Hiker With Pruritic Papules

Figure 1

Figure 2

A 37-year-old man presents with moderately pruritic urticarial papules on areas of his skin that are not covered by his shorts and T-shirt. He recently returned from a trip to Upstate New York, where he had stayed in several rustic cabins that were used by different people daily. While hiking in the woods, he noted poison ivy growing along the trail but was careful to avoid it. He is otherwise healthy and takes no medications.

What does this look like to you?

• Scabies
  
• Rhus dermatitis
  
• Bedbug bites
  
• Bacterial folliculitis

(Answer on next page)

A

B

Answer: Bedbug bites

The distribution of the lesions was a clue to their cause. A linear grouping of 3 urticarial papules, often with central crusts, constitutes the classic "breakfast, lunch, and dinner" sign of bedbug bites (A).

Scabies is typically more intensely pruritic than the papules of bedbug bites. Rhus dermatitis usually manifests as a vesicular linear eruption. Bacterial folliculitis is often pustular and is confined to hair-bearing skin; it is not typically pruritic.

In recent years, bedbug infestations have increased dramatically in the United States. They have been reported in a variety of settings in which persons share beds, including homes, campgrounds, hostels, motels, and even luxury hotels. This patient said that he had seen a few bugs scurrying in the folds of the bed linens in one of the cabins where he stayed.

Bedbugs are reddish brown and about 5 mm long (B). These blood-sucking parasites feed primarily at night. During the day, they hide in crevices in the mattress, box spring, and bed frame. They may also be found in cracks in the floor and behind loose wallpaper.

Bedbug bites generally require little or no treatment. Medium- to high-potency topical corticosteroids and antihistamines can reduce inflammation and relieve pruritus.

This patient was told to apply triamcinolone 0.1% cream twice daily. After 2 weeks of treatment, the papules and pruritus resolved.

References:

REFERENCES:

1.

Return of the bedbugs.

Consultant

. 2006;46:77-80.

2.

Scheinfeld NS. Skin disorders in elderly persons: part 6, scabies.

Consultant

. 2007;47:912i-912j. Also available at:

http://www.consultantlive.com/photoEssay/skin-disorders-elderly-scabies/

.