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Vesiculobullous Disorders in Children

Article  in  The Indian Journal of Pediatrics · February 2015


DOI: 10.1007/s12098-015-1708-4 · Source: PubMed

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Indian J Pediatr (September 2015) 82(9):805–808
DOI 10.1007/s12098-015-1708-4

ORIGINAL ARTICLE

Vesiculobullous Disorders in Children


Sahana M. Srinivas & Preeti K. Sheth & Ravi Hiremagalore

Received: 14 July 2014 / Accepted: 21 January 2015 / Published online: 19 February 2015
# Dr. K C Chaudhuri Foundation 2015

Abstract literature describing the epidemiology of vesiculobullous dis-


Objective To study the frequency and clinical pattern of orders in children. Hence the authors proposed to study the
vesiculobullous disorders in children. epidemiological pattern of vesiculobullous disorders in
Methods A retrospective chart review of all children diag- children.
nosed with vesiculobullous disorders over a period of 36 mo
from January 2011 through December 2013 was performed.
All children 18 y and below were included in the study.
Results A total of 213 children presenting with vesiculo- Material and Methods
bullous lesions were examined during the study period.
Vesiculobullous disorders constituted 3.6 % of the total 5889 This study is a descriptive study, with a retrospective chart
dermatoses seen during this period. The most common review, comprising of 213 children seen over a period of
vesiculobullous disorder in children was infections (129, 36 mo from January 2011 through December 2013. All chil-
60.6 %), followed by genodermatoses (35, 16.4 %), inflamma- dren 18 y and below, with vesiculobullous disorders, attending
tory disorders (33, 15.5 %), drug reaction (7, 3.3 %) and trauma the outpatient department of pediatric dermatology at authors’
(5, 2.3 %). Autoimmune and metabolic disorders constituted institution were included in the study. A detailed clinical his-
1.4 % (three children) and 0.5 % (one child) respectively. tory and examination was done in all children and data was
Conclusions This study highlights the varied spectrum of collected on a predesigned proforma and information included
vesiculobullous disorders seen in the pediatric population. age, gender, age at onset, diagnosis, associated cutaneous and
Cutaneous infections and inherited disorders were the most systemic conditions. Investigations like gram stain, tzanck
common disorders observed in the present study. smear, KOH examination, skin biopsy, immunofluorescence
and antigen mapping was done when required for confir-
mation of diagnosis. Institutional review board approval
Keywords Vesiculobullous . Infections . Genodermatoses .
was taken.
Pediatric age group

Introduction Results

Vesiculobullous disorders are common in children. Primary A total 5889 children were examined for various dermatolog-
vesiculobullous disorders include vesicles, bullae and pus- ical problems. Among them 213 children presented with
tules. It can either be very benign or potentially fatal in some vesiculobullous disorders thus constituting 3.6 % of the total
cases. They can be either inherited or acquired depending on dermatoses. The age of presentation ranged from 1 d to 15 y,
the etiology [1]. There are however no studies in the Indian mean age of onset being 4.5 y. There were 112(52.6 %) boys
and 101(47.4 %) girls with boys to girls’ ratio of 1.1:1. The
S. M. Srinivas (*) : P. K. Sheth : R. Hiremagalore
duration of the disease ranged from 1 to 15 d. The most com-
Department of Pediatric Dermatology, Indira Gandhi Institute of
Child Health, Bangalore, Karnataka 560029, India mon group was the infantile age group (53 children, 24.9 %).
e-mail: drsahanasrinivas@rediffmail.com The demographic profile of children is described in Table 1.
806 Indian J Pediatr (September 2015) 82(9):805–808

Table 1 Demographic profile of study children Table 2 Various patterns of vesiculobullous disorders in children

Age Boys (%) Girls (%) Total (%) Vesiculobullous disorder n(%)

Neonates (Birth to 28 d) 5(2.3) 8(3.8) 13(6.1) Cutaneous infections 129(60.6)


