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Recurrent pruritic vesicles
Post Date: 06/05/2009
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A 1-year-old boy was brought in for a second opinion about the recurrent pruritic vesicles and pustules on his hands and feet. This was the third episode and in both of the previous episodes, the doctors thought the child had scabies. The child was treated with permethrin both times and within 2 to 3 weeks the skin cleared. No other family members had lesions or symptoms.
What's your diagnosis?
This patient had a typical case of infantile acropustulosis, which is often misdiagnosed as scabies. This intensely pruritic, vesiculopustular disease of young children is rare, and typically begins in the second or third months of life, though it can begin when the patient is 10 months old. It occurs slightly more often in darker skinned patients and in boys, can be recurrent, and typically remits when the child is 6 to 36 months of age.
It’s unclear what causes acropustulosis, though some speculate that it is a persistent reaction to scabies (“postscabies syndrome”). Oral antihistamines may be helpful in controlling pruritus. Pramoxine (lotion or cream) may be used topically to control itching as it works by a different mechanism than antihistamine. Corticosteroids (topical and oral) are generally not effective.
We reassured the mother that the condition is not dangerous and would go away on its own. We told her to return with her son if the pustular eruption significantly worsened.
This case was adapted from: Shedd A, Usatine R. Pustular diseases of childhood. In: Usatine R, Smith M, Mayeaux EJ, Chumley H, Tysinger J, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009: 432-434.
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