Management of a Raised Single Plaque on the Hand in a 3-Year-Old with Itching

Initial Assessment and Diagnosis

The American Academy of Dermatology suggests that the differential diagnosis for a single raised, itchy plaque in a 3-year-old includes localized atopic dermatitis/eczema, contact dermatitis, and secondary bacterial infection, with the most common being localized atopic dermatitis/eczema, especially if there is personal or family history of atopy 1
The British Journal of Dermatology recommends considering exposure to irritants like soaps, detergents, or specific allergens when diagnosing contact dermatitis 2
Secondary bacterial infection should be suspected if there are signs of crusting, weeping, or honey-colored discharge 1
Eczema herpeticum is a medical emergency that requires immediate systemic acyclovir if multiple uniform "punched-out" erosions develop 3

The American Academy of Dermatology recommends applying emollients liberally and frequently, at least twice daily and as needed throughout the day, to lock in moisture when skin is most hydrated 1
Hydrocortisone (mild potency) is recommended as a topical corticosteroid for the plaque, applied to the affected area 3-4 times daily, and the least potent corticosteroid effective for controlling symptoms should be used 1
The Journal of the American Academy of Dermatology suggests replacing soaps with gentle, dispersible cream cleansers as soap substitutes, avoiding washing hands with very hot or very cold water, and applying moisturizer after each hand washing 4

The British Journal of Dermatology recommends avoiding exposure to detergents, soaps, and known irritants like bleach, and keeping fingernails short to minimize damage from scratching 2
The American Academy of Dermatology suggests using cotton clothing and avoiding wool or synthetic fabrics, and avoiding harsh detergents and fabric softeners when washing clothes 1
For suspected contact dermatitis, a detailed history of exposure to cosmetics, personal-care products, topical medications, or specific activities should be taken, and patch testing should be considered if dermatitis is recalcitrant or pattern suggests allergic contact dermatitis 2

The American Academy of Dermatology recommends reassessing in 1-2 weeks if no improvement with initial therapy, and considering referral to dermatology if the plaque is not responding to first-line management or if diagnosis remains uncertain 1
The British Journal of Dermatology suggests that for recalcitrant cases, stronger topical steroids, phototherapy, or systemic therapy may be necessary, though these are rarely needed for a single localized plaque 2