What is the best management approach for a 6-month-old baby with widespread eczema, a soft lump behind the head, torticollis, and cradle cap, who is formula feeding due to initial slow weight gain?

Management of Multiple Conditions in a 6-Month-Old Infant

The optimal management for this 6-month-old with widespread eczema, cradle cap, torticollis, and a posterior neck lump requires aggressive skin barrier maintenance with frequent emollients, appropriate topical corticosteroid use, and early introduction of allergenic foods to prevent food allergies.

Eczema Management

First-Line Treatment

• Emollients: Apply liberally 3-8 times daily, even when skin appears normal 1

  • Ointments are preferred over creams for dry, irritable rashes
  • Continue using Sorbolene but ensure adequate frequency of application

• Topical corticosteroids: Continue DermAid but modify the regimen 1

  • For moderate eczema: Use medium potency corticosteroids for maintenance
  • For severe flares: Use higher potency corticosteroids briefly
  • Apply to affected areas twice daily during flares
  • Avoid prolonged continuous use; the 2-week on/off cycle is appropriate

Infection Prevention

• Keep nails short to prevent scratching damage 1
• Consider antiseptic measures if signs of infection develop:
  • Aqueous chlorhexidine 0.05% for erosive lesions
  • Bleach baths with 0.005% sodium hypochlorite twice weekly 1

Antihistamines

• Short-term antihistamines before bedtime may help control itching and improve sleep 1
• Appropriate for this infant who is scratching constantly, especially during sleep

Cradle Cap Management

• Apply a greasier emollient than currently using to soften scales 2
• Gently brush scales away after softening
• Consider a specialized cradle cap product containing antifungal ingredients like piroctone olamine 3
• Regular shampooing with a mild baby shampoo

Torticollis and Plagiocephaly Management

• Continue prescribed exercises from ENT department
• Encourage tummy time when awake to strengthen neck muscles
• Vary head position during sleep to prevent worsening of plagiocephaly
• Consider repositioning techniques to address the flat head

Posterior Neck Lump

• The soft, mobile, non-tender 3-4cm lump is likely a benign lymph node
• Monitor for changes in size, tenderness, or overlying skin changes
• If the lump persists beyond 4-6 weeks or changes in character, refer for further evaluation

Food Allergy Prevention

• Early introduction of allergenic foods is crucial given the severe eczema 4
• Begin introducing peanut between 4-6 months of age 4
• Also introduce cooked egg around 6 months 4
• Continue formula feeding but ensure adequate nutrition
• Consider allergy testing if eczema persists despite optimized management 1

Parent Education

• Adequate time for explanation and education is essential 4
• Demonstrate proper application of topical treatments
• Provide written information to reinforce discussed issues
• Explain that deterioration in previously stable eczema may indicate secondary infection 4

When to Refer to a Specialist

• If eczema fails to respond to first-line management with appropriate topical steroids 4
• If diagnostic uncertainty about the posterior neck lump persists
• If torticollis does not improve with prescribed exercises

Pitfalls and Caveats

• Avoid using topical corticosteroids continuously for extended periods
• Do not delay introduction of allergenic foods in this high-risk infant
• Recognize that the combination of formula feeding and severe eczema places this infant at higher risk for food allergies
• Avoid over-washing as this can worsen eczema; use soap substitutes instead
• Do not ignore the psychological impact on parents; provide appropriate support and reassurance