Male With Diabetes and a Rash

Abstract

A 64-year-old man presented with tense fluid-filled blisters on his right hand. The lesion ruptured and drained clear fluid just before his emergency department evaluation. The patient had no history of fevers, erythema, bleeding, or other systemic symptoms. There was no history of travel, chemical exposure, burns, trauma, or repetitive hand tool use. He had received glipizide for diabetes for more than a year. Physical examination revealed a ruptured bulla over his palm, which was tender but without signs of infection (Figures 1 and 2). Similar lesions were found on the distal right index finger and the fingers of his left hand. Laboratory testing revealed a glucose level of 287 mg/dL and a normal WBC count.Figure 2Radial portion of the hand, showing the generalized swelling and spread of the bulla.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Bullosis diabeticorum. Bullosis diabeticorum is a spontaneous, painless, noninflammatory blistering condition found in 0.5% of diabetic patients.1Duff M. Demidova O. Blackburn S. et al.Cutaneous manifestations of diabetes mellitus.Clin Diabetes. 2015; 33: 40-48Crossref PubMed Scopus (66) Google Scholar, 2Lipsky B.A. Baker P.D. Ahroni J.H. Diabetic bullae: 12 cases of a purportedly rare cutaneous disorder.Int J Dermatol. 2000; 39: 196-200Crossref PubMed Scopus (50) Google Scholar, 3Ghosh S.K. Bandyopadhyay D. Chatterjee G. Bullosis diabeticorum: a distinctive blistering eruption in diabetes mellitus.Int J Diabetes Dev Ctries. 2009; 29: 41-42Crossref PubMed Google Scholar It appears most commonly on acral areas and is often confused with a burn. The underlying pathophysiology is unknown. Differential diagnoses include bullous pemphigoid, porphyrias, drug eruptions, erythema multiforme, and friction blisters. The fluid is clear and sterile. Direct and indirect immunofluorescence testing results of the lesions are negative, which helps to exclude bullous pemphigoid.2Lipsky B.A. Baker P.D. Ahroni J.H. Diabetic bullae: 12 cases of a purportedly rare cutaneous disorder.Int J Dermatol. 2000; 39: 196-200Crossref PubMed Scopus (50) Google Scholar The diagnosis of bullosis diabeticorum is clinical; when performed, biopsies often show intraepidermal cleavage without acantholysis at the superficial prickle-cell layer.2Lipsky B.A. Baker P.D. Ahroni J.H. Diabetic bullae: 12 cases of a purportedly rare cutaneous disorder.Int J Dermatol. 2000; 39: 196-200Crossref PubMed Scopus (50) Google Scholar Patients with uncomplicated lesions can be given outpatient wound care.2Lipsky B.A. Baker P.D. Ahroni J.H. Diabetic bullae: 12 cases of a purportedly rare cutaneous disorder.Int J Dermatol. 2000; 39: 196-200Crossref PubMed Scopus (50) Google Scholar If the blister is drained with a needle, the roof should be kept as a covering. Lesions heal in several weeks, with minimal dyspigmentation or scarring, but often recur.2Lipsky B.A. Baker P.D. Ahroni J.H. Diabetic bullae: 12 cases of a purportedly rare cutaneous disorder.Int J Dermatol. 2000; 39: 196-200Crossref PubMed Scopus (50) Google Scholar