Original papers European Journal of

Eur J Pediatr (1993) 152 : 6-8 Pediatrics

9 Springer-Verlag 1993
Paederus dermatitis: an easy diagnosable but misdiagnosed eruption
C. Gelmetti and R. Grimalt
First Department of Dermatology and Paediatric Dermatology University of Milan, IRCCS "Ospedale Maggiore", Milan, Italy
Received March 3, 1992 / Accepted after revision May 8, 1992
Abstract. ​P a e d e r u s dermatitis is a perculia r irritant con - ​tact
dermatitis characterise d b y e r y t h e m a t o - b u l l o u s le-sions
o f s u d d e n onse t o n e x p o s e d areas o f the b o d y . T h e
disease is p r o v o k e d b y an insect b e l o n g i n g to genu s
Paederus. T ​ his beetl e does n o t bite o r sting, b u t acciden - ​tal b r
u s h i n g against o r crushing th e beetl e o v e r th e skin p r o v o
k e s th e release o f its c o e l o m i c fluid whic h contain s p a e d
e r i n , a p o t e n t vesicant agent . D u e to the p a t h o g e n i c m
e c h a n i s m , th e m o r p h o l o g y a n d locatio n o f the d e r m
a - titis change f r o m case to case. T h e lesion usually resembles
the accidental d r o p p i n g o f a caustic o r h o t liquid. T h e u n c
o m m o n association o f acut e dermatitis with minima l o r n o
complaints , whic h w o u l d be n o t e w o r t h y in the case o f
chemica l o r t h e r m a l burns , facilitates diagnosis whic h is c o r
r o b o r a t e d b y the seaso n an d b y th e case history .
K e y words : P a e d e r u s dermatitis - C o n t a c t dermatitis -
Blister beetl e dermatosi s
Introduction
P a e d e r u s dermatitis is describe d as a self - healing, blis-tering,
irritant c o n t a c t dermatitis cause d b y an insect belongin g to th
e genu s ​Paederus. T h e a r t h r o p o d does n o t bite o r sting, n
o r p r o d u c e s an y lesion b y just run - ning o v e r th e h u m a
n t e g u m e n t , b u t accidental b r u s h i n g against, pressing o r
crushing th e beetl e o v e r th e skin p r o v o k e s th e release o f
its c o e l o m i c fluid whic h contain s paederin , a p o t e n t
vesicant agent .
This substance , within 2 4 - 3 6 h , p r o v o k e s acut e der -
matitis, whic h can be a s y m p t o m a t i c o r p r e c e d e d an d
ac-c o m p a n i e d b y a mild itching - burnin g sensation .
Clinical appearanc e o f the lesions corresponds in shape an d
dimension s to th e are a affected b y the release d sub-stance . D u
e to the m e c h a n i s m b y whic h th e lesion oc-curs, its m o r p h
o l o g y a n d locatio n is different f r o m case to case b u t
resemble s an accidental d r o p p i n g o f a caustic or h o t liquid.
​ . Gelmetti, Prima Clinica Dermatologica,
Correspondence to." C
Via Pace 9, 1-20122 Milano, Italy
O n t h e skin, t h e a c u t e vesicula r lesions, b e c o m e
cruste d a n d scaly within a few days an d heal c o m p l e t e l y
in 1 0 - 1 2 days, with a transien t p o s t i n f l a m m a t o r y
hyper - c h r o m i c patch . W h e t h e r th e beetl e is c r u s h e d
n e a r the eyes o r w h e n th e vesicant fluid is passively t r a n s p
o r t e d n e a r b y b y h a n d rubbing , acut e conjunctivitis m a y
occur .
B e c a u s e c o n t a c t with th e beetl e is painless, patients m
a y r e m a i n u n a w a r e , b u t m o s t o f t h e m refe r to havin
g b e e n g a r d e n i n g o r staying outside during th e d a y b e f
o r e th e onse t o f the dermatitis . D e s p i t e its f r e q u e n c y ,
this disease is rarel y describe d in m e d i c a l literature, p r o b a
- bly b e c a u s e the c o r r e c t diagnosis m a y n o t b e m a d e .
