• Patient: 11-year-old Aboriginal boy
• Escort: Mother present
• Presenting Complaint: Rash over the anterior aspect of elbows (antecubital fossae).
• History of Presenting Complaint:
  • Recurrent rash (“on and off”).
  • Current episode associated with oozing.
  • Itchy.
• Family History: Positive for eczema.
• Provisional Diagnosis: Atopic Dermatitis with Secondary Bacterial Infection.

SOCRATES for Main Symptom (Rash/Itch)

• Site: Anterior aspect of elbows (flexural areas). Ask: Anywhere else? Face, neck, behind knees?
• Onset: Recurrent episodes (“on and off”). Ask: When did this specific flare-up start? How long do flares usually last?
• Character: Rash described initially, now with oozing. Ask: What did the rash look like before it started oozing? Was it just red and dry? Any blisters? Describe the ooze – clear, yellow, pus-like? Itchy (pruritus). Ask: How intense is the itch?
• Radiation: Usually localized but can spread. Ask: Has the rash spread recently?
• Associated symptoms: Oozing (indicates infection). Ask: Any pain (rather than just itch)? Fever? Feeling generally unwell? Swollen glands nearby? Any asthma or hay fever symptoms flaring up?
• Timing/triggers: Chronic/relapsing course. Ask: Does anything seem to trigger the flares (e.g., heat, sweat, soaps, stress, certain foods, dust mites, pets)? Is it worse at certain times of the day (e.g., night itch)?
• Exacerbating/relieving factors: Ask: What makes it worse (e.g., scratching, heat, wool clothing)? What makes it better? What treatments have you used in the past (creams, tablets)? Did they help? How are you currently managing it?
• Severity/impact: Itch affects quality of life. Ask: How much does the itch bother him? Does it affect his sleep? School attendance or concentration? Ability to play sports or activities?

Red Flags Assessment

• Questions to Ask:
  • Fever or feeling generally unwell?
  • Rapidly spreading redness, warmth, or swelling around the rash?
  • Is the area painful to touch, rather than just itchy?
  • Have you noticed any small blisters or pus spots appearing suddenly?
  • Any swollen glands (lumps) in the neck, armpits, or groin?
  • Any cold sores recently (on him or close contacts)?
• Red Flag Presentations & Significance:
  • Fever, chills, lethargy: Suggests systemic involvement of infection (bacteraemia, cellulitis). Requires urgent assessment +/- admission.
  • Rapidly spreading erythema/warmth: Suggests cellulitis spreading beyond the initial eczema patch.
  • Severe pain out of proportion: Could indicate more severe infection or rarely, necrotising fasciitis (though unlikely in this typical AD distribution).
  • Sudden appearance of monomorphic vesicles or punched-out erosions (especially if painful): High suspicion for Eczema Herpeticum (HSV superinfection). This is a dermatological emergency requiring antiviral treatment.
  • Significant lymphadenopathy: Indicates a robust inflammatory or infectious response; needs assessment to rule out systemic spread.

Differential Diagnoses (DDs) and Specific Questions

• Atopic Dermatitis (AD) with Secondary Bacterial Infection (Most Likely):
  • Presentation: Chronic, itchy, flexural rash with current oozing/crusting. Personal/family history of atopy (asthma, allergic rhinitis, AD).
  • Questions: Confirm history of atopy. Pattern of flares. Response to emollients/steroids. Itch-scratch cycle.
• Impetigo (on top of AD or primary):
  • Presentation: Characteristic honey-coloured crusts, may have started as vesicles/pustules. Can occur on eczematous skin.
  • Questions: Appearance of initial lesions? Other family members/contacts with similar sores? Prior skin trauma/insect bite in the area?
• Allergic Contact Dermatitis (ACD):
  • Presentation: Rash distribution corresponds to contact with an allergen (e.g., nickel in clothing snaps, fragrance in creams). May become secondarily infected. Less likely given flexural pattern and chronicity unless allergen is in clothing/creams used long-term.
  • Questions: Any new soaps, detergents, creams, clothing? Does the rash outline a specific contact area?
• Tinea Corporis (Fungal Infection):
  • Presentation: Annular (ring-like) lesions with central clearing and raised, scaly borders. Can be itchy. Flexural areas can be affected (tinea cruris if groin). Infection less common unless scratched open.
  • Questions: Appearance of the edge of the rash? Any pets at home (especially kittens/puppies)? Other family members with similar rash? Exposure through sports (wrestling)?
• Scabies:
  • Presentation: Intense generalized itch, often worse at night. Burrows may be visible (wrists, finger webs). Papules, vesicles, excoriations common. Secondary infection can occur. Flexural areas often involved.
  • Questions: Anyone else in the household itchy? Characteristic distribution (finger webs, wrists, axillae, groin)? Nocturnal itch?

