Blistering eruption on lower extremities

Because of the localized nature of the disease, the patient was treated with topical corticosteroids alone, which partially controlled the problem.

A 75-year-old woman presents with a chief complaint of a 1-month history of an asymptomatic blistering eruption on the lower extremities. For this problem she was briefly hospitalized and treated for cellulitis and thrombophlebitis, but new lesions continued to appear.

Non-inflammatory bullae on the leg
On examination you observe a solitary, tense, bulla on the leg, which appears to be arising from normal skin. A crusted papule below it represents a ruptured bullous lesion (Figure). The extremitiy is not edematous.

Differential diagnosis

Skin conditions to consider are those that produce bullous lesions on the leg.

INSECT BITE REACTION may occur on the leg and can be associated with a vesicle or bulla. Cependant, the base of the lesions are almost always red, indicative of the significant inflammation which occurs with these bites.

DERMATITIS HERPETIFORMIS
is a bullous disease which may appear on the legs. Cependant, the lesions are typically smaller, the lesions always have a red base, and there is profound pruritus in all cases.

PEMPHIGUS VULGARIS
is a bullous disease, the lesions of which may arise from normal skin. Cependant, in 95% of cases the oral cavity is involved and is usually the location where the lesions first occur.

STASIS DERMATITIS
occurring on the lower extremities can produce non-inflammatory bullae, which are the result of edema which extrudes through the epithelium. The absence of edema in the extremity rules out this diagnosis.

BULLOUS PEMPHIGOID
is the correct diagnosis. This is an autoimmune disease which preferentially occurs in the elderly, where vesicles and bullae are formed, occasionally localized to

the lower extremities.

Because of the localized nature of the disease, the patient was treated with topical corticosteroids alone, which partially controlled the problem.

Diagnostic pearl

Consider bullous pemphigoid in a patient with non-inflammatory vesicles or bullae localized to the lower extremities.

Dr Levine is in the private practice of dermatology in Tucson, Ariz.


Suggested reading

Olasz EB, Yancey KB. Bullous pemphigoid and related subepidermal autoimmune blistering diseases. Curr Dir Autoimmun. 2008;10:141-166.

Di Zenzo G, Marazza G, Borradori L. Bullous pemphigoid: physiopathology, clinical features and management. Adv Dermatol. 2007;23:257-288.

Patton T. Korman NJ. Bullous pemphigoid treatment review. Expert Opin Pharmacother. 2006;7(17):2403-2411.


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