Pruritic blisters on legs and feet

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Pruritic blisters on legs and feet

J Fam Pract. 2008 March;57(3):177-179

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References

1. North American arthropod envenomation and Parasitism. In: Auerbach PS, ed. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby; 2007;947–982.

2. Bjarke T, Hellgren L, Orstadius K. Cheyletiella parasitivorax dermatitis in man. Acta Derm Venereol 1973;53:217-224.

3. Shelley ED, Shelley WB. The diagnostic challenge of non-burrowing mite bites Cheyletiella yasguri. JAMA 1984;251:2690-2691.

4. Infestations and bites. In: Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Treatment. 4th ed. St Louis, Mo: Mosby; 2004;533–534.

5. Elston DM, Stockwell S. What’s eating you? Bed-bugs. Cutis 2000;65:262-264.

6. Steen C, Carbonaro P, Schwartz R. Arthropods in dermatology. J Am Acad Dermatol 2004;50:819-842.

7. The vesiculobullous reaction pattern. In: Weedon D. Skin Pathology. 2nd ed. Brisbane, Australia: Churchill Livingstone; 2002;129–191.

8. Ajithkumar K, Soshamma G, George B. Abnormal insect bite reactions: A manifestation of immunosuppression of HIV infection? Indian J Dermatol Venereol Leprol 2001;67:72-74.

9. Davis MD, Perniciaro C, Dahl PR, Randle HW, McEvoy MT, Leiferman KM. Exaggerated arthropod-bite lesions in patients with chronic lymphocytic leukemia: a clinical, histopathologic, and immunopathologic study of eight patients. J Am Acad Dermatol 1998;39:27-35.

10. Pendersen J, Carganello J, Van Der Weyden MB. Exaggerated reaction to insect bites in patients with chronic lymphocytic leukemia: clinical and histological findings. Pathology 1990;22:141-143.

11. Rosen LB, Frank BL, Rywlin AM. A characteristic vesticulobullous reaction in patients with chronic lymphocytic leukemia. J Am Acad Dermatol 1986;15:943-950.

12. Barzilai A, Shpiro D, Goldberg I, et al. Insect bite-like reaction in patients with hematologic malignant neoplasms. Arch Dermatol 1999;135:1503-1507.

13. Tokur Y, Ishihara S, Tagawa S, et al. Hypersensitivity to mosquito bites as the primary clinical manifestation of juvenile type of Epstein-Barr virus-associated natural killer cell leukemia/lymphoma. J Am Acad Dermatol 2001;45:569-578.

14. Khamaysi Z, Dodiuk-Gad RP, Weltfriend S, et al. Insect bite-like reaction associated with mantle cell lymphoma: clinicopathological, immunopathological, and molecular studies. Am J Dermatopathol 2005;27:290-295.

15. Allergic contact dermatitis. In: Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Treatment. 4th ed. St Louis, Mo: Mosby; 2004;84–97.

16. Kimyai-Asadi A, Usman A, Nousari HC. Ciprofloxacin-induced bullous pemphigoid. J Am Acad Dermatol 2000;42:847.-

17. Kashihara M, Danno K, Miyachi Y, Horiguchi Y, Imamura S. Bullous pemphigoid-like lesions induced by phenacetin. Report of a case and an immunopathologic study. Arch Dermatol 1984;120:1196-1199.

18. Mycoses and algal infections. In: Weedon D. Skin Pathology. 2nd ed. Brisbane, Australia: Churchill Livingstone; 2002: 663.

19. Nakamura E, Taniguchi H, Ohtaki N. A case of crusted scabies with a bullous pemphigoid-like eruption and nail involvement. J Dermatol 2006;33:196-201.

20. Ansarin H, Jalali MH, Mazloomi S, Soltani-Arabshahi R, Setarehshenas R. Scabies presenting with bullous pemphigoid-like lesions. Dermatol Online J 2006;12(1):19.-

21. Elston D. Prevention of arthropod-related disease. J Am Acad Dermatol 2004;947-954.

For certain patients, the DX may be less clear-cut

Similar bullous lesions following insect bites have been reported in patients with HIV,⁸ chronic lymphocytic leukemia,^9-12 EBV-associated Natural Killer leukemia/ lymphoma,¹³ and mantle cell lymphoma.¹⁴ There is ongoing debate as to whether the vesicular lesions in these patients truly represent an exaggerated response to an arthropod bite or mimic an insect-like bite reaction.^10,12

Nevertheless, when you suspect a patient has BABR, be aware of its association with both hematologic malignancies and HIV. Appropriate evaluation, such as HIV screening and complete blood count, should be performed.

FAST TRACK

Treatment centers on oral antihistamines and topical steroids for pruritus

A condition that mimics contact dermatitis

Clinically and histologically, BABR can mimic the following:

Contact dermatitis. With contact dermatitis, the blistering is more likely to appear in streaks or in a linear fashion.¹⁵ Lesions will be painful, as well as pruritic, and occur following direct contact with a plant or chemical allergen.
Drug-induced pemphigoid. The patient’s history will increase your suspicion of drug-induced pemphigoid. Patients may be taking sulfur-containing drugs (furosemide), antibiotics (penicillins, fluoroquinolones), antihypertensives (ACE inhibitors, calcium channel blockers), neuroleptics, or sulfasalazine.^7,16,17 The eruption is usually more generalized than BABR, and may involve the mucous membranes.
Fungal infections. These infections will typically occur on the palms and soles. Infiltrate is typically neutrophilic, but can be eosinophilic.¹⁸
Bullous scabies. Patients will have severe pruritus. Burrows and lesions can typically be found on moist areas (periumbilical, intertriginous skin).^19,20
Bullous pemphigoid. This is more commonly seen in elderly patients with comorbid conditions. Onset of blistering is gradual, and occurs predominantly on flexural skin.

Pemphigoid gestationis, erythema toxicum neonatorum, incontinentia pigmenti, and some pemphigus variants also have predominantly eosinophilic infiltration in the skin. These, however, are clinically distinct from BABR.