Tuesday, June 25, 2013

Vesiculobullous eruption in a three year-old

Presented by Dr. Yogesh Jain

History: A 3 year old girl presented with vesiculobullous lesions mainly over neck, upper back, right iliac region, scalp & few over abdomen & lower leg for the past week.
There was a history of fever 7 days ago that lasted for 5 days, high grade, more at night.  No loss of appetite, normal sleep, bowel & bladder habits.
Her elder brother had similar lesions over the scalp 3 weeks back, for which, he has received treatment & was cured.

O/E: She was afebrile with normal general & systemic exam. The vesicles were tense, & on rupture, producing a yellowish watery discharge, somewhat itchy, forming a scaby base with circumscribed borders.

Clinical Photos:

Diagnosis:  We are asking your help for this.


  1. The fact that the child’s older sibling had had a similar eruption 2 weeks prior to the onset of fever in the patient suggests some sort of infectious etiology, most likely viral or bacterial. The asymmetrical distribution of the lesions leads one to consider a bacterial etiology such as staph or strep. Both can produce a clinical picture of bullous impetigo, but these lesions are more extensive than I would expect. Still, the child’s hygiene might have played a role here. One also thinks of staphylococcal scalded skin syndrome, a diagnosis which would be supported by the antecedent 5-day fever.

    Did the child manifest any involvement of the mucous membranes? If so, I would think more along the lines of a viral etiology, or perhaps a drug rash.

    If this were my patient, I would treat with a 10-day course of cephalexin and daily gentle cleansing with Hibiclens. Given the extent of the eruption, I would also obtain a CBC to verify adequate numbers of neutrophils/PMNs.

  2. Interesting case - poor kiddo. I agree that the most likely etiology is bullous impetigo, given the history of a recently affected sibling. I would treat empirically with a 10 day course of oral cephalexin at ~40mg/kg/day divided TID as well as three times daily vaseline (petroleum jelly) to help with skin re-epithelialization. The evening application should be applied after a bathing with water if possible, which will help the crusting to resolve. Another possibility is a photo-accentuated viral exanthem (varicella and Parvovirus B19 can both present with dramatic bullae after sun exposure), which would fit with the h/o antecedent fever. Any h/o enanthem or upper respiratory symptoms to suggest a viral infection?

    The distribution and morphology of these bullae also made me think about pemphigus foliaceus (PF), which can closely mimic impetigo but tends to occur in a "seborrheic" distribution. There are endemic forms of PF (fogo sevalgem) that can occur in clusters (suggestive of an infectious etiology) after genetically susceptible individuals are bitten by the Simuleum black fly. This is much less likely as PF is rare, typically occurs in South America (I'm not aware of any cases in India), and tends to affect older school-aged children and adolescents. Would only consider this if the child fails to respond to supportive measures and oral antibiotics.

  3. Given the clinical scenario of a short history, fever and a recent similar condition in a sibling, i would think of bullous impetigo in this patient. Take a swab from one of the lesions and send it for culture. In fact, it is quite common to have it on the scalp as well. We see this condition fairly common in Malaysia esp malay children which cross infect among the siblings. our outpatient treatment is a wet compress (with diluted KMNO4 1:10 000) followed by topical fusion ointment. We use either oral cloxacillin or a cephalosporin ( cefuroxime or cephalexin) for 7 to 10 days. If this fail, would consider skin biopsy for conditions such as pemphigus foliaceous/vulgaris.


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