Page 19 - Journal of Special Operations Medicine - Summer 2015

Treatment Figure 1 Patient’s asymmetrically distributed erythematous
maculopapular rash.
The patient’s initial treatment at the Troop Medical
Clinic included injection of 12mg dexamethasone in-
tramuscularly (IM) in the clinic, and he was prescribed
60mg prednisone by mouth (PO) once a day for 5 days.
He was also given hydroxyzine PO as needed for the
itching. Within days, the rash reappeared and presented
with a larger distribution with more severe itching. Due
to this, the patient visited the Army Community Hos-
pital emergency department 1 week later. There he was
treated with 100mg doxycycline PO twice a day for 10
days, 50mg prednisone PO once a day for 6 days, 50mg
diphenhydramine PO as needed for 10 days, and 150mg
ranitidine PO once a day for 10 days. Both courses of
medications proved to be inadequate and worsened his
symptoms.

Six days after being seen in the emergency department,
he was came to his BAS for worsening symptoms. There,
he was treated with a 20-day tapering course of oral
prednisone (60mg once a day for 5 days, 40mg once a
day for 5 days, 20mg once a day for 5 days, and 10mg
once a day for 5 days). This 20-day tapered course gave
the patient complete relief of the pruritus and rash.
Evaluation of the biopsy specimens revealed spongiotic
dermatitis.

Discussion
dermatitis being the most common presentation. Typi-
It was determined that the cause of the rash and pruri- cally, these would be seen in the BAS, due to allergic and
tus was C. lectularius, commonly known as “bed bugs” contact dermatitis, atopic dermatitis, seborrheic derma-
(Figure 1). Bed bugs have been problematic for humans titis, and drug reactions. Interestingly, the diagnosis of
12
for more than 3,550 years. They are small (4 to 7mm), spongiotic dermatitis does not rule out a fungal infec-
3
reddish-brown, flat, wingless, oval insects that emit an of- tion ; therefore, proper testing should be completed to
13
3
fensive odor. There are three salivary proteins of bed bugs ensure the absence of fungal infection.
that may be important: a nitric oxide–liberating heme
protein, an anticoagulant, and a pyrase-like nucleotide- Although the actual immunologic pathology is still un-
binding enzyme. 9 certain, what some postulate is an allergic dermatitis
with IgE and IgG being isolated in other studies bed bug
Bed bugs hide in cracks and crevices in beds and are can cause various skin reactions. 3–5,10,14 Allergic derma-
found in overcrowded areas with high turnover. 3,10 titis is a type IV hypersensitivity reaction mediated by
Transient military housing for students are prime areas the T cell and can be of slow onset. 8,15 Allergic contact
for the transmission of several diseases and for insect dermatitis can be distinguished from irritant dermatitis
infestations, including bed bugs. Although the transient by the dominant symptom of pruritus, exposed areas of
16
housing is often treated for insects and the students are skin, vesicles and bullae, and distinct borders. Typi-
taught proper hygiene, purchasing a new mattress for cally, bed bugs do not cause severe reactions and require
each new student is not feasible. There have been several the use of only topical corticosteroids. In rare cases, a
military instillations with bed bug infestations. 11 reaction can occur that would require oral glucocorti-
coids and other medications. According to Usatine and
7
Spongiotic dermatitis is defined by the presence of epi- Riojas, there is “no evidence to support the use of long-
12
thelial intercellular edema. It can be further classified acting injectable steroids in the treatment of contact
as acute, subacute, and chronic. When vesicles form, dermatitis.” 16
12
they typically contain a protein-based fluid along with
lymphocytes and histocytes. Spongiotic dermatitis is The organ and glands that are pivotal in the area of
caused by several conditions, with subacute spongiotic concentration for treatment with glucocorticoids are the

Oral Steroids for Dermatitis 9