Infantile Bromoderma

Abstract

A 6-month-old girl had an eruption on her face and scalp present for 3 weeks. Physical examination revealed several large vegetative plaques with erythematous base and covered with yellow-gray crusts (Figure 1). Nevertheless, the patient was in good health and neither fever nor adenopathy was detected. She had been treated with phenobarbital and potassium bromide (260 mg twice daily) for 1 month for migrating partial seizures. A cutaneous swab was negative, and her serum bromide concentration was 930 μg/mL. Bromoderma was suspected and administration of potassium bromide was tapered and terminated after 2 weeks. After withdrawal of the drug, the lesion improved gradually, leaving mild erythema and pigmentation 2 months later (Figure 2; available at www.jpeds.com). The diagnosis of bromoderma was established by clinical presentation, patient's history, and healing after drug withdrawal. Bromoderma is a skin eruption caused by bromide intake.1Smith S.Z. Scheen S.R. Bromoderma.Arch Dermatol. 1978; 114: 458-459Crossref PubMed Scopus (10) Google Scholar Potassium bromide was widely used as an antiepileptic drug in the late 19th century before the advent of phenobarbital. Numerous cases of bromoderma were reported at that time. In recent years, however, bromides have again been used in case of intractable epilepsies during childhood including migrating partial seizure in infancy.2Anzai S. Fujiwara S. Inuzuka M. Bromoderma.Int J Dermatol. 2003; 42: 370-371Crossref PubMed Scopus (18) Google Scholar Apart from drowsiness and acneiform eruptions which are the most common adverse effect of bromide, cutaneous lesions also can infrequently manifest with granulomatous and vegetating nodules, referred to as bromoderma tuberosum as in our case.3Maffeis L. Musolino M.C. Cambiaghi S. Single-plaque vegetating bromoderma.J Am Acad Dermatol. 2008; 58: 682-684Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar It starts as an erythematous papule that rapidly evolves into a plaque formed by multiple pustules that coalesce to form a tuberous, fungoid, pseudotumoral, or vegetant inflammatory lesion covered by yellowish crust. The differential diagnosis includes bacterial, deep fungal and nontuberculous Mycobacterium infections, pyoderma gangrenosum, pemphigus vegetans, and ulcerative Sweet syndrome.4Bel S. Bartralot R. García D. Aparicio G. Castells A. Vegetant bromoderma in an infant.Pediatr Dermatol. 2001; 18: 336-338Crossref PubMed Scopus (17) Google Scholar Treatment consists mainly of stopping the intake of bromides. The long half-life of bromide ion (approximately 12 days) explains the slow rate of improvement after drug withdrawal.5Scola N. Kaczmarczyk J. Möllenhoff K. Infantile bromoderma due to antiepileptic therapy.J Dtsch Dermatol Ges. 2012; 10: 131-132PubMed Google Scholar The present case underscores the importance of recalling the possibility of bromoderma in patients with vegetating and ulcerating skin disorders and medication history of exposure to bromide and the importance to monitor serum bromide levels to minimize the risk of intoxication.