Infants (1 mo to 1 y) 24(11.3) 29(13.6) 53(24.9) Viral infections 99(46.5)
Toddlers (1 to 3 y) 33(15.5) 17(8) 50(23.5) HFMD 41(19.2)
Preschool (3–5 y) 12(5.6) 14(6.6) 26(12.2) Varicella 25(11.7)
School age (5–11 y) 26(12.2) 25(11.7) 51(24) Herpes labialis 14(6.6)
Adolescents (11–18 y) 12(5.6) 8(3.2) 20(9.4) Herpes zoster 11(5.2)
Herpetic whitlow 2(0.9)
Herpetic gingivostomatitis 2(0.9)
The various vesiculobullous disorders were categorized in- Herpetic genitalis 1(0.5)
to eight groups as shown in Table 2. The most common group Ocular herpes simplex 1(0.5)
was infections (129, 60.6 %) followed by genodermatoses Eczema herpeticum 1(0.5)
(35, 16.4 %) and inflammatory disorders (33, 15.5 %). Drug Chickunguniya rash 1(0.5)
reactions constituted about seven children (3.3 %). Trauma Bacterial infections 29(13.6)
was seen in five children (2.3 %). The least common disorder Bullous impetigo 24(11.3)
seen in the present study belonged to autoimmune (3, 1.4 %)
SSSS 4(1.9)
and metabolic conditions (1, 0.5 %). The various patterns of
Blistering dactylitis 1(0.5)
vesiculobullous disorders in children in the different age
Fungal infections 1(0.5)
groups are described in Table 3.
Congenital cutaneous candidiasis 1(0.5)
Genodermatoses 35(16.4)
Epidermolysis bullosa simplex 21(9.9)
Discussion Junctional epidermolysis bullosa 9(4.2)
Dystrophic epidermolysis bullosa 2(0.9)
Vesiculobullous disorders in children form a challenging do-
LOC syndrome 1(0.5)
main for treating clinicians due its varied presentation. The
Bullous ichthyosiform erythroderma 1(0.5)
pattern of blistering disorders varies in different age groups.
Incontinentia Pigmentii 1(0.5)
The etiopathogenesis of bullous disorders in children differs
Inflammatory dermatoses 33(15.5)
as compared to adults. It is categorized into inherited disor-
Pompholyx 26(12.2)
ders, infectious, inflammatory, autoimmune, reactive and met-
Bullous papular urticaria 3(1.4)
abolic disorders [2]. Majority of children in the present study
Bechets disease 2(0.9)
belonged to infantile (24.5 %) and school going age group (5–
Erythema toxicum neonatorum 2(0.9)
11 y; 24 %). Many studies have shown that skin disorders are
Drug reaction 7(3.3)
more commonly seen in this age group [3, 4].
Steven Johnson syndrome 5(2.3)
In the present study the most common vesiculobullous dis-
Bullous fixed drug eruption 1(0.5)
order was infections as seen in other studies. Infections are the
Bullous drug reaction 1(0.5)
most common pattern documented in various studies ranging
Traumatic 5(2.3)
from 35.6 to 85.2 % [5]. Among infections, viral infections
(46.5 %) were most common followed by bacterial infections Burns 3(1.4)
(36.6 %). Hand foot and mouth disease, varicella and bullous Extravasation injuries 2(0.9)
impetigo accounted 19.2, 11.7 and 11.3 % of the total infec- Autoimmune disorders 3(1.4)
tions. It is well known that children are susceptible to a host of Bullous SLE 1(0.5)
infections. Hand foot mouth disease (HFMD) is a common Bullous pemphigoid 1(0.5)
viral illness and small outbreaks occur more in spring and CBDC 1(0.5)
rainy season at different places. There have been only few Metabolic disorders 1(0.5)
studies in Indian literature regarding the epidemiology of Acrodermatitis enteropathica 1(0.5)
HFMD. Studies have shown HFMD to occur more in children
HFMD Hand foot mouth disease; SSSS Staphylococcal scalded skin syn-
less than 5 y as seen in the index study [6–8]. Varicella is a drome; LOC syndrome Laryngo-onycho-cutaneous syndrome; SLE Sys-
common viral infection seen among children. Herpes zoster temic lupus erythematosus; CBDC Chronic bullous dermatoses of
was seen in 11 children (5.2 %) in the present study. Although childhood
herpes zoster is seen more in adults it is not uncommon in
children. Pediatric zoster is seen in immunocompromised
Indian J Pediatr (September 2015) 82(9):805–808 807

