A seven-year-old girl, with a previous history of severe atopic dermatitis (AD) and sensitization to several allergens, presented to the pediatric emergency department (ED). She was previously followed by a Pediatric Allergologist since she was six months-old and medicated daily with desloratadine and topic tacrolimus, plus topic fluticasone propionate in acute flares. She had interrupted her medication for the last two months.
She presented to the ED complaining of pruritic skin lesions, progressively worse during the past week, and gait limited by pain. She denied fever or other symptoms. On physical examination, she displayed xerosis, scaly eczematous lesions, thickening of the skin and an increase in skin markings (lichenification), with extensive and painful impetiginous lesions scattered throughout the body, worse in the lower and upper limbs and around the neck (Images).
Analytically she had an increased C-reactive protein but no leukocytosis, with eosinophils in the upper normal limit (800 cells/uL). Her blood culture was positive for methicillin-sensitive
Staphylococcus aureus. Her total IgE was elevated (3340.0 kUI/L) with specific IgE positive for several types of mites and olive tree.
Treatment was initiated with flucloxacillin, daily hygiene with a chlorhexidine solution, skin hydration with application of an emollient (moisturizer) and a topic steroid (betamethasone dipropionate twice daily).
By the time of discharge, there was a clear improvement, with lesions in the healing phase, decreased pruritus, and no functional impairment. She resumed follow-up with the Pediatric Allergologist and resumed treatment with oral antihistamine, topic tacrolimus, and topic steroids in flares.
Figure 1. Infected atopic dermatitis in the back of the neck.
Figure 2. Infected atopic dermatitis in the legs.
What is the diagnosis?