Bullous Scabies in a 5-Year-Old Child

Abstract

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.

Scabies masquerading as bullous pemphigoid: scabies surrepticius

“… 8 – 27 Including the patient in this report, bullous scabies has been described in 46 individuals: 31 men (69% of patients) and 14 women (31% of patients). 8 , 25 The gender was not described in one child. 25 …”

“…Nearly two-thirds of the individuals who presented with bullous scabies (29 of 46 patients, 63%) were older than 60 years; only 17% of the individuals (8 of 46 patients) were less than 30 years. 9 , 13 , 16 , 22 , 25 , 27 …”

Tense bulla on the palm

“…The differential diagnoses of tense palmar bulla in children include infantile bullous pemphigoid, epidermolysis bullosa or bullous scabies 4,5 . As in our case, Gram‐staining of the bulla aspirate may be useful in the diagnosis of bullous impetigo with atypical presentations.…”

Case Report: Bullous Scabies in Two Children below 10 Years

“…The previous review demonstrated that BS commonly afflicts the elderly with a median age of 70 years with a male predilection, 1 and only four were younger than 10 years. [2][3][4][5] However, Boralevi et al 6 reported that 6.2% patients of scabies (12 out of 193) below 15 years presented blisters, implying that BS might not be so rare in children. Interestingly, the present two cases were boys with of age 7 years as well as 6 months and were diagnosed by our groups within only 2 years, suggesting that BS in children may be more common than our anticipation indeed.…”

“…3 Among them, only four were found to be below than 10 years. [2][3][4][5] Herein, we added another two cases with this rare condition who were younger than 10 years.…”