Female Age: 3

Background:

Three-year-old Marcella is back in your office with pruritus and eczematous lesions on her hands and feet. You saw her in a similar condition two weeks ago and prescribed tacrolimus 0.03% ointment. Marcella’s mother says she applies the ointment on schedule but worries that her daughter rubs some of it off because the child scratches so much and won’t sit still.

You discuss wet wrap therapy, but Marcella’s mother is wary of a treatment that requires multiple steps and extra time. Besides, she says, the family’s apartment has a shower but no bathtub.

Marcella won’t respond to your questions except to cry when you ask whether her hands and feet itch. She also yawns. During the checkup two weeks ago, Marcella talked and smiled. You see no signs of infection even though Marcella repeatedly rubs the lesions during your exam. You are familiar with alternate treatments such as oral antihistamines to stop the itching and improve sleep, systemic corticosteroids, and intravenous immunoglobulins.