June 2003

By Stephen Schleicher, MD, and Lawrence Schiffman, DO

		CASE: An 11-year-old boy presents with a facial rash of one week's duration. Topical diphenhydramine and an over-the-counter hydrocortisone cream have not prevented the rash from spreading. From a single small, red, crusty, pruritic patch near the left nostril, the condition has progressed to four discrete, orange-red, crusty patches. Noted are pinpoint vesicles, some of which are open and draining a serous fluid. WHAT IS YOUR DIAGNOSIS?
		This child has impetigo contagiosa, a bacterial infection most commonly caused by Staphylococcus aureus and less frequently by Streptococcus pyogenes. When the latter is involved, glomerulonephritis may be a complication. The skin infection usually occurs on exposed surfaces such as the face and hands and is more common during the summer months. Lesions begin as small microvesicles that rupture and drain a serous fluid, which dries and forms an orange crust. The infection may spread via the fingernails or fomites such as towels and clothing. More extensive cases are best treated with oral antibiotics.

Dr. Schleicher is director of the DermDx Centers for Dermatology of Northeastern Pennsylvania and a clinical instructor of dermatology at Graduate Hospital's City Line Campus in Philadelphia, Kings College in Wilkes-Barre, and Arcadia University in Glenside, Pennsylvania. He is also a member of the EMERGENCY MEDICINE editorial board. Dr. Schiffman is a fellow at the DermDx Centers for Dermatology.