Pediatric Dermatology Vol. 30 No.
3 e30–e31, 2013 5-days history of high fever reaching 39C resistant to
Severe Dyshidrotic Eczema After Intravenous
Immunoglobulin Therapy for Kawasaki
Syndrome
Abstract: Dyshidrotic eczema is one of the rare
cutaneous adverse effects of intravenous immuno-
globulin therapy, usually seen in adults. We herein
report the first pediatric case of severe dyshidrotic
eczema occurring after intravenous immunoglobulin
therapy for Kawasaki syndrome.
Intravenous immunoglobulin (IVIG) therapy is now
demonstrated to be effective in a number of inflamma-
tory, autoimmune, and neurologic disorders. Adverse
skin reactions are rare, but urticaria, pruritus, alopecia,
and erythema multiforme have been reported. In addi-
tion, pompholyx (vesicular or dyshidrotic eczema) has
recently been reported, especially in patients with neu-
rologic diseases such as amyotrophic lateral sclerosis,
chronic inflammatory demyelinating polyradiculo-
neuropathy, Guillain-Barré syndrome, motor neuron
disease, and multiple sclerosis (1). We herein report a case
of severe dyshidrotic eczematous skin reactions occurred
in a child after IVIG therapy for Kawasaki syndrome.
CASE REPORT
A 5-year-old boy with moderate atopic dermatitis was
hospitalized in the department of pediatrics, with a
A B
Figure 1. (A) A number of vesicles and scales on the diffuse erythema of the bilateral palms. (B) Dyshidrotic eczematous skin
lesions spread on the dorsa of foot and lateral malleolus.
DOI: 10.1111/j.1525-1470.2011.01717.x
e30
antibiotics (cefdinir), along with bilateral conjunctival
injection; red strawberry tongue; swelling of the lips,
hands, and feet; sore throat; and urticarial erythema.
Laboratory examination showed platelet count
498 · 103 to 341 · 103 ⁄ lL, white blood cell count 13,400
(normal 3,800 to 9,800) (68% neutrophils, 15% lym-
phocytes, 12% monocytes, and 8% eosinophils), and
C-reactive protein (CRP) 1.13 mg ⁄ dL (normal
< 0.3 mg ⁄ dL). Serum immunglobulin (Ig)E levels were
high (4,320 IU ⁄ mL, normal < 200 IU ⁄ mL). He was
diagnosed with Kawasaki disease and received IVIG
therapy (Venoglobulin IH; polyethylene glycol–treated
human normal immunoglobulin) at a dose of 1 g ⁄ kg for
1 day. Approximately 10 days after the last infusion,
pruriginous erythema and small vesicles appeared on the
palms, thereafter progressing to the soles, and he was
referred to our hospital. Physical examination revealed
diffuse erythema, numerous small vesicles, and erosions
on the bilateral palms, fingers, and soles (Fig. 1A). Ves-
icles had also spread to the dorsa of the foot and lateral
malleolus (Fig. 1B). The lesions were much improved
with simple topical application of corticosteroids (0.05%
betamethasone butyrate propionate) cream in 1 week
(Fig. 2A,B). Thereafter, dyshidrotic eczema relapsed on
the palms 3 weeks later but improved within 1 month.
DISCUSSION
Vesicular pruriginous eczematous reactions are occa-
sionally seen 5–10 days after IVIG therapy. The cuta-
neous lesions resolve spontaneously, even in severe cases.
More than 30 cases have been reported, most in indi-
viduals with neurologic disorders. The majority of the
patients are adults; children are extremely rare (2).
 2012 Wiley Periodicals, Inc.

Figure 2. Marked improvement was obtained in 1 week on the palms (A) and foot (B).
Usually, dyshidrotic eczema is located on the palms and
soles, but in extensive cases, eczematous eruptions are
widespread, extending to the extremities and trunk.
Histological examination reveals spongiotic dermatitis
with intraepidermal vesicle formation and a dermal
inflammatory infiltrate composed mainly of lymphocytes
and histiocytes.
The mechanism of the induction of dyshidrotic ecze-
ma by IVIG is unknown. A few hypotheses have been
proposed (hypersensitivity reaction to substances con-
tained within IVIG preparations (stabilizers, animal
pepsin, or unidentified constituents), viral cause, and B
cell activation under certain circumstances). Because the
majority of patients with dyshidrotic eczema after IVIG
therapy have neurologic disorders, it is speculated that
neurologic disorders may predispose patients to dyshid-
rotic eczema after IVIG infusion. In our case, the patient
had moderate atopic dermatitis. Atopic predisposition
may have a role in the induction of severe dyshidrotic
eczema after IVIG infusion (3,4). We encourage other
practitioners caring for patients with atopic dermatitis
who receive IVIG to be aware of its potential association
with the development of dyshidrosis after its adminis-
tration.
Brief Reports e31
REFERENCES
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reaction after high-dose intravenous immunoglobulin infu-
sion: report of 4 cases and review of the literature. Arch
Dermatol 2006;142:213–217.
2. Young PK, Ruggeri SY, Galbraith S et al. Vesicular eczema
after intravenous immunoglobulin therapy for treatment of
Stevens–Johnson syndrome. Arch Dermatol 2006;142:247–
248.
3. Lehucher-Michel MP, Koeppel MC, Lanteaume A et al.
Dyshidrotic eczema and occupation: a descriptive study.
Contact Dermatitis 2000;43:200–205.
4. Magina S, Barros MA, Ferreira JA et al. Atopy, nickel
sensitivity, occupation, and clinical patterns in different
types of hand dermatitis. Am J Contact Dermat 2003;14:63–
68.
Takahisa Shiraishi, M.D.
Toshiyuki Yamamoto, M.D.
Department of Dermatology, Fukushima Medical
University, Fukushima, Japan
Address correspondence to Toshiyuki Yamamoto, M.D.,
Department of Dermatology, Fukushima Medical University,
Fukushima 960-1295, Japan, or e-mail: toyamade@fmu.ac.jp.