A Case of Impetigo Herpetiformis with Unusual Clinical Features

To the Editor: Impetigo herpetiformis (IH) is an acute eruption associated with severe systemic disturbances, and typically occurring in pregnant women (1–3). The usual lesions are erythematous patches that are studded with tiny superficial pustules with histopathological findings similar to those of pustular psoriasis (4–9). It is very rarely reported; only approximately 130 cases have been reported in the English literature (1–5). We describe a 25-year-old woman with IH at four months of pregnancy. Interestingly, she also developed large bullae on the extremities, and skin lesions also appeared on her face, palms and plantar surfaces. This 25-year-old woman was admitted to our institution at 16 weeks of pregnancy. She had had one child, and the previous pregnancy was not complicated. On admission, she looked acutely ill and complained of fever, severe chills, nausea, and diarrhea. She and her family had no past medical history of psoriasis. A skin examination revealed erythematous patches that were studded with tiny superficial pustules particularly coalescing at their margins and causing pain, and a burning sensation. These were located mainly on her trunk and proximal extremities but also on her face (Fig. 1) and plantar areas. Several flaccid bullae were present on her shoulders and lower legs. A culture of the contents of the pustules was sterile, and a skin biopsy from a pustule showed the pustular psoriasis pattern with spongiform pustule diagnostic of IH (Fig. 3). Routine hematological, biochemical, thyroid function, and urinalysis examinations were within normal limits except for an elevated erythrocyte sedimentation rate, elevated white blood cell count, and decreased serum albumin. She wanted her pregnancy terminated. After termination, her trunkal pustular patches improved slightly. Several days later, however, she complained of aggravated, multiple, large bullae on the shoulders, calves, ankles, and feet (Fig. 2). Nikolsky’s sign was absent. Gradually, pitting edema developed on the legs in parallel with lower serum abumin in repeated blood tests. In addition, numerous tiny pustules developed on the side of the face and scalp. A skin biopsy from a bulla on the The Journal of Dermatology Vol. 28: 335–337, 2001