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07
Oct

A 10-year-old girl with 5 years of eczema flared up with oozing and crust involved 30% of body surface area

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Case Presentation

A 10-year-old female presents in this clinic with crusted itchy skin with 5 years of eczematous duration (Fig.1A and Fig.2A). Asthma was diagnosed when she was 3 years old (7 years before), Ventolin (salbutamol, a short-acting beta-2 agonist) and inhaled glucocorticoids were administered, wheezing and chest tightness were controlled and improved, and thereafter ventolin was used when necessary. The patient had been in her usual health until approximately 5 years before this presentation, when some rashes developed around her neck area, initially her parents thought it was a kind of heat rash and it will go off by itself, however episodes of pruritic, red, scaly, and crusted lesions on the extensor surfaces of arms and legs were developed, the patient was admitted to hospital, prednisone (oral corticosteroid) was given, and diagnoses of AD (Atopic Dermatitis) was made. During the intervening years, Elomet cream (mometasone, a class III corticosteroid) and Protopic ointment (tacrolimus, an immunosuppressant) had been administered to manage her itchy and rashes. Six months before this presentation, the patient was hospitalized for 7 days due to eczema severe flare-up and treated with prednisone (oral corticosteroid). For 5 months before this presentation, the patient had taken a few days of TCM medication (herbal ingredients unknown) and used pine tar cream, but she had stopped using steroid and tacrolimus cream.

Case_15_neck

On examination, the patient was in mild distress, the mother of patient reported her child no weight loss, cough, dyspnea, nausea, diarrhea, arthralgias, the ventolin was occasionally inhaled when she felt shortness of breath. Atopic dermatitis involved with around 30% of skin surface area of patient, sites of excoriation on the lower limbs and neck area are oozing and crusted (Fig.1A and Fig.2A), the erythema (Fig.1A and 2A) and mild swollen (Fig.2A) are noted. Eczematous lesions tend to be elevated, excoriated and coalesce to form thick plaques (Fig.1A and 2A).

Case_15_leg

The patient was introduced with Tangs derma-zema capsules, 3 capsules (1080 mg) 2 times a day. Daily use of over-the-counter (OTC) emollients to counteract dry skin is advised. One month after the TANGS medication, eczematous on patient’s neck area started to subside (Fig.1B), however flare-up occurred on her ams and legs (Fig.2B), eczematous lesion slightly spread, the skin, in general, is oozing and more reddish (Fig.2B), itching and dryness occur more often and severe than previously, eczematous flakes fall off from lesions on arms and legs are more than prior-to TANGS medication. Patient reported previous heavy application of immunosuppressive cream on her arms and legs area, erythema and edema coexist on her limbs and continue spread in the subsequent two months treatment (Fig. 2C and Fig.2D), patient feel tight and more dryness on her arms and legs but without oozing, intense itching occurs day and night, however her neck eczema respond well, continue subside and reach clinical clearance at month 2 and month 4 (Fig.1C and Fig.1D). On the 4th month of TANGS medication, her legs eczematous lesion starts to improve, reddish reduced and swollen gone (Fig.2E), pruritus are lesser, she report no tightness and dryness on her arms and legs, the itching usually occurs only during the night but bearable, her skin condition continue improved until month 6, one more flares incur only on her legs area (Fig.2G), arms and neck (Fig.1E) area not involved, flare-up on legs area last around 1 month then subside at month 8 follow-up (Fig.2H), however the patient does not turn up at the subsequent month 9 follow-up, she comes back follow-up at month 10 (Fig.1G and Fig.2I), the severity of the flare on her legs is significantly reduced (Fig.2I), itching occurs occasionally and can be stopped upon application of moisturiser. Patient does not come back for subsequent monthly visit until two month later, at month 12, her arms and neck receive full clearance (Fig.1H), the texture of majority area of legs turns to normal skin tone (Fig.2J), but multiple red papules of the legs are still noticeable (Fig.2J), patient reports no intensive pruritus, but sometime feels itchy after shower or sweat, the immediate application of moisturiser is able to relive the pruritus. After the 12 months of TANGS medication, patient has been lost to follow-up.

Discussion
When the above eczema patient presents in this clinic initially, the oozing, crust and mild edema are noted (Fig.1A and Fig.2A), this type of flare is often attributable to infection, most commonly with Staphylococcus aureus [1]. Signs of bacterial infection include weeping, crusts, pustules, failure to respond to treatment, and rapidly worsening eczema [2], hence antibiotics was advised, but her parents declined the use of antibiotics as they reported no difference was observed after a few course of oral antibiotics previously prescribed by other doctors, and they are also concerned bacterial resistance developed on their daughter’s skin. Although skin infection trigger the eczema flares, however two Cochrane reviews of anti-staphylococcal procedure in routine eczema care found no clear evidence of additional clinical benefit [3,4], the more evidence is needed to determine the exact role of antibacterial measures in routine clinical practice.

The above patient receives a recovery gradually in a wavelike process due to the effect of immunosuppressant topical and oral administered previously, the wavelike flares occur on her arms and legs initially and subsequently (Fig.2A-J) during the TANGS treatment, however each subsequent flare is less severer than previous wave (Fig.2A-J), such wavelike flare-up mainly incurs on the leg areas where the corticosteroid cream was frequently applied, there is no wavelike flares observed on neck and trunk areas (Fig.1A-H) where steroid cream was not heavily applied. The time to reach full clearance, the frequency and severity of wavelike process significantly depend on the dosage and potency of cumulated prior immunosuppressive therapy [5], unfortunately the patient is lost to follow-up when she is to be reaching full eczema clearance.

Reference
[1] Bieber T. Atopic dermatitis. New England Journal of Medicine. 2008;358:1483-94.
[2] M A McAleer, C Flohr, A D Irvine.  Management of difficult and severe eczema in childhood. British Medical Journal. 2012;345:e4770.  doi: 10.1136/bmj.e4770
[3] Birnie AJ, Bath-Hextall FJ, Ravenscroft JC, Williams HC. Interventions to reduce Staphylococcus aureus in the management of atopic eczema. Cochrane Database Systemic Review. 2008;3:CD003871.
[4] Bath-Hextall FJ, Birnie AJ, Ravenscroft JC, Williams HC. Interventions to reduce Staphylococcus aureus in the management of atopic eczema: an updated Cochrane review. British Journal of Dermatology. 2010;163:12-26.
[5] T Tang. A Nonimmunosuppressant Approach on Asia Psoriasis Subjects:
5-Year Followup and 11-Year Data Analysis. Dermatology Research and Practice, vol. 2012, Article ID 304172, 11 pages, 2012. doi:10.1155/2012/304172

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