M o s t patients, at least in o u r e x p e r i e n c e , hav e b e e n r e
f e r r e d with suspecte d diagnose s o f m o r e severe diseases.
T h u s , a descriptio n o f o u r tw o r e c e n t cases coul d b e
useful as a diagnostic r e m i n d e r o f this disease.
Case reports
Case 1
A 6-year-old boy came as an emergency in September
1991, the end of the summer season in our country. His mother
referred that a few hours before, when she was dressing the child,
she noticed the presence of erythemato-vesicular lesions on his
shoulder.
Clinical examination revealed an eruption localized on the
right shoulder and upper back, consisting primarily of vesicles and
bullae containing a serous liquid over an erythematous skin. The
overall arrangement resembled an herpes zoster, but the
distribu-tion of the lesions did not fit the dermatomal patterns. The
lesions were grouped in crops as a gun shot (Fig. 1), with a larger,
bullous lesion at the centre and smaller lesions located at the
periphery. A closer view showed that some lesions were eroded,
while some others were small, scantily visible vesicles. All lesions
showed ery-thematous borders which faded towards the unaffected
skin.
Besides the clinical appearance, which differed from common
pyodermas and herpes zoster, there was no significant discomfort.
Routine blood tests, urine analysis, cultures for bacteria and fungi
and Tzank smear for herpetic cells were negative. The course was
uneventful and cleared within a few days without any treatment.
When asked about the child's activities during the preceding
days, his mother said that they went to join his grandmother at her
country house. Due to the warm temperature the child was dressed
in only a pair of shorts.
 

Fig. 1. Clinical aspect of the lesion showing a well circumscribed
eruption localized on the left shoulder and upper back. Lesions are
vesicles and bullae, containing a serous liquid over an
erythema-tous skin. The lesions are distributed as a gun shot
Fig. 2. Clinical aspect of case 2. Note the involvement of the
ocular mucosa
Case 2
A 7-year-old boy was referred to our hospital as an
emergency in October 1991 because of an acute dermatitis
which started the same morning on the left malar area.
Clinical examination revealed a circumscribed acute,
erythem-atous-oedematous dermatitis. Closer inspection
showed that the central part of the lesion was constituted by a
large superficial eroded blister whose thin epithelial borders
were clearly visible. The erythematous margins faded gradually
towards the unaffected skin.
Oedema of the eyelids was prominent and acute conjunctivitis
with minimal symptoms was also present (Fig. 2). Routine blood
tests, urinary analysis, cultures for bacteria and fungi and Tzank
smear for herpetic cells were negative. The course was uneventful
and had cleared within a few days without any treatment for the
skin and mild antihistaminic eye drops for the eye.
When interviewed, the mother had tried to remove from her
child's face an insect which was crushed accidentally onto the skin.
Discussion
P a e d e r u s dermatitit s is p r o d u c e d b y on e of the 815000
species of insects so far described . C o n c e r n i n g blister
~~91'-"-'-'~' ANTENNA
HEAD
l
E
If)
EN
l
Fig. 3. ​Dorsal aspect of an adult male ​Paederusfuscipes
(Original​ ​drawing by R. Grimalt)
beetl e dermatosis , thre e families, ​Meloidae, Oederneridae
and ​Staphylinidae, hav e b e e n describe d [15]. T h e m o s t
notoriou s of the first famil y is ​Lytta vesicatoria, also cal-led
"Spanis h fly", whic h is f r e q u e n t l y r e c o r d e d durin g s
u m m e r in souther n E u r o p e [11, 20]. T h e least k n o w n
, limited to the Pacific Basin an d the C a r i b b e a n , is due to
the secon d famil y [5, 7]. T h e third group , mainl y rep -
resente d b y the genu s P ​ aederus, has b e e n foun d world -
wide [1, 3, 6, 8, 9, 10, 13, 16, 17, 19].
