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JAMA Pediatrics Clinical Challenge
August 2017

Acral Bullae in a Young Girl

Author Affiliations
  • 1Louisiana State University Medical School, New Orleans
  • 2Medical University of South Carolina, Charleston
  • 3Pediatric Dermatology, Department of Dermatology, Medical University of South Carolina, Charleston
JAMA Pediatr. 2017;171(8):805-806. doi:10.1001/jamapediatrics.2017.0769

A young girl presented to the pediatric emergency department for evaluation of blisters on both of her hands. Three weeks prior, she had returned from school with 2 itchy papules on her right hand. The papules continued to enlarge over the course of the day and progressed to form blisters. The following day, she noticed similar lesions appearing on her left hand. She was evaluated by her pediatrician, who prescribed oral cefdinir and hydrocortisone, 2.5%, cream, but there was no substantive improvement. On further questioning, she recalled similar itchy papules appearing on her feet without progression to blisters. Her medical history was significant for atopic dermatitis that was well controlled with topical triamcinolone, 0.1%, cream. Physical examination demonstrated numerous skin-colored tense bullae on her bilateral hands (Figure 1, A). Xerosis was on the trunk and extremities. On her dorsal and plantar feet, there were macerated, erosive plaques without vesicles or bullae (Figure 1, B). Results of herpes simplex virus polymerase chain reaction, bacterial culture, potassium hydroxide preparation, mineral oil preparation, and direct immunofluorescence were negative.