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A Fussy Infant With a Generalized Papulovesicular Rash

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 7-week-old, previously healthy full-term male infant presented with a 4-week history of a worsening, widespread, papulopustulovesicular eruption, which began as scattered papulovesicles over the chest. The infant was born to a 31-year-old mother by normal vaginal delivery. The mother had a benign prenatal course during pregnancy. Since the rash developed, the infant had been fussy with increasing restlessness at night. The parents denied any personal or family history of rash. On further questioning, the parents reported that the infant had had contact with a babysitter who reported pruritus, especially at night. The sitter had provided domestic care for the infant since birth until leaving that position 3 weeks earlier.

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Neonatal scabies

C. Perform skin scraping of burrows from multiple sites

The key to the correct diagnosis is the widespread inflammatory burrows without excoriations, the history of contact with a babysitter with symptoms consistent with scabies, and the fussiness and restlessness at night in an otherwise healthy neonate. Unlike in adults, the palms, soles, trunk, and skin above the neck are commonly affected by characteristic scabies skin lesions in neonates. Contact with an individual with signs and symptoms of scabies can strongly suggest the diagnosis.

Scabies is a global health problem affecting more than 300 million individuals annually. Scabies is an extremely contagious skin infestation caused by female Sarcoptes scabiei mites.1 Scabies often affects children, with varying presentations in different age groups.2 Given that neonates are developmentally ineffective scratchers, fussiness, irritability, and restlessness at night, rather than scratching with its secondary excoriations, are common in neonatal scabies. In neonates, the infestation is insidious and lasts for relatively long periods, frequently leading to multiple lesions in different developmental stages ranging from papulopustulovesicles to nodules. Compared with the intact burrows found predominately in the interdigital web spaces and the extremities of adults, neonates often present with highly inflamed burrows over the whole body, characterized by red, edematous, oval to elongated, serpiginous or J-shaped papules, vesicles, and nodules.

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Article Information

Corresponding Author: Wu Guo, MD, Department of Dermatology, Children’s Hospital Affiliated to Zhengzhou University, No 255 Gangdu St, 450053 Zhengzhou, China (guoscho@126.com).

Published Online: January 14, 2019. doi:10.1001/jama.2018.20666

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s mother for providing permission to share the patient’s information.

References
1.
Hill  TA, Cohen  B.  Scabies in babies.  Pediatr Dermatol. 2017;34(6):690-694. doi:10.1111/pde.13255PubMedGoogle ScholarCrossref
2.
Subramaniam  S, Rutman  MS, Wenger  JK.  A papulopustular, vesicular, crusted rash in a 4-week-old neonate.  Pediatr Emerg Care. 2013;29(11):1210-1212. doi:10.1097/PEC.0b013e3182aa1411PubMedGoogle ScholarCrossref
3.
Tarbox  M, Walker  K, Tan  M.  Scabies.  JAMA. 2018;320(6):612. doi:10.1001/jama.2018.7480PubMedGoogle ScholarCrossref
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Ross  BG, Wright-McCarthy  JK, DeLaMora  PA, Graham  PL  III.  Transmission of scabies in a newborn nursery.  Infect Control Hosp Epidemiol. 2011;32(5):516-517. doi:10.1086/659954PubMedGoogle ScholarCrossref
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Obasanjo  OO, Wu  P, Conlon  M,  et al.  An outbreak of scabies in a teaching hospital: lessons learned.  Infect Control Hosp Epidemiol. 2001;22(1):13-18. doi:10.1086/501818PubMedGoogle ScholarCrossref
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Zou  Y, Hu  W, Zheng  J, Pan  M.  Nail infestation: an atypical presentation of typical scabies.  Lancet. 2018;391(10136):2272. doi:10.1016/S0140-6736(18)31079-1PubMedGoogle ScholarCrossref
7.
Ladizinski  B, Rukhman  E, Lee  KCA.  A 4-day-old neonate with a widespread vesicular rash.  JAMA. 2013;310(9):971-972. doi:10.1001/jama.2013.276963PubMedGoogle ScholarCrossref
8.
Qian  G, Ji  J, Wu  J.  Sudden onset of generalized pustules in a newborn.  JAMA. 2016;315(9):934-935. doi:10.1001/jama.2016.0006PubMedGoogle ScholarCrossref
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Strong  M, Johnstone  P.  Interventions for treating scabies.  Cochrane Database Syst Rev. 2007;(3):CD000320.PubMedGoogle Scholar
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