What is the appropriate management for a 3-year-old with a raised single plaque on the hand accompanied by itching?

Management of a Raised Single Plaque on the Hand in a 3-Year-Old with Itching

For a 3-year-old with a raised, itchy single plaque on the hand, initiate treatment with liberal emollient application and a mild topical corticosteroid (such as hydrocortisone) applied 3-4 times daily, while carefully evaluating for secondary infection or contact dermatitis. 1, 2

Initial Assessment Priorities

The differential diagnosis for a single raised, itchy plaque in this age group includes:

• Localized atopic dermatitis/eczema - most common, especially if there is personal or family history of atopy 1, 3
• Contact dermatitis (irritant or allergic) - consider exposure to irritants like soaps, detergents, or specific allergens 4
• Tinea corporis (ringworm) - fungal infection presenting as an annular plaque 3, 5
• Secondary bacterial infection - look for crusting, weeping, or honey-colored discharge 1
• Eczema herpeticum - if multiple uniform "punched-out" erosions develop, this is a medical emergency 6

Critical Red Flags to Identify Immediately

Watch for signs requiring urgent intervention:

• Multiple uniform, punched-out erosions or vesiculopustular eruptions suggest eczema herpeticum, which requires immediate systemic acyclovir as it "may progress rapidly to systemic infection in the absence of antiviral therapy" 6
• Crusting, weeping, or spreading erythema indicates secondary bacterial infection requiring antibiotics like flucloxacillin or cephalexin 6, 1
• Annular (ring-shaped) border with central clearing suggests tinea corporis requiring antifungal therapy 3, 5

First-Line Treatment Protocol

Emollient therapy (cornerstone of management):

• Apply emollients liberally and frequently, at least twice daily and as needed throughout the day 1
• Use immediately after hand washing to lock in moisture when skin is most hydrated 1
• Avoid products in jars to prevent contamination; use tubes instead 4

Topical corticosteroid for the plaque:

• Hydrocortisone (mild potency) is FDA-approved for children 2 years and older, applied to affected area 3-4 times daily 2
• Use the least potent corticosteroid effective for controlling symptoms 1
• Avoid prolonged continuous use to prevent side effects 1

Hand hygiene modifications:

• Replace soaps with gentle, dispersible cream cleansers as soap substitutes 4, 1
• Avoid washing hands with very hot or very cold water 4
• Apply moisturizer after each hand washing 4
• Use lukewarm water only 1

Trigger Avoidance and Preventive Measures

Identify and eliminate potential irritants:

• Avoid exposure to detergents, soaps, and known irritants like bleach 4
• Keep fingernails short to minimize damage from scratching 1
• Use cotton clothing and avoid wool or synthetic fabrics 1
• Avoid harsh detergents and fabric softeners when washing clothes 1

For suspected contact dermatitis:

• Take detailed history of exposure to cosmetics, personal-care products, topical medications, or specific activities 4
• Consider patch testing if dermatitis is recalcitrant or pattern suggests allergic contact dermatitis 4

When to Escalate Treatment

If bacterial infection is suspected (crusting, weeping, spreading):

• Flucloxacillin is the most appropriate antibiotic for treating Staphylococcus aureus 1
• Consider empirical antibiotics like cephalexin or flucloxacillin to cover secondary bacterial infection 6

If fungal infection is suspected (annular plaque with scale):

• Initiate topical antifungal therapy with imidazoles or consider systemic antifungals if extensive 5

If eczema herpeticum develops:

• Immediate oral acyclovir is required 6, 1
• This is a medical emergency requiring prompt treatment 6

Common Pitfalls to Avoid

• Do not use topical antibiotics (neomycin, bacitracin) as these are known allergens and can worsen contact dermatitis 4
• Do not occlude with adhesive bandages impregnated with bacitracin or benzalkonium chloride, as occlusion without underlying moisturizer worsens dermatitis 4
• Do not use dish detergent or disinfectant wipes on the hands, as these are significant irritants 4
• Avoid steroid phobia - reassure parents about the safety of appropriate topical corticosteroid use, as fear often leads to undertreatment 1

Parent Education Essentials

• Demonstrate proper application technique for emollients and medications 1
• Explain that deterioration in previously stable skin may indicate infection or contact dermatitis 1
• Provide written instructions to reinforce verbal guidance 1
• Emphasize that emollients should be applied liberally - "you cannot use too much" 1

Follow-Up and Monitoring

• Reassess in 1-2 weeks if no improvement with initial therapy 1
• Consider referral to dermatology if the plaque is not responding to first-line management or if diagnosis remains uncertain 4, 1
• For recalcitrant cases, stronger topical steroids, phototherapy, or systemic therapy may be necessary, though these are rarely needed for a single localized plaque 4