T h e s e insects are 7 - 8 m m long and slim, the y weigh ca.
4 m g and m a y r e s e m b l e an ant (Fig. 3). P ​ aederi are p r e
d a t o r s and scavanger s which fee d on debris an d live o n d
e a d larva e of othe r insects; the y p r e f e r to live in sand y
soil n e a r water , such as on river banks . A d u l t in-sects e m
e r g e during or t o w a r d the end o f the rain y sea-son or, as
in ou r latitude, at the en d of s u m m e r , charac - teristically
durin g the first w e e k s of S e p t e m b e r [1].
Differen t species of the genu s P ​ aederus [2 - 4 , 12, 18]
hav e b e e n show n causing the disease. In n o r t h e r n Italy,
P.fuscipes ​has b e e n the m o s t f r e q u e n t l y isolated species
[1, 3, 18]. O t h e r species as P . s e b a e u s , ​P. colombinus, ​P.
alternans, P. peregrinus, P. goeldii ​an d P. crebrepunc-tatus
hav e b e e n r e p o r t e d all o v e r the worl d [6, 8 - 10 , 16, 1​ 7,
19].
I n p a e d e r u s dermatitis , objectiv e findings contras t
with mild s y m p t o m s which fad e in few days w h e n the
le-sions, b y contrast , b e c o m e s full d e v e l o p e d with ne
w p e r i p h e r a l vesicles. T h e acut e lesions b e c o m e
cruste d and scaly within a few days and heal c o m p l e t e l y
in 10 - 1 2 days, with a transitor y p o s t - i n f l a m m a t o r y
h y p e r c h r o m i c patch .
T h e blistering fluid, at first t h o u g h t to b e cantharidi n
[19], is different and called paederi n [2, 4, 18], a substance
also capabl e of having therapeuti c effects on w o u n d
heal-ing [12, 14].
A recen t stud y [3] s h o w e d tha t p a e d e r i n m a y
caus e a wide s p e c t r u m of histopathologica l changes ranging f
r o m epidermal necrosis and blistering in early stages, to m a r k e
d acanthosi s with mitoti c figures in the late r stages.
Diagnosis , if suspected , is usually not difficult and is c o r r
o b o r a t e d b y the seaso n an d case history . A m o n g the
 c o m m o n misdiagnoses, impetigo , herpe s simplex o r zos - ter,
are th e m o s t frequent . Also , o t h e r irritative o r aller-gic c o n
t a c t dermatitide s an d factitial dermatitis, ca n b e easily
mistaken .
I m p e t i g o m o r e easily affects periorificial o r o c c l u d e
d areas, is highly contagiou s an d S ​ taphylococci o r
Strep-tococci c​ an be isolated . P r i m a r y herpe s simplex shows
le-sions havin g similar size, whic h quickly d e v e l o p a typical
central umbilication . H e r p e s zoste r present s a d e r m a t o -
real p a t t e r n a n d it has always b e e n p r e c e d e d b y
varicella. Irritan t caustic o r t h e r m a l dermatitis hav e typical
local s y m p t o m s an d exhibit a longe r course . Allergic c o n t
a c t dermatitits, rar e in children, usually present s n o blisters
(except fo r R ​ hu s dermatitis) a n d always itches. Factitial
dermatitis can be the m o s t difficult differential diagnosis, b o t h
b e c a u s e th e inducing m e c h a n i s m m a y b e e x t r e m e l
y varied an d b e c a u s e th e p a t i e n t (o r parents , in case o f
small children) will n o t collaborate . I n this case, h o w - ever, th
e histor y m a y reveal r e c u r r e n c e s o f the s a m e dis-ease.
A s a self - healing disorder , p a e d e r u s dermatitis n e e d s
n o t r e a t m e n t . W e t dressings a n d topical steroids,
associ-ated, if necessary, with antibiotics t o p r e v e n t impetigini
- sation, m a y b e useful in th e acut e phase .