Past Medical History

• Specific Eczema History: Age of onset, typical sites, severity, previous flares, triggers identified.
• Other Atopic Conditions: History of asthma (control, medications), allergic rhinitis (seasonal/perennial, medications), diagnosed food allergies.
• Previous Treatments: Types of emollients, topical steroids (strength, duration, frequency), antibiotics (oral/topical) used. Response and any side effects.
• Hospitalizations: Any previous admissions for severe eczema or skin infections?
• Growth & Development: Plot on standard growth charts. Chronic severe AD can sometimes impact growth.

Family History

• First-degree relatives: Eczema, asthma, allergic rhinitis, food allergies?
• Severity: Any family members with severe or difficult-to-treat atopic disease?

Psychosocial History (Culturally Sensitive Approach)

• Family & Living: Who lives at home? Housing conditions (overcrowding can increase infection risk, access to bathing facilities)? Presence of environmental triggers (dust mites, mould, pets)?
• School: Impact on attendance, concentration, bullying?
• Cultural Context: Understanding of the condition within the family/community? Use of traditional remedies or healers (important to know for potential interactions or effectiveness)? Barriers to accessing care or adhering to treatment plans (cost, distance, understanding)?
• Healthcare Engagement: Regularity of access to primary care? Relationship with local Aboriginal Medical Service or Health Worker?

Preventative Health

• Immunisation Status: Up-to-date according to the National Immunisation Program Schedule? (Important general health, also Varicella vaccine relevant due to risk of Eczema Herpeticum).
• Skin Care Routine: Current bathing practices, soaps/cleansers used, frequency and type of moisturiser application.

Focused System Review

• Skin: Ask about dryness, rashes, or itching elsewhere on the body. Any signs of chronic scratching (lichenification)? Nail changes?
• Respiratory: Cough, wheeze, shortness of breath (asthma association).
• ENT: Sneezing, runny/blocked nose, itchy eyes (allergic rhinitis association).
• GI: Any symptoms suggestive of food allergy triggers (less common trigger in older children unless previously diagnosed).

ICE (Ideas, Concerns, Expectations)

• Ideas: “What do you think might be causing the rash this time?” “Have you heard about eczema before?”
• Concerns: “What worries you most about this rash?” (e.g., pain, scarring, spreading, infection, missing school, chronic nature).
• Expectations: “What were you hoping we could do for him today?” “What results would you like to see from treatment?”

General Appearance

• Key Observations:
  • Well or unwell? Signs of distress or discomfort (due to itch)? Lethargic? Febrile?
  • Nutritional status and growth parameters (plot height/weight on percentile charts).
  • Any obvious signs of scratching?
• Vital Signs:
  • Temperature: (Normal: ~36.5-37.5°C). Fever >38°C is significant.
  • Heart Rate: (Normal for 11yo: ~60-100 bpm). Tachycardia may indicate systemic illness.
  • Respiratory Rate: (Normal for 11yo: ~18-30 bpm). Tachypnoea less likely unless concurrent asthma.
  • Blood Pressure: (Check if systemically unwell).
  • Oxygen Saturation: (Normal >95% on room air).