Table 3 Vesiculobullous disorders in different age groups

Diagnosis 0–28 d Upto 1 y 1 to 3 y 3 to 5 y 5 to 11 y 11 to 18 y Total

Hand foot and mouth disease – 16 15 4 5 1 41


Epidermolysis bullosa 8 9 6 5 3 2 33
Pompholyx – 3 8 4 9 2 26
Varicella 1 3 3 3 10 5 25
Bullous impetigo 2 5 7 3 7 24
Herpes labialis – 1 2 3 4 4 14
Herpes zoster – 1 1 7 2 11
Stevens Johnson syndrome – 2 – 1 – 2 5
Staphylococcal scalded skin syndrome – 4 – – – – 4
Bullous papular urticaria – 1 1 – 1 – 3
Burns – 3 – – – – 3
Behcet’s disease – – – – 2 – 2
Erythema toxicum neonatorum 2 – – – – – 2
Extravasation injury – 1 1 – – – 2
Herpetic whitlow – – – – 2 – 2
Herpetic gingivostomatitis – – – 1 – 1 2
Acrodermatitis enteropathica – – 1 – – – 1
Blistering dactylitis – – – – – 1 1
Bullous fixed drug eruption – – 1 – – – 1
Bullous pemphigoid – – 1 – – – 1
Bullous ichthyosiform erythroderma – – 1 – – – 1
Bullous systemic lupus erythematosus – – – – 1 – 1
Chronic blistering disease of childhood – – 1 – – – 1
Chikungunya rash – 1 – – – – 1
Congenital cutaneous candidiasis – 1 – – – – 1
Drug reactions – – 1 – – – 1
Eczema herpeticum – – 1 – – – 1
Herpes genitalis – – – 1 – – 1
Incontinentia pigmenti – 1 – – – – 1
Ocular herpes simplex – 1 – – – – 1

children or those who had primary intrauterine infection or and 0.99 and recessive dystrophic EB 2.04 and 0.92,
acute varicella within first year of life or occasionally occurs respectively [12, 13].
without any risk factors [9, 10]. Bullous impetigo is the most Among the inflammatory dermatoses, pompholyx consti-
common bacterial infection seen in children less than 10 y of tuted about 12.2 % of the total dermatoses. Banerjee et al. in
age as observed in the present study [11]. their study have reported 0.3 % of the children to have
In the present cohort the second most common pompholyx [14]. Pompholyx in children is uncommon in pre-
vesiculobullous disorder was genodermatoses. pubertal or pubertal age and rare in preschool children [15].
Epidermolysis bullosa (EB) had a frequency of 15.5 % Bullous papular urticaria was seen in 1.4 % of total children.
of the total dermatoses. Indira Gandhi Institute of Child Information regarding prevalence of insect bite reaction is
Health, Karnataka, being a tertiary care children hospital, limited. Various studies have reported the prevalence of insect
a large number of genetic cases were referred thereby bite reaction varying from 5.1 to 10.6 % [16, 17]. Among the
contributing to its increased frequency. Worldwide data different morphological patterns of insect bite reaction, vesi-
suggests that there is no gender, racial or geographical cles and bullous lesions are less common. Kar et al. in his
predilection of EB. According to the National EB regis- study found only 5 % of insect bite reactions to have vesicles
try project from USA, the incidence and prevalence rates and bullae [18].
of EB simplex are 10.75 and 4.65, of junctional EB are Drug reactions comprised 3.3 % of the total dermatoses.
2.04 and 0.44, and dystrophic EB dominant type 2.86 Adverse cutaneous drug reactions are quiet frequently
808 Indian J Pediatr (September 2015) 82(9):805–808

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