Vesicular and Bullous Eruptions
Vesicular and Bullous Eruptions: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Marcia J. Chesebro
Approach
The initial approach to the patient with fluid-filled lesions involves assessment of the severity of the illness: Does the patient look sick or toxic or does the patient appear generally well?
History
A. Age. Newborns develop epidermolysis bullosa, pemphigus neonatorum, and syphilitic pemphigus. Children are more likely to have varicella (if unimmunized); primary herpes simplex; hand, foot, and mouth disease (HFM); and bullous impetigo. Recurrent herpes simplex, porphyria cutanea tarda (PCT), pemphigus vulgaris, dyshidrotic eczema, and dermatitis herpetiformis occur primarily in adults. Bullous pemphigoid and herpes zoster are more common in the elderly. Other vesiculobullous diseases that have no particular age predilection include allergic contact dermatitis, allergic vasculitis, erythema multiforme bullosum (EMB), toxic epidermal necrolysis (TEN), insect bites, and second-degree burns.
B. Season. Varicella, HFM, and primary herpes simplex are often seen in epidemics after gatherings of children. Summer brings more bullous impetigo (from staphylococcal infection) and dyshidrotic eczema (increased sweating of hands and feet). Contact dermatitis caused by Rhus species can be seen in the spring, as people landscape their yards; in the summer, as people spend more time outdoors; and in the fall, as people rake leaves and cut firewood.
C. Special precipitators. Recurrent herpes simplex can be precipitated by trauma, sunlight, wind, menses, dry skin, smoking, drinking alcohol, lack of sleep, and fever. PCT is precipitated by exposure to sunlight, ingestion of drugs metabolized in the liver, and by drinking alcohol (1). EMB can be caused by a viral or bacterial infection or by drug ingestion within 3 weeks preceding the eruption (Chapter 13.2). Allergic vasculitis is usually caused by drugs. Persons with contact dermatitis have been exposed to the allergen 12 to 48 hours before the rash appears.
D. Pain or pruritus. Itching is very common with acute contact dermatitis, dyshidrotic eczema, varicella, dermatitis herpetiformis, and bullous pemphigoid (Chapter 13.5). Before the eruption of recurrent herpes simplex, the site may itch or tingle for a few hours or days; before herpes zoster erupts, the area may burn or mimic internal or visceral pain.
E. Duration. Some diseases are chronic with exacerbations: dermatitis herpetiformis, dyshidrotic eczema, bullous pemphigoid, epidermolysis bullosa, and PCT. Some are episodically recurrent: acute contact dermatitis and herpes simplex. Some occur acutely without preceding episodes: EMB, varicella, bullous impetigo, herpes zoster, allergic vasculitis, HFM, TEN, and pemphigus vulgaris.
Physical
A. Sick or toxic appearing
1. In those who look sick, toxic, or ill, consider the possible diagnoses of EMB, pemphigus vulgaris, TEN, or primary herpes simplex. Rubbing normal skin in patients with pemphigus vulgaris and TEN may induce new blister formation or enlarge existing blisters (Nikolsky’s sign).
2. Patients with varicella and HFM may have low-grade fever and malaise. Patients with EMB, primary herpes simplex, or varicella may have preceding or concurrent fever and malaise.
3. Oral lesions. The presence of oral lesions, either as vesicles or the secondary lesion of erosion or ulcer, tends to have more serious consequences because of decreased oral intake; consider EMB, pemphigus vulgaris, TEN, primary herpes simplex, varicella, and HFM.
B. Size of vesicles and bullae. The only distinction between vesicles and bullae is size: vesicles are less than 1 cm; bullae are more than 1 cm. The fluid in them can be clear, purulent, or hemorrhagic. Secondary lesions (e.g., erosions, ulcers, and crusts) evolve from vesicles and bullae. Most of the diseases in this section primarily will have either vesicles or bullae, but can have some of both. The primarily vesicular diseases are herpes simplex, varicella, herpes zoster, contact dermatitis, dyshidrotic eczema, hemorrhagic vasculitis, HFM, Kaposi’s varicelliform eruption (KVE), and dermatitis herpetiformis; the bullous diseases are generally pemphigus vulgaris, bullous pemphigoid, bullous impetigo, PCT, EMB, TEN, and epidermolysis bullosa.
