Case 4: Prolonged and Intensely Pruritic Rash on the Hand of a 6-year-old Girl

Presentation

A 6-year-old girl presents with a 9-month history of a nontender but intensely pruritic rash on her left hand and right index finger. She has been evaluated by numerous physicians; diagnosed as having tinea manuum, eczema, and cellulitis; and treated with antifungal agents, antiyeast agents, topical corticosteroids of varying strengths, and 3 courses of oral antibiotic drugs. The rash improves with application of corticosteroids but reappears as corticosteroids are withdrawn. She has normal growth and development with no systemic symptoms. Her medical history includes eczema, asthma, and seasonal allergies. Besides topical corticosteroids, her current medications include cetirizine and montelukast.

Physical examination reveals a well-appearing, well-developed white girl. Inspection of her left hand reveals a well-defined geometric erythematous plaque spanning the lateral one-third of the palm on the left hand, including the first through third digits (Fig 1). A similar rash is present on the right index finger. There is no tenderness, fissuring, or signs of secondary infection. There are no nail changes. Her face, scalp, neck, ears, flexural creases, including antecubital and popliteal fossae, wrists, and ankles are free of lesions.

After physical examination, the patient requests to use her mother’s cell phone. She places the cell phone, which has a plastic cover, in her left hand and supports the phone with her distal palm and second digit. The patient’s mother confirms that the patient …