Acropustulosis

 

Infantile acropustulosis is a recurrent, self-limited, pruritic, vesicopustular eruption of the palms and the soles occurring in young children during the first 2-3 years of life. Newly described in 1979, infantile acropustulosis is probably much more common than the scarcity of reports would imply.¹

Pathophysiology

The pathophysiology of infantile acropustulosis is unknown. Many cases of infantile acropustulosis are preceded by well-documented or suspected scabies infestation, and a scabies id reaction has been suggested.^2,3,4 More often, cases of infantile acropustulosis occur despite scabies having been thoroughly ruled out. Bacterial and viral culture results are consistently negative, and negative immunofluorescence results suggest that infantile acropustulosis is not an antibody-mediated autoimmune process

History

The classic history of infantile acropustulosis is an infant aged 2-12 months developing pruritic erythematous macules or papules that progress into vesicles and then pustules. Children are fretful, irritable, and obviously uncomfortable, but otherwise healthy. Individual bouts of infantile acropustulosis last 7-15 days and recur in 2- to 4-week intervals.

Often, children have been empirically treated with antiscabies medicines prior to presentation⁴ . The intensity and the duration of infantile acropustulosis attacks diminish with each recurrence.

Physical

The hands and the feet are always involved in infantile acropustulosis, usually on the palms, the soles, and the lateral surfaces. Lesions may occur on the dorsal aspects of the hands and the feet as well as the trunk, the scalp, and the face.

Infantile acropustulosis lesions begin as small macules or papules that then form distinct, noncoalescing vesicles and pustules (see the image below). They heal with macular hyperpigmentation. No other organ systems are involved in infantile acropustulosis,

Causes

The cause of infantile acropustulosis is unknown. Scabies as a preceding or concomitant infestation is well documented in some cases. Many children are undoubtedly misdiagnosed as having scabies and treated with lindane or permethrin without any confirmatory scrapings. No other infectious agent has been documented.

Laboratory Studies

No laboratory studies are needed to make the diagnosis of infantile acropustulosis. A complete blood cell count often shows eosinophilia. Cultures and smears help to rule out an infectious etiology.

Histologic Findings

A unilocular, subcorneal, or intraepidermal pustule containing polymorphonuclear neutrophils or eosinophils is characteristic in infantile acropustulosis. Papillary dermal edema and a mild perivascular, mostly lymphocytic, infiltrate in the dermis may be present.⁵ Direct immunofluorescence results are negative.

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Medical Care

Treatment is often unnecessary because of the self-limited nature of infantile acropustulosis. Topical steroids⁴ and oral dapsone⁷ have been used successfully, if justified in more difficult cases. Topical pramoxine preparations are available without prescription for the treatment of pruritus. Oral antihistamines may be useful in infantile acropustulosis.

Consultations

In infantile acropustulosis, consult a dermatologist or a pediatric dermatologist.

Activity

Isolation is not warranted.

Medication

High-potency topical steroids (classes 1 and 2) have been used successfully for control of pruritus. Children who are extremely symptomatic may be treated with dapsone.

Topical steroids

These agents provide symptomatic relief of pruritus.

Betamethasone (Diprolene, Betatrex)

For inflammatory dermatoses responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Use fluorinated topical steroids with caution in children.