What is the likely diagnosis and recommended management for a dry, scaly rash on both cheeks of a 6‑month‑old infant?

Atopic Eczema (Atopic Dermatitis)

The most likely diagnosis is infantile atopic eczema, and management should begin with liberal emollient application at least twice daily to the entire body plus mild topical corticosteroids for inflammatory areas. 1

Diagnostic Confirmation

This presentation is classic for atopic eczema in a 6-month-old infant:

• Facial involvement—especially both cheeks—is the hallmark distribution pattern for children younger than 4 years, distinguishing infant eczema from the flexural pattern seen in older children 1, 2
• The diagnosis is clinical and does not require laboratory testing; it is confirmed when itchy skin (observable as scratching or rubbing behavior in infants) is present together with three or more of: facial involvement in children <4 years, generalized dry skin, family history of atopic conditions, or visible eczematous lesions 1
• The diaper area is characteristically spared in infantile atopic dermatitis, which helps differentiate it from irritant or infectious diaper rashes 2, 3

Common Diagnostic Pitfall to Avoid

• Do not dismiss facial rashes in infants as simple "baby acne" without evaluating for atopic features such as dry skin, observable scratching/rubbing, and family history of atopy 1

First-Line Management

Emollient Therapy (Foundation of Treatment)

• Instruct parents to apply emollients liberally at least twice daily to the entire body—not only to affected areas—and provide written instructions on proper application technique 1
• Emollients address the fundamental skin barrier dysfunction that underlies atopic eczema and should be continued even when the rash improves 1, 4

Topical Corticosteroids for Flares

• Use mild topical corticosteroids for inflammatory areas (the dry, red patches on the cheeks) 1, 4
• Demonstrate proper application to parents and address common corticosteroid fears by explaining that appropriate use is safe 1
• Apply corticosteroids to inflamed skin, then layer emollients over the entire body 1

Red-Flag Signs Requiring Urgent Evaluation

Watch for complications that necessitate immediate intervention:

• Crusting or weeping lesions suggest possible Staphylococcus aureus superinfection; obtain swabs for culture when bacterial infection is suspected 1, 3
• Multiple uniform "punched-out" erosions or vesiculopustular eruptions indicate eczema herpeticum (herpes simplex infection), a medical emergency requiring immediate systemic acyclovir therapy 1, 3

Parent Education Essentials

• Spend adequate time demonstrating proper treatment application and emphasizing the need for generous emollient use 1
• Educate caregivers about signs of infection—weeping, crusting, or punched-out lesions—that require prompt medical attention 1
• Explain that deterioration in previously stable eczema may indicate infection or contact dermatitis 1

Dietary Restriction Warning

• Do not recommend dietary restrictions without professional supervision, as they rarely benefit eczema and may cause nutritional deficiencies 1, 5
• Introducing or avoiding allergenic foods at any particular age does not modify eczema risk 5

When to Refer

Refer to dermatology or allergy/immunology if:

• The infant fails to respond to first-line management (emollients plus mild topical corticosteroids) within 1–2 weeks 1
• Suspected eczema herpeticum or extensive crusting/severe bacterial superinfection is present 1