Does the recurrent rash in this infant signal an infestation?

Dermclinic
A Photo Quiz to Hone Dermatologic Skills 

Case: A 10-month-old boy has had a recurrent rash on his palms and soles for the past few months. His parents describe several episodes of multiple pustules that appear and then “dry up” in about 2 weeks. They think the rash may bother the infant because he sleeps less well during flares. The family physician who initially evaluated the infant treated the entire family for scabies; however, the rash has continued to recur.

Does the recurrent rash in this infant signal an infestation?

(Answer on next page.)

Dermclinic – Answer

No, acropustulosis of infancy is a chronic skin eruption that may
mimic scabies infestation

Acropustulosis of infancy (infantile acropustulosis) is an unusual, benign, chronic vesiculopustular eruption that predominantly affects the hands and feet. It may be present at birth but is more commonly first noted in early infancy. There is no racial or sex predilection. Although the cause of the condition is unknown, it is not infestation with scabies. Acropustulosis of infancy has been reported to occur after treatment of a scabies infestation. Its similar clinical appearance to scabies seems to suggest an immunologic postscabetic reaction; however, this association is unusual. Scabies should not be diagnosed in children until a mite can be identified microscopically.

Acropustulosis of infancy typically presents as 1 to 2-mm edematous papules that evolve into distinct vesicles and vesiculopustules; the rash is often pruritic. The lesions erupt in crops that resolve within 7 to 10 days only to recur within a few days to weeks. They most commonly occur symmetrically on the palms and soles and may develop along the sides of the fingers and toes.

Skin biopsies show an inflammatory condition, which exhibits superficial pustules filled with neutrophils, without any evidence of infection or infestation.

Acropustulosis of infancy resolves spontaneously within 2 to 3 years. Potent topical corticosteroids are useful in the initial stages of the eruption; however, this treatment should be discontinued once the vesiculopustules become dry and yellow-brown. Simple emollients can be used between acute flares. Because of the prominence of neutrophils on skin biopsies, systemic dapsone has been tried in patients who show no response to potent topical corticosteroids; successful use of this
treatment in these patients has been reported.