Focused Examination Approach: Dermatological

• Sequence: Inspect affected areas → Palpate lesions/surrounding skin → Examine other typical AD sites → Complete skin survey → Palpate regional lymph nodes.
• Inspection:
  • Lesion Morphology:
    • Primary Eczema: Erythematous patches/plaques, possibly dry and scaling or oedematous. Ill-defined borders.
    • Secondary Changes: Excoriations (scratch marks), lichenification (thickened skin lines from chronic rubbing/scratching – may be present if chronic), oozing (serous exudate), honey-coloured crusting (pathognomonic for impetiginisation/Staph aureus), pustules, erosions. Fissures (painful cracks).
  • Distribution: Confirm location in antecubital fossae. Check other flexural areas (popliteal fossae, neck, wrists, ankles), face (especially cheeks, perioral), trunk. Note symmetry.
  • Extent: Estimate Body Surface Area (BSA) involved (patient’s palm ≈ 1% BSA). Assess severity (e.g., mild/moderate/severe based on redness, thickness, scratching, extent).
  • Atopic Stigmata: Look for Dennie-Morgan folds (extra fold under lower eyelid), allergic shiners (dark circles under eyes), increased palmar linearity, Hertoghe’s sign (thinning outer eyebrows), pityriasis alba (hypopigmented patches, usually face).
• Palpation:
  • Lesions: Assess texture (e.g., induration, thickening/lichenification). Check for tenderness (may indicate deeper infection/cellulitis) or warmth.
  • Regional Lymph Nodes: Palpate epitrochlear (above medial epicondyle) and axillary nodes. Note size, tenderness, mobility. Reactive lymphadenopathy is common with secondary infection.
• Complete Skin Examination: Briefly check the entire skin surface for any other rashes or lesions (e.g., signs of tinea, scabies).

Key Clinical Tests/Manoeuvres

• Diascopy: Pressing a glass slide on a lesion can help differentiate erythema (blanches) from purpura (doesn’t blanch – not expected here). Not essential for this case.
• Skin Swab for M/C/S (Microscopy, Culture, Sensitivity): Office test. Use a sterile swab, moisten with sterile saline if needed, firmly roll over an area of active oozing or crusting (lift crust if possible). Send for bacterial culture and sensitivities.
• Skin Scraping for Fungal KOH/Microscopy: Office test. If tinea is suspected (e.g., annular lesions), scrape scale from the active edge of a lesion onto a glass slide, add potassium hydroxide (KOH), and examine under a microscope for hyphae.

Expected Findings

• Normal (if eczema controlled, no infection): Dry skin, perhaps mild erythema or lichenification in flexures. No oozing, crusting, or significant warmth/tenderness. No significant lymphadenopathy.
• Potential Abnormal Findings (This Case):
  • Erythematous, ill-defined, possibly oedematous plaques in bilateral antecubital fossae.
  • Superimposed serous or serosanguinous oozing.
  • Yellowish or honey-coloured crusting.
  • Multiple excoriations.
  • Possible background lichenification if chronic.
  • Skin surrounding the plaques may be erythematous and warm.
  • Potentially tender, mobile, enlarged epitrochlear and/or axillary lymph nodes.
  • May have signs of AD in other typical locations.

Provisional Diagnosis: Atopic Dermatitis with Secondary Bacterial Infection (Impetiginisation)

• Supporting features: History of recurrent itchy rash, typical flexural location (antecubital fossae), family history of eczema, current presentation with oozing and likely crusting (as per case description + common complication). Pruritus is a hallmark.
• Pre-test probability: High.

Differential Diagnoses (Ordered by Likelihood)

1. Infected Atopic Dermatitis (as above):
   • Supporting: All features listed above.
   • Contradicting: None apparent from initial information.
2. Primary Impetigo:
   • Supporting: Oozing, crusting. Aboriginal children have higher rates.
   • Contradicting: History of recurrent underlying rash suggests AD is primary. Impetigo often starts with vesicles/bullae or on traumatised skin, less typically in a purely flexural pattern without preceding eczema.
3. Allergic Contact Dermatitis with Secondary Infection:
   • Supporting: Localized rash with infection.
   • Contradicting: Chronic/recurrent nature and typical flexural distribution less classic for ACD unless related to clothing/creams used over flexures. Less likely without a clear allergen history.
4. Tinea Corporis with Secondary Infection:
   • Supporting: Can occur in flexures, can be itchy, scratching can lead to infection.
   • Contradicting: Morphology usually annular with central clearing; less likely to be bilateral symmetric plaques without classic fungal features. Requires confirmation with microscopy/culture.
5. Scabies with Secondary Infection:
   • Supporting: Itchy, can affect flexures, excoriations lead to infection. Higher prevalence in some communities.
   • Contradicting: Usually more widespread itch, characteristic burrows often seen elsewhere (finger webs, wrists), other family members typically affected. Less likely confined to elbows.
6. Eczema Herpeticum (Not-to-miss serious condition):
   • Supporting: Patient has underlying AD (risk factor). Can present with erosions/oozing.
   • Contradicting: Typically presents with more pain, characteristic monomorphic vesicles or punched-out erosions, often with fever/malaise. Oozing/crusting alone is more typical of bacterial infection. Must consider if any vesicles are seen.

