“This is a follow-up visit for a rash behind the kid's knee,” the nurse says, handing me the medical record. “I guess the mother had scheduled a telemedicine visit after hours a week and a half ago. It doesn't seem to be getting better. Good luck on this one.”

Over years of practice, I've learned that whenever I'm prompted before a patient visit with the phrase “good luck,” it most likely suggests a significant challenge waiting in the wings.

I open the chart to review the contents. I have not seen this 3-year-old child before; I do not recall this mother or the family. The problem list is short: health maintenance visits, respiratory viral illnesses, a couple of episodes of otitis media. By all parameters, he seems to be a healthy child.

I walk down the hallway and rap on the door before stepping into the examination room.

“Hello,” I say, introducing myself with a fist bump. “Please pardon the mask. It's just part of office protocol in the wake of this pandemic.”

“Oh, I understand completely,” the mother says. “I'm glad to see that your office is still taking precautions.”

I reach for the stool and roll it over to sit down.

“I understand that you had a telemedicine visit the other week: something about a rash behind the knee?”

“Yes, that's right. I saw it after his bath one evening. It didn't seem bad, but I was a little worried when it didn't go away. What with this COVID virus and all, I thought it might be something that should be looked at. Our health insurance plan offers telemedicine visits, so I thought that might be better than bringing him into the office.”

“Was this with a dermatologist?” I ask.

“Well, he said he was a skin doctor. Anyway, he seemed to know what he was doing. He asked me a couple of questions, then told me to turn the camera on my phone so he could see the rash. It was a little tricky at first to get it pointed just right.”

“He didn't ask you to take a digital photo and text it to him?”

“No, he said he got a good look through the camera. It was classic childhood eczema, he said. I guess you see that behind the knees and sometimes in the elbow creases. Anyway, he prescribed this cream,” she hands me a crimped tube, “which I've been using as directed, but it hasn't helped. Actually, the rash got worse—maybe because he picks at it? I don't know, but I thought, well, it's time to bring him in.”

I study the label on the crimped tube of cream: triamcinolone, 0.1%, apply to affected area three times daily. I estimate that half the prescribed amount has been used. The rash is no better, perhaps a bit worse. Something doesn't add up.

“Has your boy had a history of sensitive skin in the past?” I ask. “Any recurrent rashes that come and go? Any symptoms suggestive of allergies to foods or pollen? Asthma? Do any of those conditions run in the family?”

“My husband has some seasonal allergies, but they're mild. No one has asthma or food allergies.”

“I understand,” I say. “Let's have a look at the rash.”

She lifts the boy off her lap to the floor. I bend down and study the popliteal fossae. The area behind the right knee is relatively clear. The left knee shows a cluster of tiny dome-shaped pearly lesions. I reach for the otoscope to scan them under magnification. A couple of the larger lesions demonstrate central umbilication.

I sit back on the stool and rest the otoscope in my lap. Mentally, I search for the right words.

“It looks like he's got molluscum,” I begin, “a little viral wart—very common in young children. It can spread locally, especially by scratching. It's hard to treat, and sometimes the treatment is worse than the condition itself. Most times, if left alone, the body will take care of it on its own.”

“And the cream?”

“Oh, yes—I would stop it. It hasn't helped—no sense continuing to use it.” I decide not to begin a discussion about immunomodulators, and the fact that they can actually predispose the spread of these viral lesions.

“So, what are my options?”

I walk her through the list: chemical cauterization, curettage, imiquimod; I go over the risks and advantages. When I'm done, she asks what I would do if he were my child. “I would let them alone,” I say, “and give his body a couple of months to build up immunity against the virus.”

She ponders the words. “Okay,” she says with a sigh. “I guess I could always bring him back if I need to.”

“Certainly,” I say. “Pandemic or no, the office door is always open.”

They say a picture is worth a thousand words. Many times that's true. But in this case, even if Internet telephotos are an option, there's no substitute for a visual examination in the office.