ITCHY RED BUMP DISEASE --------------------------------------------------- Does itchy red bump disease exist and if so does anyone have an effective treatment. The reason I ask is that I have a 48yo female who is going crazy itching with small red slightly crusted papules over her trunk that on biopsy fits nicely with IRBD-namely spongiosis,central crusting,perivascular lymphcytic infiltrate without deep component,some eosinophils--Clinically these look like bites but she has a negative scabies smear and did not respond to lindane and has no history suggesting any other source for bites--she clears with prednisone but resumes off it--she has a classic presentation for IRBD but I have not made this Dx before(probably just haven't considered it)--Any ideas? By the way FS shampoo is a shampoo base with 0.1% triamcinolone--I've forgotten who makes it but it does help for itchy scalps especially those that appear normal otherwise. W H Burrow -------------------- Maybe the Germans are right about Subacute Prurigo responsive to Dapsone!! Diane Thaler -------------------- I wish you well, since these patients are perfectly miserable, and can be difficult to manage and deal with! Robert I. Rudolph, M.D., FACP -------------------- I've had several of these patients: all female. I've always considered bites and papular urticaria in these patients, and usually get the same path report you've gotten. I've always done immuno on the biopsies looking for "atypical DH". but have never gotten + results. Most of the patients do require occ. bursts of oral prednisone and need Atarax. I have one patient, however, who has responded very well to Dapsone (just like a DH patient), in the face of - immuno findings (both direct and indirect). I wish you well, since these patients are perfectly miserable, and can be difficult to manage and deal with! Robert I. Rudolph, M.D., FACP -------------------- There is a disease which the Germans (maybe Dr. Kammler can help on this one) call Subacute Prurigo, seen in middle-aged females with histology of possible bite which dramatically responds to Dapsone. I have had 3 women with this problem, and all responded to Dapsone. If the lesions do have a central bite type punctum, maybe you should search for occult mites. Ideas at this time of year are racoon mites via a chimney nest, pigeon mites via an air vent, or rat mites via a nearby dumpsite. That might be why scabies rx doesn't clear the problem. My other favorite is chyletiella (sp?), the cat dandruff mite. My vet feels the problem is endemic in our area of the Midwest, USA. You might empirically try cetirizine to test the insect bite reaction response zapper. Diane Thaler -------------------- Look for contact allergy to formaldehyde releasing textile resins (i.e., Melamine formaldehyde (Kaurit M70)) in these patients. These allergens are found in durable press fabrics. These patch test allergens can be obtained from Chemotechnique. http://www.mc.vanderbilt.edu/vumcdept/derm/contact/Textiles.html Trey Truett, MD -------------------- This is a great idea. I had wondered about a contact in my first patient, and she was patch test negative, but I didn't test to Kaurit M70. Why do you think it manifests as isolated red bumps, instead of the usual contact appearance. Serious question. Diane Thaler -------------------- Temovate didn't work in my patients with "subacute prurigo", but Dapsone did. Diane Thaler -------------------- i too have had female patients with itchy red bump disease...all have done well with temovate bid...seems a bit safer than parenteral corticosteroids...and i do think they are insect bites, probably seen in females more often because of perfumes etc so i d/c the perfumes and perfumed creams... steve emmet -------------------- I don't know if itchy red bump disease exists, but I see a fair amount of it (3-4 cases per year). Although it is probably not a syndrome, I love the other way to say it---"red itchy bumb syndrome", or "RIBS", AKA prurigo papularis. These terms are not my own, but taken from DR. Richard Odom of Univ. Of CA San Francisco. bill Liss -------------------- I have had several similar prurigo-like patients who responded to low dose Dapsone and/or tar/ UVB. Some act like DH though I have been unable to prove it. Philip Hughes, M.D. -------------------- It is also a great idea to go to the Academy one day early to catch the Contact Dermatitis Society Meeting. Besides all of the great info, and getting to see Dr. Alex Fisher before he really really retires, all of the allergen companies are there.... Diane Thaler -------------------- Allergy to formaldehyde textile resins does not specifically appear as discrete papules. It can have that appearance and I have seen it many times. Contact allergy is generally under investigated. Seeing the label "itchy red bump disease" as a resident was one of the reason that I became interested in contact dermatitis. You certainly don't find