Photo Rounds Friday Archive

Blisters on back

Post Date: 07/31/2009

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A 57-year-old man sought treatment for blisters on his back and arms that had developed 2 weeks earlier. He had hypertension and was recently started on metoprolol. He denied previous dermatologic disease and was otherwise feeling well. Pressure applied directly to the bulla did not cause lateral spread.

What's your diagnosis?

Bullous pemphigoid was suspected and a shave biopsy (ordered rush) was performed on the edge of an intact bulla. The physican started the patient on prednisone 60 mg daily while awaiting the biopsy result. In 2 days, the biopsy confirmed bullous pemphigoid and no new blisters formed during the time the patient was on the prednisone. The physician switched the patient to another antihypertensive agent just in case the metoprolol contributed to the new onset of the bullous pemphigoid.

After 2 weeks, the prednisone was dropped to 40 mg a day and tetracycline 500 mg 3 times a day was started. Later in the course, nicotinamide 500 mg 3 times a day was added while the prednisone dose was dropped even further. The bullae healed and the patient continued to do well as long as he took his medicine.

The differential diagnosis for bullous disease is long, but includes pemphigus, porphyria cutanea tarda, bullous impetigo, and pityriasis lichenoides.

Photos and text for Photo Rounds Friday courtesy of Richard Usatine, MD. This case was adapted from: Mohmand A. Bullous pemphigoid. In: Usatine R, Smith M, Mayeaux EJ, Chumley H, Tysinger J, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:539-544.

To learn more about The Color Atlas of Family Medicine, see:
* http://www.amazon.com/Color-Atlas-Family-Medicine/dp/0071474641
* http://www.mhprofessional.com/product.php?isbn=0071474641