Clinical Decision Rule Application

• Not applicable in this scenario. Diagnosis is primarily clinical, supported by investigations like swabs.

First-line Investigations

• Skin Swab for M/C/S (Microscopy, Culture & Sensitivity):
  • Rationale: To confirm bacterial infection, identify the causative organism (usually Staphylococcus aureus, sometimes Streptococcus pyogenes), and determine antibiotic sensitivities to guide treatment, especially if systemic therapy is needed or infection is recurrent/severe. Check for MRSA.
  • Expected results: Likely positive for Staphylococcus aureus. Microscopy may show Gram-positive cocci in clusters. Sensitivity results guide antibiotic choice.
• (Optional) Skin Scraping for Fungal Microscopy (KOH prep):
  • Rationale: If morphology is atypical or tinea is suspected (e.g., raised annular border).
  • Expected results: Negative for fungal hyphae in typical infected AD.

Second-line Investigations

• Complete Blood Count (CBC / FBC):
  • When to consider: If the child appears systemically unwell, febrile, or has rapidly spreading cellulitis.
  • Interpretation guidelines: Leukocytosis (raised White Cell Count) with neutrophilia supports significant bacterial infection. Eosinophilia may be present due to underlying atopy but is non-specific.
• IgE Levels (Total and Specific RAST):
  • When to consider: Generally not indicated for routine diagnosis or management of AD or its infections. May be considered by a specialist (Dermatologist/Immunologist) in severe, refractory cases or if specific food/environmental triggers are strongly suspected despite avoidance measures.
  • Interpretation guidelines: Total IgE is often elevated in AD but lacks specificity. Specific IgE (RAST) indicates sensitisation, but clinical correlation is required to confirm allergy.
• Viral Swab for HSV PCR:
  • When to consider: If Eczema Herpeticum is suspected (vesicles, punched-out erosions, significant pain).
  • Interpretation guidelines: Positive PCR confirms HSV infection.

Non-pharmacological Management

• Skin Care Education (Crucial):
  • Bathing: Daily or twice daily baths/showers in lukewarm water (5-10 mins). Use soap-free washes or gentle cleansers (e.g., pH-neutral, fragrance-free). Avoid harsh soaps and bubble baths.
  • Drying: Gently pat skin dry with a soft towel; avoid vigorous rubbing.
  • Emollients: Apply generous amounts of a thick, bland, fragrance-free emollient (ointment or cream preferred over lotion) all over the body within 3 minutes of bathing (“soak and seal”) and at least 2-3 times daily. Continue even when skin looks clear.
  • Wet Dressings (Wraps): Can be considered for moderate-severe flares (often requires specialist nurse guidance) to soothe itch and enhance topical treatment penetration, but use cautiously over infected areas initially.
• Trigger Avoidance:
  • Identify and avoid known irritants (e.g., specific soaps, detergents, chemicals).
  • Wear soft, breathable fabrics like cotton; avoid wool and synthetics next to the skin.
  • Keep fingernails short to minimize trauma from scratching.
  • Manage overheating and sweating (use fans, appropriate clothing).
  • Environmental control (if relevant triggers identified, e.g., dust mite covers, pet restrictions).
• Itch Management:
  • Cool compresses.
  • Distraction techniques.
  • Consider non-sedating antihistamines for daytime itch if allergy suspected (limited evidence for itch in AD itself) or sedating antihistamines (e.g., promethazine – Phenergan, alimemazine – Vallergan) at night to aid sleep (use cautiously and short-term).