contact allergy in all cases of "itchy red bump disease" but it should extensively sought - particulary with the histopathology of spongiotic dermatitis. Trey Truett, MD -------------------- I had the pleasure of attending a wonderful talk on contact dermatitis given by Fran Storrs last week in Ashville,NC.She included in her talk the sources for topical steroid allergans and I'm patiently waiting for her list of sources,addresses,etc which I understand will be mailed to each attendee.Tixocortal pivacate(?sp) is considered the marker for hydrocortisone allergy, apparently the most frequently occuring of the corticosteroid allergic contacts. Pierre Jaffe -------------------- I was as excited as you guys were about steroid contact. I have been regularly testing for steroid contact for 2 years, average 2-3 patients per week. What a let down. Not one positive yet. diane thaler -------------------- In my opinion (for what it's worth), itchy red bump disease (Mitch Sams' term originally I think) is in most cases atopic dermatitis, as I suspect this case is. Since this is a diagnosis of exclusion, you do have to attempt to exclude other causes (such as bites, mites, atypical drug reactions). She does respond to oral steroids, as you would expect an atopic to (in adequate doses). Look for irritant triggers or perhaps an emotional trigger and try to deal with that if possible. If that is what this is, it will subside at some point due to the periodic nature of this disease. Mark Naylor, M.D. -------------------- I don't know if I'll fare better in finding steroid allergy,but the cases presented resembled "shoe dermatitis" and "seb dermatitis"...I am not exactly looking forward to that next case of hiv(-),stubborn seb derm, but I plan to add a more complete patch test series to the w/u (if it comes to that). Pierre Jaffe -------------------- Besides steroid contact, compositae allergy is another favorite rare bird diagnosis for the red scaley face. Mark, which steroid did you test with? I thought I was covered, but maybe I am missing one. Also, maybe Trey Truett could post the steroid allergens and their cross reactant steroids, so we know which to avoid topically and which to avoid IM, PO, and IV if we get a positive. Diane Thaler -------------------- Information on availibility of commercial patch test allergens is also available at my web site. The telephone numbers and addresses of distributers are listed. http://www.mc.vanderbilt.edu/vumcdept/derm/contact/ A.P. Truett III, MD ---------- think Cheyletiella! I hate to become the pied piper of this little critter, but I've made this post before and heard no replies. Please see the excellent article: Lee BW, Cheyletiella dermatitis: a report of fourteen cases, Cutis (1991 Feb) 47(2):111-4. This annoying little pest is more widespread than previously thought (reports from Europe, Asia and the Americas). It lives on our mammalian pets and is easily transmittable if your pet leaves home even briefly or is kenneled. It is fairly common in kennel animals and strays. The pet may not be symptomatic and only a few vets can diagnose it, or are even aware of it. It only causes trouble when it falls off the host animal and finds a human--which it bites repeatedly before dying or falling off. They do not burrow and won't be found on path. The reaction is most often seen in the middle aged woman in the family (?more reactive/intolerant immune systems), but if present long enough will appear in other family members (the older males in the family react the last). The lesions look like small isolated insect bites and excoriations on the trunk and proximal extremities and the path report routinely contains insect bite in the differential. The itch is global, intense (similar to scabies and in excess of findings) and the patient has usually been given Kwell by their primary MD, and sometimes Dapsone by their dermatologist (with some improvement in the itch with Dapsone). The eruption is most common in the fall and winter, but can happen any time. The infected pet may not be at home, but instead might be at a place the patient frequents (one of my cases was from a security dog at the patient's place of employment...it slept near her cubicle at night!!). Some vets are very helpful with this suspected condition, but others will ignore your concerns due to their lack of knowledge of the parasite. I've had phenomenal and quick "cures" and many very grateful patients by insisting the suspect animals be treated with ivermectin whether the vet can confirm the diagnosis or not. I now give these patients copies of Dr. Lee's article for themselves and to take to their vet. I also keep a list of vets in my area who are "believers." Please consider this diagnosis strongly in the future--you'll save your patient and yourself a lot of grief. REFERENCES: Lee BW Cheyletiella dermatitis. In: Arch Dermatol (1981 Oct) 117(10):677-8 Cohen SR Cheyletiella dermatitis. A