A 21-day-old male infant born at 34 weeks gestation is evaluated in the pediatric clinic f… — USMLE Step 2 CK

A $21$ -day-old male infant born at $34$ weeks gestation is evaluated in the pediatric clinic for a spreading rash in the diaper area that has worsened over the past $4$ days. He was discharged from the neonatal intensive care unit one week ago after a $14$ -day stay for prematurity and suspected early-onset neonatal sepsis, for which he received a $7$ -day course of intravenous ampicillin and gentamicin. Currently, he is breastfeeding well and gaining weight appropriately. Vital signs include a temperature of $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), heart rate of $140$ /min, and respiratory rate of $38$ /min. Physical examination of the perineal region reveals sharply demarcated, beefy-red plaques that prominently involve the inguinal creases. Several pinpoint erythematous papules and pustules are scattered on the lower abdomen and upper thighs, distinct from the primary confluent rash. Which of the following is the most appropriate next step in management for this patient's skin condition?

Topical nystatin therapyCevap
B
Topical hydrocortisone and zinc oxide therapy
C
Topical mupirocin therapy
D
Oral fluconazole therapy
E
Reassurance and increased frequency of diaper changes

Cevap

Topical nystatin therapy

This neonate's clinical presentation is highly characteristic of Candidal diaper dermatitis. The infection is caused by the overgrowth of Candida albicans, which is particularly common in infants who have recently received broad-spectrum systemic antibiotics (such as the ampicillin and gentamicin this patient received in the NICU). The classic physical exam findings are beefy-red, sharply demarcated plaques that prominently involve the intertriginous areas (inguinal creases/skin folds). The presence of 'satellite lesions'—small, discrete erythematous papules or pustules located beyond the margins of the primary rash—is pathognomonic. The standard, most appropriate next step in management is the application of a topical antifungal agent, such as nystatin, clotrimazole, or miconazole, to the affected area.

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Analyze the physical examination findings of the rash.

The rash features beefy-red plaques that involve the inguinal skin folds, accompanied by outlying satellite papules and pustules.

Identifying the specific morphological characteristics and distribution of a diaper rash is the critical first step in diagnosis.

Evaluate the patient's medical history for relevant risk factors.

The infant recently completed a 7-day course of intravenous broad-spectrum antibiotics (ampicillin and gentamicin).

Systemic antibiotics alter normal gastrointestinal and cutaneous flora, strongly predisposing neonates to opportunistic fungal overgrowth, specifically Candida albicans.

Synthesize the findings to differentiate between common diaper dermatoses.

The involvement of the skin folds and presence of satellite lesions confirms Candidal diaper dermatitis, distinguishing it from irritant contact dermatitis (which spares the folds).

Accurate differentiation ensures that inflammatory vs. infectious conditions receive appropriate, targeted therapy.

Determine the optimal pharmacotherapy for the established diagnosis.

Topical antifungal therapy (nystatin) is selected.

First-line management for localized cutaneous candidiasis is a topical antifungal agent.

Anahtar Kavram

Diagnosis and management of Candidal diaper dermatitis in neonates

Soru

Cevap

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