Seven Year Old Boy with Chronic Dermatitis

A.D. is a 7 year-old boy who was adopted from Siberia by a family in western Massachusetts at 21 months of age. Since adoption he has had recurrent dermatitis on torso and extremities. The lesions are mostly nummular by history. They have responded to systemic antibiotics on occasion. He was seen here yesterday for the first time for a second opinion.

The child appears normal otherwise. He has no evidence of atopy. This is the largest lesion. All are plaques, all covered with some crust, intensely pruritic. I applied some pressure to the large plaque with a cotton tipped applicator and a small amount of creamy pus was extruded.

My working diagnosis is nummular eczema driven by hypersensitivity to staph. A culture was taken and I'll wait for results before treating. This has been going on for 5 years. I may do a biopsy, but am not sure it will be helpful.

Any thoughts would be appreciated. The parents are at their wits end. He has also been treated with mupirocin cream in past with some success. Tacrolimus was not helpful.

The culture grew out coagulase positive staph sensitive to everything; even Penicillin G. This is unusual in the U.S. where most Saph is resistant to penicillin. One wonders if this is a strain he brought over from Russia when he was adopted. I started him on Pen VK 250 mg qid. I will add a topical corticosteroid and mupirocin - the latter for nares and crural folds. Will give follow-up after a couple of weeks. If he continues to have staph infections like this, I will look into his Ig status.


Right leg