mite infestation of rabbit, cat, dog, and man. In: Arch Dermatol (1980 Apr) 116(4):435-7 Two patients with recurrent, intensely pruritic, grouped red papules on the chest, abdomen, and thighs were examined and found to have Cheyletiella dermatitis. Cheyletiella, a nonburrowing species of mite, was isolated from fur brushings of the household pets, including one dog and two cats. Treatment of the affected pets resulted in complete resolution of symptoms and signs in both animals and patients. This appears to be the third instance of human Cheyletiella dermatitis recorded in North America. Bakkers EJ Fain A Dermatitis in man and in a dog caused by the mite Cheyletiella yasguri Smiley. In: Br J Dermatol (1972 Sep) 87(3):245-7 Rivers JK Martin J Pukay B Walking dandruff and Cheyletiella dermatitis. In: J Am Acad Dermatol (1986 Nov) 15(5 Pt 2):1130-3 Two patients presented with pruritus and rash caused by Cheyletiella mites that lived on our patients' cats. Only with veterinary assistance was the correct diagnosis made and effective therapy instituted. Shelley ED Shelley WB Pula JF McDonald SG The diagnostic challenge of nonburrowing mite bites. Cheyletiella yasguri. In: JAMA (1984 May 25) 251(20):2690-1 Endemic pruritus in a family of four proved to be caused by the "bite and run" habits of the Cheyletiella yasguri mites that lived on the family dog. The mystery was solved only after the 6-year-old daughter experienced an explosive attack of pruritic papules after taking a nap in the dog's sleeping box. Virtually invisible ectoparasites remain a common cause of endemic pruritus within families. Since these patients show no acarologic, clinical, or laboratory evidence for the cause fo their itch, a good rule remains, cherchez le chien. Lee BW Cheyletiella dermatitis: a report of fourteen cases. In: Cutis (1991 Feb) 47(2):111-4 Cheyletiella dermatitis is an infrequently reported eruption caused by an ectoparasite whose normal hosts are household pets. Fourteen cases, documented over an eight-year period, are reported. All cases were found in one practice in a small community. Typical patients are female, aged forty years or younger, who experience pruritic papules in the winter months. Cheyletiella dermatitis is not a rare problem. Dal Tio R Tara Vercelli A [Dermatitis caused by Cheyletiella. Description of 8 cases and review of the literature] Dermatite da Cheyletiella. Descrizione di otto casi e revisione della letteratura. In: G Ital Dermatol Venereol (1990 Feb) 125(1-2):19-24 (Published in Italian) The Authors report eight cases of Cheyletiella dermatitis, parasite mite of domestic animals but also known as pathogenic for man. This animal parasitosis mentioned many times in other countries, seems to be very diffused in Italy, too. Nevertheless, the literature tells that normally, in our country, Cheyletiella dermatitis is a pathology completely underestimated and almost unknown. The Authors, because of the aspecificity of the clinical and histopathological data, lay special stress on the differential diagnosis pro OF 15) 8013675und mit der Milb6 persons exposeation is reported. Two of the dogs appeared to have been infected during a stay in a kennel. The dogs presented with moderate itching and slight to massive floury squamack. In the infeogs had been remIENCE***** Niiyama M Ohbayashi M Cheyletiella blakei in a cat. In: Nippon Juigaku Zasshi (1979 Aug) 41(4):395-9 Fain A Scheepers L De Groot W [Long-lasting pruriginous dermatitis in a woman caused by an acarian dog parasite, Cheyletiella yasguri Smiley] Dermatite prurigineuse de longue duree chez une femme, produite par l'acarien parasite du chien Cheyletiella yasguri Smiley. In: Rev Med Liege (1982 Sep 15) 37(18):623-5 (Published in French) McGarry JW Identification of Cheyletiella eggs in dog faeces. In: Vet Rec (1993 Apr 3) 132(14):359-60 Biomedical Science Division (Veterinary Parasitology) Liverpool School of Tropical Medicine. Kip Cullimore, MD -------------------- Another kitty dandruff incognito sleuth! I have one, and only one, vet who assumes the infestation is endemic, and will treat empirically if I send the patient. There is another great reference in the fabulous British book on Arthropods-I will check my shelf tomorrow. It is a must have book along with Art's book and Wolverton's book and Shelley's book and du Vivier's. They do bite several times in a pretty well circumscribed area, may be evanescent, and lots of times have central vesico-pustules. Patients like this diagnosis much better than fleas, which is akin to telling them (they feel) that they keep a dirty house , don't wash, and are covered by coodies. I am glad someone else out there practices veterinary medicine! Yes, I know there are veterinary dermatologists.......but have you ever been to their meeting at the academy. I could barely stay quiet, let alone seated. They call everything "pemphigus" or staph. Diane Thaler --------------------