A 6-year-old boy is brought to the accident and emergency department by his parents with a 5-day history of worsening eczema associated with malaise and lethargy. He has worsening pruritus, sleeplessness, painful skin, around his face, neck, chest and forearms. He scores pain as 8 out of 10. His current flare is not responding to diligent application of his usual eczema treatments according to his ‘step-up’ management plan. The onset of his eczema was at the age of 4 months, and although moderately severe in infancy it has been reasonably controlled since starting primary school, with regular use of emollients and mild to moderately potent topical steroids. His background history includes egg allergy (now partially outgrown in that he tolerates well cooked egg in cakes) and asthma, currently stable. He has never been admitted to hospital before. He is fully vaccinated to date and had chickenpox at the age of 4 years. His father suffers from hay-fever and experienced childhood eczema and asthma. He has one older sister (aged 14) who is well.
His medication includes: • Regular emollients • Topical tacrolimus 0.1% twice daily • Hydroxyzine 10 mg nocte during flares and salbutamol inhaler on a prn basis.
Examination
He looks unwell and is febrile at 38.5 °C. Systemic examination is normal except for widespread lymphadenopathy. There is no conjunctival erythema. He has generalized moderate to severe eczema with erythema, dryness, excoriation and lichenification. He has a superimposed monomorphic eruption over his lower face, chest and forearms. The eruption is composed of multiple 23-mm monomorphic ‘punched-out’ erythematous lesions in various stages of evolution. Some of the lesions are vesicular, others pustular, some coalescing, most are eroded and covered with a golden exudate and others haemorrhagic crust.
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