Pharmacological Options

• Treating the Infection:
  • Topical Antibiotics: For localized, mild-moderate infection.
    • Mupirocin 2% ointment (Bactroban): Apply TDS to affected areas for 5-7 days. (PBS listed). Monitor clinical response. Good Staph/Strep coverage.
    • Fusidic Acid 2% cream/ointment (Fucidin): Apply TDS for 5-7 days. (PBS listed). Monitor clinical response. Resistance can be an issue with prolonged/repeated use.
  • Systemic Antibiotics: For more widespread infection, moderate-severe signs, associated cellulitis, or failure of topical treatment. Guided by swab results when available, but start empirically. Duration typically 5-7 days.
    • Flucloxacillin: (If no penicillin allergy). First-line for S. aureus. Dose: 12.5-25 mg/kg (max 500mg) QID. (PBS listed). Monitor clinical response.
    • Cephalexin: (If mild penicillin allergy – non-anaphylactic). Alternative Gram-positive cover. Dose: 12.5-25 mg/kg (max 500mg) QID. (PBS listed). Monitor clinical response.
    • Trimethoprim-sulfamethoxazole (Bactrim/Septrim) OR Clindamycin: Consider if MRSA is suspected (previous history, community prevalence, no response to first-line). Dosing requires careful calculation. Refer to guidelines/specialist advice. (PBS listed). Monitor clinical response.
• Treating the Eczema (Inflammation): Commence once infection is under control (or sometimes concurrently with antibiotics if inflammation is driving the cycle).
  • Topical Corticosteroids (TCS): Apply after emollients (allow emollient to soak in for 15-30 mins). Use appropriate potency for site and severity. Aim for short-term control of flare (e.g., 1-2 weeks), then taper frequency or step down potency.
    • Mild Potency (e.g., Hydrocortisone 1%): Suitable for face, sensitive areas, or very mild flares elsewhere. Apply BD. (PBS listed). Monitor for skin thinning (rare with appropriate use).
    • Moderate Potency (e.g., Mometasone furoate 0.1% – Elocon, Methylprednisolone aceponate 0.1% – Advantan): Suitable for trunk/limbs in moderate flares. Apply OD. (PBS listed). Monitor for skin thinning (low risk with appropriate use).
  • Topical Calcineurin Inhibitors (TCIs): (e.g., Tacrolimus – Protopic, Pimecrolimus – Elidel) – Second-line, steroid-sparing agents, often initiated by specialists. Can be used on sensitive sites. May sting initially. Not typically first-line in primary care for an infected flare.

Patient Education Points

• Nature of Atopic Dermatitis: Explain it’s a chronic condition with flares and remissions, not contagious. Focus on control, not cure. Genetic predisposition (“runs in families”). Role of skin barrier dysfunction.
• Infection: Explain the signs (oozing, crusting, increased redness/pain), that scratching breaks the skin allowing germs in. Emphasise completing the antibiotic course if prescribed. Explain infection *is* potentially contagious through direct contact with ooze/crusts.
• Skincare: Demonstrate correct application of emollients (smooth down gently in direction of hair growth) and TCS (fingertip unit = amount from end of finger to first crease, treats area of 2 adult palms). Reinforce the “soak and seal” technique. Emphasise consistent emollient use is key for prevention.
• Treatment Plan: Clearly explain the role of each medication (antibiotic for infection, TCS for inflammation, emollient for barrier repair/prevention). Provide a written action plan if possible.
• When to Return: Explain red flags warranting urgent review (spreading redness, fever, severe pain, blisters/erosions suggesting Eczema Herpeticum). Schedule follow-up.
• Resources: Provide links to reputable websites (e.g., ASCIA, DermNet NZ, Eczema Association Australasia). Connect with Aboriginal Health Service resources if appropriate.

Follow-up Planning

• Short-term: Review in 3-5 days to assess response to antibiotics and initial flare management. Check swab results.
• Medium-term: Review in 2-4 weeks to assess overall eczema control, reinforce education, adjust treatment plan (e.g., taper TCS), ensure adherence.
• Long-term: Regular reviews (e.g., every 3-6 months when stable) to monitor control, adjust maintenance therapy, manage flares proactively.
• Parameters for Reassessment: Resolution of infection signs (oozing, crusting). Reduction in erythema, itch, and excoriations. Improvement in sleep and quality of life. Family’s understanding and confidence in management plan.

Referral Considerations

• Dermatologist:
  • Diagnostic uncertainty.
  • Severe or widespread AD (>10-20% BSA).
  • Recurrent severe flares or frequent infections despite optimal primary care management.
  • Failure to respond to appropriate topical therapy (including potent TCS).
  • Significant impact on quality of life.
  • Consideration for second-line therapies (phototherapy, systemic agents, biologics).
• Immunologist/Allergist:
  • If specific food or aeroallergen triggers are strongly suspected based on history and require formal assessment (skin prick testing, specific IgE).
  • Multiple allergic comorbidities (asthma, rhinitis, food allergy) requiring integrated management.
• Paediatrician: If concerns about growth, systemic illness, or complex comorbidities.
• Aboriginal Health Worker/Liaison Officer: To provide culturally appropriate support, education, and help navigate the healthcare system. Crucial for engagement and adherence.

