Fig. 36.1
Typical pustules and vesicles infantile acropustulosis occurring on the hands in an 18-month-old boy and month after clearance of scabies
Infantile acropustulosis occurs worldwide. Reports in East Asian children and occasionally Caucasian children have appeared in the literature [6]. Onset is usually in infancy or toddler years, especially between 2 and 10 months of age [6], but cases do occur even in adolescents, often being precipitated by or mistaken for scabies in this setting. Resolution by age 2 is usual [7]. Cases reported in international adoptees highlight that the lesions are often misdiagnosed as scabies, and that more than half of cases go undiagnosed. The setting of crowded unclean prior living conditions can be a risk factor [8]. An association with underlying atopic dermatitis was also noted in a series of international adoptees [8].
Clinical Features/Diagnosis
Diagnosis is clinically made by the presence of pruritic vesicopustules over the palms and soles extending up to the wrist and calf in some cases.
Exclusion of scabies as a diagnosis is needed and can be accomplished by mineral oil preparation.
Infantile acropustulosis is a recurrent, pruritic, vesicopustular disorder of the palms and soles [4]. 1–2 mm papules and pustules of the soles (100 %) and hands (94 %) will be noted in infantile acropustulosis [8]. The disease is usually seen in young patients within the first 1–2 years of life. Biopsy demonstrates necrolysis of keratinocytes followed by formation of intraepidermal pustules with neutrophils and eosinophils [9]. Peripheral eosinophilia and high IgE levels have been demonstrated in some cases [10, 11]. A mineral oil preparation can be performed to rule out scabies. Direct immunofluorescence is negative for these lesions.
Differential diagnosis includes pustular psoriasis [12], allergic contact dermatitis, and scabies, which must always be ruled out. Recently, cases of hand-foot-mouth disease have been reported with severe lesions of the extremities mimicking acropustulosis [8]. Similarly, IL-1 receptor antagonist deficiency has been described to cause infantile acropustulosis mimicking infantile pustular psoriasis of the extremities [13].
Treatment
Brief application of Class I or II topical corticosteroids usually clears specific episodes.
Disease remission can be achieved through the usage of oral dapsone in patients who do not have G6PD deficiency.
Therapy of infantile acropustulosis was originally systemic dapsone therapy which was complicated by risk of hemolysis and methemoglobinemia, requiring pretreatment G6PD screening (especially in children of color) and ongoing blood counts [14]. More recently, this therapy has been replaced with usage of mid- to high-potency topical corticosteroids which are highly effective, although relapses and recurrences can be noted [15]. In the setting of suspected scabies, therapy of scabies should first be initiated. A case report highlighted good response in a 9-month Japanese male infant with topical maxacalcitol 0.0025 % (Oxarol, Chugai Pharmaceutical Co., Ltd., Tokyo, Japan) applied twice a day for one week followed by usage every 3–4 days with complete crop cessation and clearance of lesions [16].
Research
This author is currently in the process of publishing her experience with the usage of topical dapsone 5 % gel twice daily for corticosteroid-resistant lesions. Monitoring of blood counts to identify hemolysis should be done in these cases until such time as it is understood how much dapsone is absorbed by infants and children through the palms and soles.
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