Itchy Crusty Rash on Face in a 5-Year-Old
The most likely diagnosis is atopic dermatitis (eczema) with secondary bacterial infection (impetigo), and treatment should include liberal emollients, mild topical corticosteroids (hydrocortisone 1% applied 3-4 times daily to the face), and oral antibiotics if crusting suggests bacterial superinfection. 1, 2, 3
Diagnosis
The clinical presentation strongly suggests atopic dermatitis affecting the face, which is the characteristic distribution in children under 5 years old. 4, 1 The diagnosis is clinical and requires an itchy skin condition plus three or more of the following: 4, 1
- History of itchiness in skin creases (or cheeks/forehead in children under 4 years)
- Personal or family history of asthma, hay fever, or atopic disease
- General dry skin in the past year
- Visible eczema on cheeks or forehead in young children
- Onset in the first two years of life
The "crusty" component is critical - this suggests secondary bacterial infection (impetigo), which commonly complicates atopic dermatitis. 4, 3 Crusting, weeping, or honey-colored discharge indicates Staphylococcus aureus or Streptococcus pyogenes superinfection. 4, 3
Critical Red Flag to Rule Out
Examine carefully for eczema herpeticum - look for multiple uniform "punched-out" erosions or vesiculopustular eruptions that are very similar in shape and size. 2 This is a medical emergency requiring immediate systemic acyclovir. 1, 2 If suspected, send swabs for viral culture and electron microscopy. 4
Treatment Algorithm
Step 1: Baseline Management for All Cases
Emollients are the foundation of treatment and should be applied liberally at least twice daily and as needed throughout the day. 1, 2, 5 Use gentle dispersible cream cleansers as soap substitutes and avoid harsh detergents. 1, 2
Step 2: Topical Corticosteroids for Inflammation
Hydrocortisone 1% (mild potency) applied to the affected facial area 3-4 times daily is first-line for facial involvement in children. 2, 6 This is safe for children 2 years and older when used appropriately. 6 The face requires mild potency steroids due to thinner skin and higher absorption risk. 4
Step 3: Address Secondary Bacterial Infection
If crusting is present, treat for bacterial superinfection. 4, 3 The options are:
- Topical antibiotics (mupirocin or fusidic acid) for localized infection 3, 7
- Oral antibiotics for extensive crusting: 3, 7
Send bacterial swabs for culture if infection is suspected to guide antibiotic selection. 4
Follow-Up and Escalation
Reassess in 1-2 weeks if no improvement with initial therapy. 1, 2 Refer to dermatology if: 1
- Not responding to first-line management within 1-2 weeks
- Suspected eczema herpeticum (urgent referral)
- Extensive crusting or severe bacterial superinfection
- Diagnosis remains uncertain
Parent Education Points
Demonstrate proper application technique for emollients and medications with written instructions. 4, 1 Explain that: 1, 5
- Deterioration in previously stable eczema may indicate infection requiring prompt evaluation
- Appropriate topical corticosteroid use is safe - address parental fears about steroids
- Avoid irritants including scented products, harsh soaps, and fabric softeners
- Even mild eczema can significantly impact sleep and quality of life, justifying active management 5
Common Pitfalls to Avoid
Do not delay treatment if bacterial infection is suspected - the crusting component requires prompt antibiotic therapy. 4, 3
Do not assume dietary restriction will help - it is of little or no benefit except in selected infants under professional supervision. 4, 5
Do not miss eczema herpeticum - this is a true dermatologic emergency that can be fatal if untreated. 1, 2