Case 1: A ‘rash’-ional approach to recalcitrant diaper dermatitis

A five-month-old female infant who was born at 24 weeks gestational age presented with a five-week history of an erythematous eruption that began in the perineum. It progressed to involve the entire lower face, with areas of excoriations and erythematous crusted patches around the mouth and distal extremities. The rash did not respond to oral nystatin or topical terbinafine. Due to the persistence of the rash and an intercurrent upper respiratory tract infection, the patient presented to the emergency department. Upon review of systems, the patient had mild diarrhea and no history of alopecia. She was exclusively breastfed. The patient's past history included respiratory distress syndrome, bronchopulmonary dysplasia, retinopathy of prematurity and gastroesophageal reflux disease. Physical examination revealed an irritable infant. She had an axillary temperature of 37.8ºC. The rest of her vital signs were normal. She had multiple confluent maculopapular lesions over her perioral and perineal area (Figures 1 and 2), with erosions, desquamation and crusting. Her fingers and toes were similarly affected, with sparing of the inframammary, labial and gluteal creases. The rest of the examination was normal.