Erythroderma in a 1-month-old boy

Abstract

Report of a caseA 1-month-old Hispanic boy was referred to our department of dermatology for an erythroderma, with the suspicion of seborrheic dermatitis or atopic dermatitis. The first lesions had developed 5 days before on the palms and spread to involve the entire body, associated with an increased irritability. Furthermore the patient was healthy and was fed since his birth exclusively with artificial milk.Physical examination revealed a generalized squamous erythroderma ( Fig. 1). Micropustules, vesicles and several burrows were found on the palms, soles and arms. Papules and vesicles were also present on the face and neck, and a widespread secondary eczematisation was noted particularly on the trunk and legs. General examination was normal without lymphadenopathy and hepato-splenomegaly. Routine laboratory tests were within normal limits with the exception of hypereosinophilia in the blood-cell count (1800/mm 3 ). No history of itching neither cutaneous lesions were observed after examination of the parents. With the exception of the parents, further relatives were not examined.Our clinical suspicion was scabies with a secondary erythroderma. Microscopic examination of burrows scraping revealed a mite of Sarcoptes scabiei hominis (S.S.H.) confirming our diagnosis.The patient was treated in our institution with topical application of permethrin 5% cream from scalp to toes for 6 hours before rinsing with water and soap. The application was repeated one week later and the family members were treated too. A topical corticosteroid was also prescribed to control the secondary eczematisation. One month after the treatment, there was no evidence of recurrence. After 3 years of follow up, the child is healthy without recurrence of any cutaneous symptoms.Scabies is a contagious disorder caused by infestation of the skin by S.S.H. It is characterized by pruritus and a cutaneous eruption of variable severity. Furthermore in neonates, scabies is often misdiagnosed because lesions differ both clinically and morphologically from those in older children and adults. Typical lesions in infants tend to be more widespread distributed, including the face, neck, palms and soles; areas not generally affected in older children and adults [4,5]. The lesions are more often papular, vesicular and nodular with an early tendency to pustules formation. Moreover, the pathognomonic linear burrows are rarely observed and can be obliterated by vesiculation, excorations, crusting, eczematous secondary changes and vigorous hygiene. Irritability, tiredness and poor feeding are also quite characteristic as a result of pruritus [4,5].The diagnosis of scabies in neonates is difficult. Scabies can mimic frequent dermatitis in neonates such as atopic Eur J Pediatr (2007) 166:979-980

A narrative review of the roles of topical permethrin and oral ivermectin in the management of infantile scabies

“…A total of seven articles describing the use of topical permethrin to manage scabies in infants under the age of two months were included from the literature search; six case reports and one retrospective single-centre case series involving seven infants (Table 1). 6,22,[33][34][35][36][37] A total of 13 patients from the seven articles were included. Baseline patient characteristics are provided in Table 1.…”

“…Two articles described cases where permethrin was used in combination with topical corticosteroids to control secondary eczematisation or eczematous reactions. 22,33 Of the seven articles, one failed to provide information on the vehicle used for topical formulation and the treatment regimen. 35 With reference to the six articles that provided details on intervention including a total of 12 patients, the prescribed dose of topical permethrin cream ranged from 2.5 to 5%, and the number of applications ranged from 1-3, with the majority of patients receiving two applications (n = 6; 50%).…”

“…All patients were diagnosed with classical scabies; one patient had secondary erythroderma. Two articles described cases where permethrin was used in combination with topical corticosteroids to control secondary eczematisation or eczematous reactions 22,33 . Of the seven articles, one failed to provide information on the vehicle used for topical formulation and the treatment regimen 35 .…”

“…56,57 Despite these concerns, permethrin is increasingly being used in young infants (Table 1). 6,17,22,[33][34][35][36][37] According to the limited number of cases in the literature reporting the use of topical permethrin to treat scabies in children younger than two months, there is evidence that this medication is highly effective, welltolerated and has an excellent safety profile in this age group, with minimal side effects including mainly eczematous reactions, and no serious or long-term sequelae.…”

“…21 The pathognomonic linear burrows are rarely observed and can be obliterated by vesiculation, pustulation, crusting or secondary eczematous changes. 22 Infants are developmentally ineffective scratchers, and as a result, they generally present with an absence of excoriations, more burrows, and a moderate organism load, which may involve a few hundred mites. 9 Nodular scabies, a well-known clinical variant, is often seen in infants and young children.…”