Man With Bulging Blisters

Abstract

A 54-year-old Hispanic man presented with a generalized pruritic and blistering rash for 8 days, involving his face, oral cavity, neck, torso, back, upper extremities, and groin (Figures 1 and 2). He denied fever, and vital signs were within normal limits. Physical examination was notable for diffuse and symmetric, variably sized, tense bullae over the affected areas and intertriginous folds, with negative Nikolsky’s sign (Figure 3). Oral mucosa was moist, with tender erosive ulcers involving the hard palate and gingiva (Figure 4). Laboratory results were remarkable for mildly elevated blood glucose and inflammatory marker levels.Figure 2Symmetrically distributed bullous lesions over the neck, torso, and upper extremities.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Areas of erythema and dry skin in association with blisters located over the axilla and similarly over the intertriginous folds.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Erosive oral lesions on the hard palate.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Bullous pemphigoid. Bullous pemphigoid is an autoimmune and inflammatory condition manifested by a blistering rash as a result of deposits of immunoglobulins and complement within subepithelial layers of the skin and mucosa. Immunoglobulin G autoantibodies bind to the basement membrane, degrading hemidesmosomal proteins; as a result, immunofluorescence study results exhibit subepidermal deposits. Skin biopsy typically reveals eosinophilic infiltrate. Oral erosions may also be present in 10% to 30% of patients. Cutaneous involvement commonly manifests along flexural folds, but may be symmetrically distributed. Mainstay of treatment rests with corticosteroids, adjuvant immunomodulators, and anti-inflammatories.1Venning V.A. Taghipour K. Mohd Mustapa M.F. et al.British Association of DermatologistsGuidelines for the management of bullous pemphigoid.Br J Dermatol. 2012; 167: 1200-1214Crossref PubMed Scopus (108) Google Scholar, 2Kirtschig G. Middleton P. Bennett C. et al.Interventions for bullous pemphigoid.Cochrane Database Syst Rev. 2010; : CD002292PubMed Google Scholar Optimal management of precipitants and comorbidities and prevention of infections reduce morbidity and mortality.3Ren Z. Hsu D.Y. Brieva J. et al.Hospitalization, inpatient burden and comorbidities associated with bullous pemphigoid in the USA.Br J Dermatol. 2017; 176: 87-99Crossref PubMed Scopus (76) Google Scholar The patient was treated with systemic and topical steroids and wound care. He received a diagnosis of new-onset diabetes mellitus, and aggressive glycemic control was pursued as the potential precipitant. Formal biopsy confirmed the diagnosis.