I n conclusion , this disease m u s t be suspecte d w h e n c o n f
r o n t e d with an acute lesion mimickin g a caustic o r infective
dermatitis o f s u d d e n o n s e t o n a e x p o s e d p a r t o f th e b
o d y , with few o t h e r disturbances . A careful case histor y will
n o r m a l l y revea l th e answer .
References
1. Baccaredda A (1935) Dermatite vescicobolIosa stagionale
pro-dotta da un coleottero ​(Paederus fuscipes ram.
Stahylinidae).
G Ital Dermatol Sifilogr 6 : 1423-1458
2. Bernocchi G, Garagna S, Manfredi Romanini MG, et al (1982)
Histomorphological and histoenzymological analysis of skin
regeneration process in the rat after pederin treatment. Pubbl
Ist Entomol Univ Pavia 22 : 1-15
3. Borroni G, Brazzelli V, Rosso R, et al (1991) ​Paederus
fus-cipes d​ ermatitis. A histopathological study. Am J
Dermato-pathol 13 : 467-474
4. Cardani C, Ghiringhelli D, Montelli R, et al (1965) Propridt6
biologiques et composition chimique de la p6d6rine. Ann Soc
Entomol Fr 1 : 813-816
5. Christmas TI, Nicholls DSH, Holloway BA, et al (1987) Blister
beetle dermatosis in New Zealand. N Z Med J 100 : 515-517
6. Deneys JB, Zumpt F (1963) Rove beetle dernaatitis in south
west Africa. S Afr Med J 37 : 1284-1285
7. Fleisher TL, Fox I (1970) Oedemerid beetle dermatosis. Arch
Dermatol 101 : 601-605
8. George AO, Falope Z (1989) An epidemic of paederus
der-matitis in southern Nigeria. Contact Dermatitis 20:314-315
9. George AO, Hard PD (1990) Outbreak of paederus dermatitis
in southern Nigeria. Int J Dermatol 29 : 500-501
10. KerdeI-Vegas F, Goihman-Yahr M (1966) Paederus
dermati-tis. Arch Dermatol 94 : 175-185
11. Lehmann CF, Pipkin JL, Ressmann AC (1955) Blister beetle
dermatosis. Arch DermatoI 71 : 36-38
12. Leigheb G, Maroni P, Pavan M (1982) New results of the
ap-plication of pederin to ulcerative skin lesions. Pubbl Ist
Ento-mol Univ Pavia 20 : 1-37
13. Mank HG (1923) The biology of the S ​ taphylinidae.​ Ann
En-tomol Soc Am 16: 220
14. Matsuda F, Yanagiya M, Matsumoto T (1982) Total synthesis
of pederine. A simple synthetic method for N-amides.
Tetra-hedron Lett 23 : 4043-4046
15. Nicholls DSH, Christmas TI, Greig DE (1990) Oedemerid
blister beetle dermatosis: a review. J Am Acad Dermatol 22:
815-819
16. Pampiglione S, Trentini M (1991) Dermatite
eritemato-ves-cicolare da P ​ aederus sabaeus Erichson 1840
(Coleoptera, S ​ taphylinidae) i​ n Republica di Guinea. Ann
Ital Dermatol Clin​ ​Sper 45 : 15-20
17. Papasarathorn T, Areekul S, Chermsirivatana S, et al (1961)
Study of the rove beetle (Paederus fuscipes curt.) causing
ves-icular dermatitis in Thailand. J Med Assoc Thai 44 :
60-81
18. Pavan M, Bo G (1953) Pederin, toxic principle obtained in the
crystalline state from the beetle P ​ aederusfuscipes. Curt
Physiol Comp Oecol 3:307-312
19. Roy DN, Brown AW A (eds) (1970) Entomology (medical
and veterinary). Bangalore Printing and Publishing, Bangalore,
pp 429-437
20. Swarts WB, Wanamaker JF (1946) Skin blisters caused by
ves-icant beetles. JAMA 131 : 594-595