SEVERE DIFFUSE DESQUAMATING RASH IN AN INFANT WITH ATOPIC DERMATITIS

Abstract

<h3>Introduction</h3> Atopic dermatitis (AD) encompasses defects in the skin barrier and immune dysregulation which can coexist with other rashes. Here we present a diagnostically challenging case of severe desquamating rash in the setting of underlying AD. <h3>Case Description</h3> A 22-week old male referred to the allergy clinic for evaluation of AD was found to have a severe desquamating rash involving > 75% BSA. Four days prior, he was prescribed amoxicillin for a febrile otitis media with development of a tender, erythematous rash on the upper chest, hours after the first dose with no other immediate reaction symptoms. He was switched to clindamycin/prednisolone on day 3 for impetigo and the rash began to peel. Exam was notable for diffuse coalescing erythematous patches with overlying desquamation that spared the genitalia, hands, soles, and mucosal membranes. He was admitted due to risks of dehydration and infection where he underwent further evaluation. Skin biopsy pathology was consistent with early nutritional dermatitis and labs revealed low zinc levels. Rash improved within a few days with topical hydrocortisone/vaseline and he was discharged on zinc supplementation. <h3>Discussion</h3> The differential diagnosis for desquamating rash in an infant is broad, including staphylococcal scalded skin syndrome, drug rash, Steven-Johnson syndrome/toxic epidermal necrolysis, and contact dermatitis. Ultimately this patient's evaluation supported likely zinc deficiency, despite lack of genital involvement and normal growth/nutrition. It is proposed that the patient's underlying history of AD may have contributed to an atypical presentation of a generalized exfoliative dermatitis, exemplifying the importance of keeping a broad differential.