Photo Quiz

Infant with Diaper Rash and White Bumps



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Am Fam Physician. 2014 Jun 15;89(12):973-974.

A 14-month-old boy is brought to his physician's office because of a diaper rash. Three weeks earlier, he was seen in the emergency department for a beefy-red, plaquelike perineal rash with multiple erythematous papules. The rash did not improve with over-the-counter topical creams and topical nystatin alone, but responded briefly to a regimen of oral cephalexin (Keflex) and fluconazole (Diflucan) with topical nystatin cream. The patient subsequently developed white bumps and blisters in the diaper area and a fever of 105°F (40.5°C). His mother reported that she had recently developed lesions on her lip that crusted over and resolved within a few days.

Physical examination revealed multiple vesicles with discharge in the groin and perineum. There was significant erythema in the groin, perineum, and scrotal area with multiple ruptured and intact vesicles that were 0.3 × 0.3 cm in size (Figures 1 and 2). Ulcerated skin was observed in the gluteal cleft and intertriginous areas. The infant was admitted to the hospital for treatment.

Figure 1.

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Figure 1.


Figure 1.

Figure 2.

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Figure 2.


Figure 2.

Laboratory testing showed an elevated C-reactive protein level of 2.08 mg per L (19.81 nmol per L) and a white blood cell count of 23,000 mm3 (23 × 109 per L). Vesicle fluid was collected for bacterial and viral testing.

Question

Based on the patient's history and physical examination findings, which of the following treatment options is most appropriate?

A. Acyclovir (Zovirax).

B. Fluconazole.

C. Mupirocin (Bactroban).

D. Vancomycin.

E. Zinc oxide cream.

Author disclosure: No relevant financial affiliations.

Address correspondence to H. Daniel Fahrenholtz, MD, at Dan. Fahrenholtz@bannerhealth.com. Reprints are not available from the authors.

REFERENCES

1. Beauman JG. Genital herpes: a review. Am Fam Physician. 2005;72(8):1527–1534.

2. Usatine RP, Tinitigan R. Nongenital herpes simplex virus. Am Fam Physician. 2010;82(9):1075–1082.

3. Wald A, Zeh J, Selke S, et al. Reactivation of genital herpes simplex virus type 2 infection in asymptomatic seropositive persons. N Engl J Med. 2000;342(12):844–850.

4. Reading R, Rannan-Eliya Y. Evidence for sexual transmission of genital herpes in children. Arch Dis Child. 2007;92(7):608–613.

5. Smith JS, Robinson NJ. Age-specific prevalence of infection with herpes simplex virus types 2 and 1. J Infect Dis. 2002;186(suppl 1):S3–S28.

6. Langenberg AG, Corey L, Ashley RL, Leong WP, Straus SE. A prospective study of new infections with herpes simplex virus type 1 and type 2. Chiron HSV Vaccine Study Group. N Engl J Med. 1999;341(19):1432–1438.

7. Humphrey S, Bergman JN, Au S. Practical management strategies for diaper dermatitis. Skin Therapy Lett. 2006;11(7):1–6.

8. Drage LA, Bundrick JB, Litin SC. Clinical pearls in dermatology. Mayo Clin Proc. 2012;87(7):695–699.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

A collection of Photo Quizzes published in AFP is available at http://www.aafp.org/afp/photoquiz.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.



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