This patient has bedbug bites, and the most appropriate treatment is topical glucocorticoids. Bedbugs (Cimex lectularius) are parasites that feed on human blood, often producing pruritic papules in a characteristic grouped pattern (“breakfast, lunch, and dinner”). Bites occur in exposed skin areas and are more pronounced in the morning because bedbugs are nocturnal and feed at night, usually without being noticed. Bedbugs are about the size of a dog tick and are brownish in color with flat bodies. They frequently inhabit spaces in furniture such as mattresses and cushions. Bedbug bites can be extremely pruritic, and topical glucocorticoids provide anti-inflammatory and symptomatic relief. However, the lesions will self-resolve, so treatment is not mandatory. Professional exterminators are required for evaluation and removal of the bedbugs with pesticides, and eradication can be difficult, making their infestation a significant public health concern. Travel is a risk factor for bedbug infestation, and often multiple family members, if they share the same sleeping quarters, can be affected.

Body lice (pediculosis) also can lead to pruritic papules, but do not occur in a characteristic grouped pattern. Pruritic lesions can occur diffusely, as body lice usually live within the seams of clothing and not on the skin.

Flea bites also result in pruritic papules, but these lesions are not typically grouped. Additionally, because fleas are external parasites and do not live on humans, bites are more commonly present on the lower extremities because fleas typically jump from another location (such as a dog or cat) and bite the legs.

Scabies is an infestation of a mite that lives on the human skin and results in intensely pruritic papules and eruptions involving the waistline, genitals, finger web spaces, wrists, and axillae. A hypersensitivity reaction also can occur. The distribution of lesions in the patient described here is uncommon for scabies infestation.

Spider bites can result in pruritic lesions, but they typically occur as an isolated finding without evidence of multiple or recurrent bites. The number of bites and frequency in which the patient is developing lesions would be atypical for spider bites.