C. Appearance of the blisters
1. The bullae of bullous impetigo are thin, fragile, short-lived, and easily ruptured, leaving a thin, varnishlike crust with occasionally a delicate remnant of the blister roof at its rim.
2. Contact dermatitis may be mostly excoriations by the time the patient presents.
3. Varicella will have a variety of lesions—the newest ones vesicular (“dew drop on a rose petal”), the older ones becoming purulent, then crusting over.
4. The bullae of bullous pemphigoid are large and tense; those of pemphigus vulgaris are flaccid and easily ruptured, leaving large denuded, bleeding, and weeping erosions.
5. The lesions of PCT, dermatitis herpetiformis, and allergic vasculitis may be hemorrhagic, and secondarily crusted.
6. Umbilication. Always examine a fresh blister. Umbilication (a small dimple in the center) is characteristic of a viral cause—herpes simplex, herpes zoster, varicella, KVE, and molluscum contagiosum. EMB lesions, although not umbilicated, may have a depression in the center as part of the “bull’s eye.”
D. Location or distribution
1. Localized. If the lesions are found primarily on sun-exposed or usually uncovered areas, consider contact dermatitis, insect bites, and PCT (esp., the dorsum of the hands). Contact dermatitis is localized to the area of exposure and is frequently recognizable by its shape (linear streaks from contact with leaves, recognizable geometric patterns in reaction to shoe leather, belts, rings, necklaces, elastic bands, and so on). If the contactant is airborne or reacts with sunlight, the dermatitis will be on exposed surfaces (neck, arms, face, and so forth). The palms and soles are usually spared because of the skin thickness, unless the contactant is related to shoes, socks, or gloves. Allergic vasculitis occurs primarily distally—on the feet and lower legs—and under areas of pressure. HFM occurs in the mouth and on the hands and feet. Dermatitis herpetiformis occurs primarily on the shoulders, buttocks, elbows, and posterior upper back. Herpes zoster affects a sensory (cutaneous) dermatome and rarely crosses the midline. Bullous impetigo is frequent around the mouth, nose, and genital area. Dyshidrotic eczema involves the lateral aspects of the fingers, palms, and soles. KVE occurs at sites of preexisting dermatitis, especially areas of atopic dermatitis.
2. Some diseases begin in one area then become generalized. Varicella begins on the trunk or head, with successive crops erupting more distally. TEN begins in the oral cavity, groin, or axilla. Pemphigus vulgaris may begin in the oral cavity. Bullous pemphigoid occurs mostly in the flexor surfaces, axilla, and groin, but can be generalized. EMB involves the hands, feet, face, genitals, and mouth, but in severe cases is generalized.
Testing
A. The Tzanck smear is used to diagnose viral dermatoses: herpes simplex, herpes zoster, KVE, and varicella. Select an early intact vesicle without infection or trauma; remove the blister top and scrape the floor lightly with a scalpel; smear the material on a clean glass slide; air dry and fix; stain with Wright or Giemsa stain. A positive test is the presence of multinucleated giant cells (2).
B. Biopsy of the edge of the blister and subsequent immunofluorescent staining is helpful for diagnosing pemphigus vulgaris, bullous pemphigoid, and EMB (3).
Diagnostic assessment
The presence or absence of a toxic appearance guides the clinician initially. History that includes age, season of onset, special precipitators, whether the lesions are itchy, and the duration of lesions then further assists in classification. Finally, the appearance of the lesions and their distribution further reduce candidate illnesses. It is important to remember that significant and occasionally life-threatening illnesses present as vesiculobullous lesions.
References
1. Robin KL, Piette WW. Cutaneous manifestations of systemic diseases. Med Clin North Am 1998;82(6):1359–1379, vi–vii.
2. Brodell RT, Helms SE, Devine M. Office dermatologic testing: the Tzanck preparation. Am Fam Physician 1991;44(3):857–860.
3. Gellis SE. Bullous diseases of childhood. Dermatol Clin 1986;4(1):89–98.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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