash, clindamycin was added to the regimen of cefazolin to cover for related staphylococcal or streptococcal exotoxin.

Diaper dermatitis was included in the differential due to a history of previously diagnosed diaper dermatitis in combination with a known prevalence of diaper dermatitis in this specific patient population as high as 40%. ¹ The erythroderma associated with the diaper area of this patient spared the inguinal folds, as is classically associated with diaper dermatitis. Due to the chronic nature of this patient’s diaper dermatitis, we suspect a fungal pathogen, such as Candida albicans, resulted in skin breakdown and a superimposed bacterial infection.

This clinical presentation highlights the complexity of diffuse erythroderma and the management of its respective differential diagnoses. Because there may be multiple infectious and noninfectious pathologic processes underlying such a presentation, it is important in the acute setting to broadly treat to allow for quicker healing. This is why we opted to use antibiotics as well as topical steroids. Unfortunately, this approach can make it difficult to determine if there was one specific treatment that would have caused symptom improvement. It can also be difficult to determine if the presentation is entirely a result of acute illness or if it is instead an acute worsening of an underlying chronic condition. In these cases, it is imperative to have an outpatient follow-up after symptom resolution to determine if there is an underlying chronic pathology. Our patient was able to follow up with the dermatology outpatient, who felt that our patient showed signs of underlying inverse psoriasis, and she will follow up with them as needed. The multiple possible etiologies that range from infectious to noninfectious emphasize the importance of collaboration between Pediatric Hospitalists, Dermatologists, and Infectious Disease specialists.

Conclusion

This case presented the unique circumstance of multiple erythroderma etiologies presenting in combination with one another as an acute-on-chronic fungal and bacterial process. This case also further demonstrates the intricacies of understanding erythroderma presentations and the collaborative management across medical disciplines to come to a differential diagnosis list and management. The differential list in this specific case included eczema herpeticum, seborrheic dermatitis, diaper candidiasis, streptococcal skin infection, bullous impetigo, SSSS, and inverse psoriasis. The possibility of each differential was considered based on clinical presentation, consultation, and evidence-based literature review. In conclusion, the final diagnosis of progressive fungal diaper dermatitis, bullous impetigo with progression to SSSS, and inverse psoriasis was accepted due to the patient’s rapid improvement and response to anti-fungal treatment, antibiotics, and Triamcinolone. The diagnosis was also accepted due to the clinical presentation of the characteristics of erythroderma, which coincided with expected physical exam findings. A follow-up of the exploration of inverse psoriasis as a potential cause of presentation was performed in an outpatient setting. Dermatology ultimately felt that the patient’s symptoms were consistent with the most common presentation of psoriasis in infants and that they highly suspected a diagnosis of inverse psoriasis.