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Osteomyelitis of the distal phalanges in three children with severe atopic dermatitis
S Boiko1, R A Kaufman, A W Lucky
1Department of Dermatology, University of Cincinnati College of Medicine, OH 45267.
Insights
Severe atopic dermatitis in children can lead to osteomyelitis of the fingers. Intense scratching and minor trauma may cause infections to spread to the bone.
Area of Science:
- Pediatric infectious diseases
- Dermatology
- Orthopedic surgery
Background:
- Atopic dermatitis (eczema) is a chronic inflammatory skin condition often associated with secondary infections.
- Infections in children with compromised skin barriers require careful monitoring for deeper tissue involvement.
Observation:
- Three children with severe, infected atopic dermatitis presented with distal phalangeal osteomyelitis.
- Symptoms included distal subungual black macules, digital swelling, erythema, and pain, without fever or elevated ESR.
- Radiographic or scintigraphic evidence confirmed bony destruction in all cases.
Findings:
- Staphylococcus aureus was identified in skin, nail bed, and bone cultures in two children.
- Streptococcus viridans was also cultured from a nail bed in one patient.
- Immunologic function tests were normal in two children, suggesting non-immunodeficiency-related pathways.
Implications:
- The study highlights a rare but serious complication of severe atopic dermatitis in children.
- It suggests a mechanism involving scratching-induced microtrauma and contiguous spread of infection from the nail bed to bone.
- Early recognition and aggressive management are crucial for favorable outcomes in pediatric osteomyelitis secondary to skin infections.
Abstract:
Three children with severe, secondarily infected atopic dermatitis since infancy developed osteomyelitis of the distal phalanges of the hands. The insidious onset of one or more distal subungual black macules was followed by edema, erythema, and pain in the involved fingers. No child had an elevated erythrocyte sedimentation rate or fever, but all had roentgenographic or scintigraphic evidence of bony destruction. In two children, Staphylococcus aureus grew from skin surface cultures; S aureus also grew from nail bed and osseous cultures of the distal phalanges; Streptococcus viridans grew from one child's nail bed. All children had prolonged hospitalizations. In two children, laboratory evaluation of immunologic function disclosed normal findings. We postulate that intense scratching of infected skin coupled with minor trauma to the fingertips created distal subungual microabscesses that spread contiguously to the underlying bone.