Bullous eruption

153 Bullous eruption



Instruction


Look at this patient.



Salient features



History




• Onset and blisters


• History of mucosal involvement (mouth ulcers)


• Drug history: thiols (e.g. benzylpenicillin), ACE inhibitors, aspirin, NSAIDs, rifampin. levodopa, phenobarbital, interferon, propanolol, nifedipine.



Examination




• Bullous eruption (Fig. 153.1)


• Crusts or superficial erosions (these suggest a preceding fluid-filled lesion).


image

Fig. 153.1 Bullous eruption.


Proceed as follows:



• Comment on the distribution: knee, thighs, forearms and umbilicus in the elderly (pemphigoid).


• Look in the mouth for ulceration; if the blisters break easily leaving denuded skin, it is more likely to be pemphigus.


• Tell the examiner that a biopsy of the skin is essential to confirm the diagnosis.



Diagnosis


This patient has a bullous eruption (lesion) caused by sulphonamides (aetiology); it is widespread with involvement of mucous membrane and mild dehydration (functional status).



Questions




What do you understand by the term bulla?


It is a circumscribed elevation of the skin, larger than 0.5 cm and containing fluid.



How would you confirm the diagnosis?


A biopsy of a fresh blister (<12 h old) with a portion of perilesional skin for histology and immunofluorescent studies.



Advanced-level questions




Mention a few blistering conditions




• Common: friction, insect bites, drugs, burns, impetigo, contact dermatitis


• Uncommon:


• Autoimmune bullous diseases (pemphigoid, pemphigus vulgaris, dermatitis herpetiformis, immunoglobulin-A-mediated diseases, bullous erythema multiforme, epidermolysis bullosa acquisita)

• Porphyria cutanea tarda

• Paraneoplastic pemphigus.


How would you manage a patient with pemphigus vulgaris?


Barrier nursing, antibiotics, intravenous fluids, large doses of systemic steroids, usually with immunosuppressive drugs (azathioprine, cyclophosphamide or methotrexate), which act as steroid-sparing agents. Other drugs used include dapsone, nicotinamide, gold and ciclosporin.

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Dec 4, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Bullous eruption

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