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5-Month-Old Female with Rash on Feet, Soles, Hands, and Palms

Can you diagnose this case?

Christa Root, DO, MPH, and Sharon Dabrow, MD, (University of South Florida, Tampa, Florida ) – Series Editor

Signs and Symptoms

A 5-month-old African American girl presented to a general pediatric clinic for an emergency department (ED) follow-up visit with a rash on her feet, soles, hands, and palms.

The infant had an unremarkable medical history—she had been born at full term and had been healthy prior to the onset of the rash. She did not attend daycare, and no one else in the household had been sick or had had a rash.

The mother reported that the girl had seen multiple providers for the rash, which had not improved. The infant reportedly had been treated with several courses of permethrin for possible scabies, with no improvement in the rash. She then had been seen in the ED and had received a diagnosis of a viral infection.

At a clinic follow-up visit 1 week later, the patient received a diagnosis of varicella. The rash was pruritic and was minimally relieved with diphenhydramine.

She returned to the clinic 2 weeks later for lack of resolution of symptoms. Upon examination at that time, crops of vesicles were present on her soles along with a few sporadic vesicles across her abdomen and back.

What’s your diagnosis?

Choose one to reveal diagnosis and discussion

Eosinophilic pustular folliculitis
Infantile acropustulosis
Erythema toxicum neonatorum
Transient neonatal pustular melanosis

ANSWER: Infantile acropustulosis

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Infantile acropustulosis is a recurrent, pruritic, vesiculopustular cutaneous eruption that occurs predominantly on the hands and feet, including the palms and soles, and occasionally occurs on the scalp, trunk, and face.1-3 The eruptions start as papules that turn into vesicles within 24 hours.1

Background. Onset is usually in the first year of life but can extend to age 3 years.4 The condition is recurrent, and the duration of eruptions varies from 3 to 14 days.1,3,5 Episodes recur every few weeks to months, with spontaneous resolution by age 2 to 3 years.2-5 In the United States, the condition originally had been reported to be more common in the black male population,5 but upon further investigation in international settings, gender and race predominance has not consistently been reported.3,6,7

It is unclear whether a true relationship exists between infantile acropustulosis and scabies—infestation with Sarcoptes scabiei mites—or whether infantile acropustulosis is initially incorrectly diagnosed as scabies. Studies have associated infantile acropustulosis with a history of scabies infestation3,4 and with treatment failure with various scabies medications.3,4,6 The possible association with scabies is controversial, because the diagnosis often is a clinical one that is not confirmed with microscopy.4 In a study of internationally adopted children, Good and colleagues7 found that the children who received a final diagnosis of infantile acropustulosis had seen a provider and received scabies medications an average of 2.2 times for recurrent scabies despite the lack of scabies infestation in family members or other close contacts.

Pathologic examination reveals subcorneal or intraepidermal vesicles and pustules filled with neutrophils, eosinophils, or polymorphonuclear leukocytes.3,4,8 Vicente and colleagues9 described a case of infantile acropustulosis and eosinophilic pustular folliculitis in which lesions biopsied from the scalp and foot had similar histologic features. This finding led them to question whether infantile acropustulosis and eosinophilic pustular folliculitis were the same condition presenting in different locations. Additionally, studies have reported coexisting atopic dermatitis3,7 and eosinophilia.3,9

Differential diagnosis. Other pustular disorders must be considered when evaluating a vesiculopustular eruption. Lesions can appear at birth, during the neonatal period, and from infancy through early childhood.4,10 Therefore, neonatal conditions such as transient neonatal pustular melanosis and erythema toxicum neonatorum should be considered and are differentiated from infantile acropustulosis by their lack of pruritus.

Scabies should be considered with vesiculopustular eruptions occurring in populations with overcrowding and socioeconomic disadvantage11 and when other family members also have pruritus and a rash. In children, the distribution of scabies encompasses the palms, soles, and scalp, whereas in adults, the webs of the fingers, wrists, axillae, and periumbilical areas are most often involved.11

Contact dermatitis should be considered, and skin patch testing can be done for diagnostic purposes.12,13 Dyshidrotic eczema is another relapsing and remitting vesiculopustular rash often affecting the hands, palms, and soles that can develop in adolescence14 and that has been well described in adults13 but is rare in infants.5,14 Cases of dyshidrotic eczema that may be related to receiving intravenous immunoglobulin have been reported in children as young as 7 years.15 Eosinophilic pustular folliculitis, miliaria, and neonatal acne can be considered but often can be differentiated by the location of eruptions and lack of intense pruritus.

Infectious eruptions, such as bullous impetigo from Staphylococcus aureus infection and congenital Candida albicans infection, occurring in the first week of life should be considered.1 The presence of additional symptoms such as fever, irritability, malaise, or upper respiratory tract symptoms should raise concern for varicella, herpes simplex virus, or cytomegalovirus, or bacterial sepsis.1

Management. Various treatments have been described for infantile acropustulosis, and no consenss exists about a cure or symptom relief.

If scabies is suspected, sample the lesions for microscopic confirmation and treat the patient and family/household members, regardless of symptoms,11 with scabies medications.4

Topical corticosteroid use for infantile acropustulosis has been reportedly successful, with improvement noted in 3 to 14 days.4 Mancini and colleagues4 reported that the potency of the topical corticosteroid was not associated with response, although most patients who improved with treatment were taking class II or III topical corticosteroids. However, multiple reports have documented that topical corticosteroids did not help resolve the lesions or improve the pruritus, or were only intermittently beneficial.5,8,14 Betamethasone under occlusion bandages has been reported to decrease the duration of episodes to 2 days.3,16

The use of antihistamines in high doses has been reported to reduce pruritus.14 Maintenance therapy with the antibiotic dapsone (1-2 mg/kg/day, divided twice daily) has been documented to resolve current lesions and decrease recurrence.2,10,14 However, the use of dapsone has been limited due to concern for adverse effects,4 although none were documented in separate studies by Jarratt and colleagues14 and Kahn and colleagues.10

Kimura and colleagues17 described improvement of infantile acropustulosis with maxacalcitol ointment, 0.0025% (an active form of vitamin D3), and noted a decrease in the number of new eruptions and a gradual increase in the duration between episodes.

    1. Van Praag MCG, Van Rooij RWG, Folkers E, Spritzer R, Menke HE, Oranje AP. Diagnosis and treatment of pustular disorders in the neonate. Pediatr Dermatol. 1997;14(2):131-143.
    2. Findlay RF, Odom RB. Infantile acropustulosis. Am J Dis Child. 1983;137(5):455-457.
    3. Dromy R, Raz A, Metzker A. Infantile acropustulosis. Pediatr Dermatol. 1991;8(4):284-287.
    4. Mancini AJ, Frieden IJ, Paller AS. Infantile acropustulosis revisited: history of scabies and response to topical corticosteroids. Pediatr Dermatol. 1998;15(5):337-341.
    5. Jennings JL, Burrows WM. Infantile acropustulosis. J Am Acad Dermatol. 1983;9(5):733-738.
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    15. Gerstenblith MR, Antony AK, Junkins-Hopkins JM, Abuav R. Pompholyx and eczematous reactions associated with intravenous immunoglobulin therapy. J Am Acad Dermatol. 2012;66(2):312-316.
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