Disseminated Bullous Impetigo in Children with Atopic Dermatitis

Disseminated Bullous Impetigo in Children with Atopic Dermatitis

• Impetigo is the most common bacterial infection in children, with 30% of cases being bullous impetigo caused by exfoliative toxins A, B, and D from Staphylococcus aureus.
• Atopic dermatitis (AD) is a common pediatric dermatologic disorder that increases the risk of bacterial and viral cutaneous infections, including S. aureus and S. pyogenes.
• AD is also linked to increased risk of extracutaneous infections, including streptococcal pharyngitis, viral upper respiratory infection, influenza, pneumonia, sinus infections, varicella, and urinary tract infections.
• The immune response in AD patients is dysregulated and biased toward type 2 responses, leading to an increased risk of infections.
• Disseminated bullous impetigo (DBI) in children with AD is rare, with only one case report published, and no reports of DBI in AD causing dissemination.
• A study describes 12 children diagnosed with DBI, eleven of which occurred in the context of severe AD, within a six-month period by the Johns Hopkins Pediatric Dermatology Division.
• Misdiagnosis of DBI is common, with the most frequent being a flare of AD, and other misdiagnoses including scabies, eczema herpeticum, ecthyma, varicella, and eczema coxsackium.
• DBI overlying chronic AD can be difficult to diagnose, as true bullae may not be visible.
• Viral cultures are not indicated for DBI unless clinical findings are consistent with eczema herpeticum or eczema coxsackium.
• Rapid clearing of lesions with antibiotic treatment confirms the diagnosis of DBI.
• MSSA is likely the cause of the majority of DBI cases, and clindamycin resistance is more common than methicillin resistance among DBI cases.
• Antibiotic coverage for MRSA (clindamycin or TMP/SMX) to treat uncomplicated cases of DBI is likely unnecessary, particularly in the mid-Atlantic region of the United States.