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Case Report Quiz THE PATIENT CASE REPORT 7-year-old boy SIGNS & SYMPTOMS þ QUIZ – Body-wide, pruritic, papular rash Richard Temple, MD, – Scalp lesion CAPT, MC, USN; Kevin McDermott, DO, LT, MC, – Excoriation USN; Theodore Rogers, DO, LT, MC, USN Naval Medical Center Camp Lejeune, NC Richard.w.temple2. THE CASE [email protected] A 7-year-old boy presented with a one-week history of a pruritic rash, which first appeared The authors reported no potential conflict of interest on his back and continued to spread across his entire body. The patient’s medical history was relevant to this article. significant for a scalp lesion FIGURE( 1) that was being treated with oral griseofulvin (started The views expressed in this article are those of the authors 3 days earlier). He had no history of seasonal allergies, asthma, recent illness, or recent and do not necessarily reflect immunizations. the official policy or position of the Department of the Navy, The physical exam was significant for a body-wide, nonerythematous, papular rash Department of Defense, or the US Government. (FIGURE 2). There was evidence of excoriation due to itching. No mucosal involvement was appreciated. The remainder of the examination was unremarkable. QUESTION Based on the patient’s history and physical exam, which of the following is the most likely diagnosis? A Gianotti-Crosti syndrome B Atopic dermatitis C Dermatophytid reaction D Morbilliform drug eruption. FIGURE 1 FIGURE 2 A scalp lesion preceded the Diffuse, nonerythematous, body-wide, pruritic rash papular rash COURTESY OF: NAVAL MEDICAL CENTER CAMP LEJEUNE OF: NAVAL COURTESY MDEDGE.COM/JFPONLINE VOL 67, NO 7 | JULY 2018 | THE JOURNAL OF FAMILY PRACTICE 429 CASE REPORT THE DIAGNOSIS z Morbilliform drug eruptions are the The answer isC , dermatophytid reaction. most common type of dermatologic drug reaction.5 These rashes occur approximately DISCUSSION one to 2 weeks after exposure to a causative A dermatophytid reaction is a type of id re- drug; they consist of pruritic, erythematous action, or autoeczematization. An id reac- papules or macules that start centrally and tion is when a localized dermatitis becomes may spread to the proximal extremities.5 a generalized pruritic eruption.1 In this case, Treatment involves discontinuation of the the patient’s dermatitis was the result of a offending agent. Symptomatic relief may be dermatophyte infection (tinea capitis), but achieved with oral antihistamines or topical an id reaction can also occur in response to or systemic corticosteroids.5 noninfectious dermatitides and may be of an atopic, contact, or seborrheic nature.1 Treatment of dermatophytid reactions Dermatophytid reactions occur in up to While the initial impulse in the treatment 5% of all dermatophyte infections (most com- of a dermatophytid reaction may be to monly tinea pedis) and are proposed to be type discon tinue oral antifungals, these treat- IV hypersensitivity reactions to the release of ments actually help resolve the underly- fungal antigens.1 These reactions can occur ei- ing dermatophyte infection and should be While the initial ther before or after the initiation of antifungal continued. For children with tinea capitis, impulse may be treatment. They manifest as symmetric, pruritic, at least 6 weeks of treatment with an oral to discontinue papulovesicular eruptions with fine scaling antifungal agent is warranted. Medications oral antifungals, and commonly affect the face, trunk, extremi- approved by the US Food and Drug Admin- these treatments ties, palms, and interdigital spaces.1 istration include terbinafine (for patients help resolve the >4 years of age) and griseofulvin (for pa- underlying What about other possible diagnoses? tients >2 years of age). Dosages are weight- dermatophyte Gianotti-Crosti syndrome is an asymptomatic, based. (Fluconazole and itraconazole are infection and symmetric, papulovesicular dermatosis that in- not approved for this indication.) Lubricants, should be volves the face, limbs, and buttocks of children topical corticosteroids, and oral antihista- continued. 2 to 6 years of age.2 The lesions develop in re- mines can be used for acute management of sponse to a respiratory or gastrointestinal pruritus.1 illness.2 They are typically associated with Ep- z Our patient was treated successfully stein-Barr virus, hepatitis B, cytomegalovirus, with griseofulvin and an oral antihistamine. respiratory syncytial virus, and coxsackievirus, However, he experienced headaches attrib- but can occur with bacterial infections or follow- uted to griseofulvin and was switched to terbi- ing administration of routine immunizations.2 nafine 5 mg/kg/d for 4 weeks. His tinea capitis The lesions are self-limited and resolve was resolved at 8 weeks. JFP within 2 months.2 Symptomatic lesions may be treated with oral antihistamines or steroids CORRESPONDENCE Richard Temple, MD, CAPT, MC, USN. Department of Family 2 (topical or systemic). Medicine, Naval Medical Center Camp Lejeune, 100 Brewster z Atopic dermatitis is characterized by Blvd, Camp Lejeune, NC 28547; Richard.w.temple2.mil@mail. mil. symmetric involvement of the flexural sur- faces of the body with a pruritic, erythema- tous rash that may have a fine scale.3 It usually REFERENCES 1. Cheng N, Rucker Wright D, Cohen BA. Dermatophytid in tinea manifests prior to 2 years of age, is recurrent, capitis: rarely reported common phenomenon with clinical im- and is commonly associated with allergic rhi- plications. Pediatrics. 2011;128:e453-e457. 3 2. Brandt O, Abeck D, Gianotti R, et al. Gianotti-Crosti syndrome. J nitis and asthma. Treatment involves trigger Am Acad Dermatol. 2006;54:136-145. avoidance, topical emollients, topical corti- 3. Berke R, Singh A, Guralnick M. Atopic dermatitis: an overview. costeroids, dilute bleach baths, and topical Am Fam Physician. 2012;86:35-42. 4. Eichenfield LF, Boguniewicz M, Simpson EL, et al. Translating 3,4 calcineurin inhibitors. For patients with sig- atopic dermatitis management guidelines into practice for pri- nificant nocturnal symptoms and sleep loss, mary care providers. Pediatrics. 2015;136:554-565. 5. Riedl MA, Casillas AM. Adverse drug reactions: types and treat- 4 oral antihistamines may be helpful. ment options. Am Fam Physician. 2003;68:1781-1790. 430 THE JOURNAL OF FAMILY PRACTICE | JULY 2018 | VOL 67, NO 7.
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