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A man in his mid-20s with a history of atopic dermatitis presented to the emergency department with a 1-week history of a worsening painful and pruritic generalized rash. Examination revealed erythematous erosions on the trunk and limbs with shallow bullae (Figure 1; Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org) and absence of Nikolsky sign.
Swabs were negative for herpes simplex and varicella zoster viruses. Punch biopsy showed superficial acantholysis (Figure 2). Direct immunofluorescence was negative. He was diagnosed with disseminated bullous impetigo and treated with cefadroxil, doxycycline, and topical corticosteroids with acetic acid wet dressings with improvement (Supplemental Figures 2 and 3, available online at http://www.mayoclinicproceedings.org).
Bullous impetigo is a common skin infection in children; disseminated bullous impetigo (defined as more than 10 lesions and involvement of multiple body sites) is reported in children and 1 adult with severe atopic dermatitis.
Clinical clues include history of atopy, lack of systemic symptoms, widespread shallow bullae and erosions, and absence of Nikolsky sign. Thorough history, examination, and bacterial and viral swabs aid in diagnosis. Skin biopsy specimens for histopathologic evaluation and direct immunofluorescence should be obtained if immunobullous conditions are considered. Oral antibiotics and treatment of underlying atopic dermatitis lead to rapid improvement. Disseminated bullous impetigo should be considered in patients with a blistering rash and a history of atopic dermatitis.
Potential Competing Interests
The authors report no competing interests.
We are grateful to the Appignani Lichen Planus Benefactor Gift and the British Association of Dermatologist’s Geoffrey Dowling Fellowship for supporting Dr Xie’s visiting research fellowship.
Supplemental Online Material
Disseminated bullous impetigo and atopic dermatitis: case series and literature review.