Acropustulose infantile L44.4

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

acropustulosis infantilis; acropustulosis of infancy; infantile acropustulose; Infantile acropustulose; infantile acropustulosis

History
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Kahn and Rywlin, 1979

Definition
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Rare, on the palms of the hands and soles of the feet, usually strongly itchy, intermittent (relapsing period 2-3 weeks), temporary sterile pustulose. Episodic progression with freedom from symptoms for months. Spontaneous healing between the ages of 2-4 years.

Etiopathogenesis
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Unexplained; possible triggers are atopic diathesis and scabies (persistent immune reaction in a previous scabies infection).

Manifestation
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Usually begins in the first months of life, manifestation peak in infants and toddlers, rarely connatal.

Localization
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Palms of hands, soles of feet; also on the dorsal sides of hands and feet. Rarely, and then only sporadically, pustulation of the trunk, buttocks or capillitium.

Clinical features
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Disseminated, inflammatory reddened papules rapidly transform into papulovesicles and finally into pustules and subsequently into crusty lesions. No confluence. Regression within 1-2 weeks. Severe itching. Chronic recurrent course with disease careers of up to 3 years. In the last phase of the disease, the intervals without appearance are prolonged, while at the same time the acuteity of the disease flattens.

Histology
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Intraepidermal, mainly subcorneal unilocular pustules with neutrophil, partly also eosinophilic granulocytes. Perivascular round cell infiltrate in the upper dermis.

Diagnosis
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Clinical signs (acral localization, severe itching, intermittent course) and medical history are diagnostic.

Differential diagnosis
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Therapy
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Self-limiting course; causal therapy not known. Parents should be informed in detail about benignity and the particularities of the clinical course.

External therapy
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Symptomatic, e.g. astringent shaking mixtures or ointments with oak bark or synthetic tanning agents (e.g. Tannolact cream, Tannosynt Lotio).

If the pustulation is very pronounced, application of weakly effective (possibly under-dosed) external glucocorticoids such as 0.5% hydrocortisone cream.

Alternatively a 2-3% polidocanol cream should be used.

Internal therapy
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Therapy with DADPS (1.0-3.0 mg/kg bw/day) successful, but only to be used with a self-limited clinical picture under strict indication (Met-Hb formation, haemolysis!). Recurrence at weaning.

Progression/forecast
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Spontaneous healing between the ages of 2 and 4.

Case report(s)
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The 7-month-old infant suffered since the 2nd month of life from relapsing-like pustular formations on both soles of the feet. The parents reported an agonizing itching, which regularly affected their postpartum rest. All local measures had been unsuccessful so far.

Findings: On both soles of the feet disseminated and grouped vesicles of 0.1-0.3 cm in size and pale yellow pustules on bright red erythema and plaques. Older lesions were characterized by a coarse lamellar scaling.

Diagnosis: No evidence of scabies. Pustule smear: Sterile. Histology: Detection of subcorneal unilocular pustules with neutrophil, sometimes eosinophilic granulocytes. Bulky, perivascular round cell infiltrate in the upper dermis.

Therapy: 0.5% hydrocortisone cream alternating with a 3% polidicanol cream.

Course: Further relapsing activities until 18 months of age. Afterwards, the relapses subside for another 3 months and healing takes place.

Literature
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  1. Braun-Falco M et al (2003) Palmoplantar vesicular lesions in childhood. dermatologist 54: 156-159
  2. Good LM et al (2011) Infantile acropustulosis in internationally adopted children. J Am Acad Dermatol 65:763-771
  3. Hürlimann AF, Wüthrich B (1992) Infantile Acropustulosis. Z Hautkr 67: 1073-1079
  4. Kahn G, Rywlin AM (1979) Acropustulosis of infancy. Arch Dermatol 115: 831-833
  5. Klein CE et al (1989) Infantile Acropustulosis. Dermatologist 40: 501-503Mazereeuw-skin
    J (2004) Infantile acropustulosis. Presse Med 33:1352-1354.
    Meiss F et al. (2008) Infant with pustules on both plantae. dermatologist 59: 323-324

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Last updated on: 29.10.2020