Jiaci

J Investig Allergol Clin Immunol 2019; Vol. 29(5): 403-404

doi: 10.18176/jiaci.0428

Acute Generalized Pustular Bacterid: An Uncommon Dermatosis That Commonly Presents With Acral Pustules

Manuscript received March 18, 2019; accepted for

publication June 21, 2019.

Cheng Tan

Department of Dermatology, Affiliated hospital of Nanjing

University of Chinese Medicine

155 Hanzhong Road, Nanjing, China, 210029

E-mail:

tancheng@yeah.net

infection (eg, tonsils, gums, sinuses, vagina), and clearance of

the pustules by eradication of the infection [2,4]. The triad of

sudden onset of the disease, acral distribution of the pustules,

and concomitant sore throat with high fever in the case we

report was consistent with AGPB. The differential diagnosis

forAGPB is exhaustive and includes pustular psoriasis,AGEP,

palmoplantar pustulosis (PPP), and dermatophytid reaction

(Supplementary Material). Unlike patients with AGPB, most

patients with pustular psoriasis have a relapsing course with

Munro microabscesses and psoriasiform acanthosis, which are

diagnostic. The patient withAGEPusually has a history of drug

intake, and the pustules are tiny and mostly affect the inguinal

folds or other intertriginous areas [5]. All these features are

sufficient to confirm AGPB. PPP is a recalcitrant recurrent

afebrile pustular dermatosis. In contrast to AGPB, the typical

PPP pustule is confined to the palms and the soles. Although

similar pustules present in dermatophytid reaction, they take

the form of generalized eczematous eruptions caused by remote

localized infection by tinea or staphylococcal colonization,

which can be excluded in the case we report.

Many factors contribute to the formation of pustules in

AGPB. Onset is usually shortly after a focal infection such as

pharyngitis or tonsillitis by group A β-hemolytic streptococci

or other bacteria [4,6]. It is speculated that superantigens and

toxins from the bacteria upregulate the expression of tumor

necrosis factor α and interferon γ, leading to activation of the

complement C3 and C5a cascade. Complement C5a has been

proven to be an attractant for neutrophil accumulation in the

epidermis and results in pustular eruptions.

There is a proven causative relationship between AGPB

and focal bacterial infections, and AGPB usually follows

a focal bacterial infection. Clinicians should consider this

diagnosis in individuals with sudden onset of acral pustular

eruptions. Recognizing and eradicating focal infections are

the most important steps in the management of AGPB and can

reduce misuse and overuse of antibiotics. Pustules in AGPB

usually resolve spontaneously in 7-14 days without relapse;

therefore, most authors agree that aggressive treatment is

unnecessary [4]. Antibiotics are still one of the mainstays

of treatment and improve outcomes in those who have

previously been infected or who could develop complications

of glomerulonephritis and reactive arthritis [4]. The fact

that AGPB with tonsillitis is aggravated after tonsillectomy

indicates that eradication of the infection alone is not a

radical cure for some patients. Corticosteroids showed no

beneficial effect on the patient, although methotrexate and

group A streptococcal vaccination have proven effective in

some patients.

Funding

The authors declare that no funding was received for the

present study.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

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