A 5-year-old child presented with a 1-month history of nocturnal and generalized pruritus and multiple tense bullae over both hands. No family members were affected with similar signs or symptoms. Physical examination revealed multiple tense blisters, 0.5-1.2 cm in size, containing clear fluid on both palms (Figure 1). Nikolsky sign was negative. Burrows, erythematous papules, and excoriations on the web spaces of fingers were noted (Figure 2; available at www.jpeds.com). With the clinical diagnosis of bullous scabies, whole-body applications of 5% permethrin lotion and oral antihistamines were used. Cultures did not show growth of any bacteria or fungus. Lesions completely resolved after 1 month. Scabies affects approximately 300 million people annually worldwide. Early diagnosis, generally based on clinical manifestations, is critical. Bullous scabies is a rare subtype of the disease, with only 4 cases reported in individuals aged <14 years. 1 Although several possibilities have been suggested, including superinfection of scabies lesions with Staphylococcus aureus, type 1 hypersensitivity reaction to mites, and autoantibody-mediated bullae formation, the mechanism behind the appearance of blisters remains unclear. 2 The differential diagnosis should include bullous impetigo, erythema multiforme, contact dermatitis, drug eruption, pemphigus, and pemphigoid. The diagnosis of bullous scabies can be confirmed based on the presence of typical scabies lesions (burrows, nodules, and palmoplantar involvement), bullous lesions over typically affected localizations, nocturnal and generalized itching, shared symptoms in family members, and good response to antiscabies treatment. Of note, the scalp and face are specific localizations in the pediatric population and 1 out of 5 infants and children may have mainly daytime pruritus. 3 Recommended treatments include 5% permethrin cream, 1% lindane lotion, and oral ivermectin. 4 In cases involving hyperkeratosis, topical urea or salicylic acid may be useful. Oral antihistamines can attenuate the pruritus. A short course of oral steroids may be needed in some cases to resolve hypersensitivity. We strongly recommend a careful clinical examination and anamnesis to avoid the need for skin biopsy, laboratory tests, or any other invasive examination in children with vesicles or bullae in typical areas of scabies. ■ We thank Pablo Fernandez-Peñas, MD, PhD, FACD, for correcting the manuscript.