Scenario 1: Suspected Eczema Herpeticum

• Key Clinical Variation: Child presents with rapid worsening of eczema, but instead of just oozing/crusting, there are clusters of small, uniform vesicles (like tiny blisters) or painful, circular, ‘punched-out’ erosions, often on the face or upper body. Child may have fever, be irritable and unwell. Pain is often more prominent than itch.
• Impact on Diagnosis: High suspicion for Eczema Herpeticum (HSV superinfection). This is a dermatological emergency.
• Modified Management Approach:
  • Urgent assessment required (consider ED presentation).
  • Viral swab of a vesicle base/erosion for HSV PCR.
  • Commence systemic antiviral therapy immediately (do not wait for results): Oral Aciclovir (age/weight appropriate dosing). IV Aciclovir if severe, unable to take orally, or immunocompromised.
  • Continue appropriate topical care for AD and treat secondary bacterial infection if also present (often co-exists).
  • Ophthalmology review if eye involvement suspected.
• Learning Points: Recognise the distinct morphology (monomorphic vesicles/erosions) and systemic symptoms. Prompt antiviral treatment is crucial to prevent dissemination and complications (e.g., herpes keratitis, encephalitis).

Scenario 2: Severe Atopic Dermatitis Resistant to First-line Therapy

• Key Clinical Variation: Despite consistent use of appropriate emollients, potent topical steroids, and trigger avoidance, the child continues to have widespread (>20% BSA), intensely itchy, lichenified eczema significantly impacting sleep and daily life. May have frequent secondary infections.
• Impact on Diagnosis: Severe, recalcitrant Atopic Dermatitis.
• Modified Management Approach:
  • Confirm adherence and correct technique with current therapies. Re-evaluate triggers.
  • Referral to a Dermatologist is essential.
  • Specialist options may include:
    • Wet wrap therapy (can be initiated inpatient or taught outpatient).
    • Phototherapy (Narrowband UVB).
    • Systemic immunosuppressants (e.g., ciclosporin, methotrexate, azathioprine – used less commonly now).
    • Biologic therapy (e.g., Dupilumab – targets IL-4/IL-13 pathway, PBS subsidised under specific criteria for severe AD > 6 years old).
• Learning Points: Recognise when first-line management fails. Understand the stepped-care approach and the indications for specialist referral and advanced therapies. Importance of multidisciplinary care.

Scenario 3: Atopic Dermatitis with Community-Acquired MRSA Infection

• Key Clinical Variation: Child presents with typical infected AD (oozing, crusting, +/- pustules/boils). However, a recent skin swab confirms Methicillin-Resistant Staphylococcus aureus (MRSA), OR the infection fails to improve significantly after 3-5 days of appropriate first-line beta-lactam antibiotic (Flucloxacillin/Cephalexin), OR there’s a history of previous MRSA infections/colonisation, OR infection is unusually aggressive/purulent.
• Impact on Diagnosis: Infected Atopic Dermatitis complicated by MRSA.
• Modified Management Approach:
  • Obtain (or review) skin swab M/C/S results – specifically check MRSA status and sensitivities.
  • Choose systemic antibiotic based on sensitivities if available.
  • Empiric oral options for community-acquired MRSA (while awaiting sensitivities or if unavailable) include:
    • Trimethoprim-sulfamethoxazole.
    • Clindamycin (check local resistance patterns; risk of C. difficile).
  • Consider topical decolonisation strategies if recurrent MRSA (e.g., mupirocin nasal ointment, antiseptic body washes like chlorhexidine or bleach baths) – usually under specialist guidance.
  • Reinforce hygiene measures for patient and family (hand washing, not sharing towels).
  • Consider Infectious Diseases consultation for complex/recurrent cases.
• Learning Points: Be aware of local MRSA prevalence. Check M/C/S results carefully. Know appropriate empiric choices for MRSA when needed. Understand importance of hygiene and potential decolonisation.

Summary Table: Key Diagnostic Features

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