Vesicular & Bullous Lesions
Vesicular & Bullous Lesions: Excerpt from In a Page: Signs and Symptoms
Vesicular and bullous rashes must be approached systematically so that serious causes are not missed. Initially, a determination as to whether the lesions are focal or diffuse is made, followed by a history of the lesions, a review of systems, and a focused physical examination. For lesions that do not have an obvious diagnosis, referral to a dermatologist can be invaluable.
Differential Diagnosis
Localized
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Allergic contact dermatitis (e.g. rhus)
–Localized vesicular and bullous eruptions
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Herpes-zoster or shingles
–Due to reactivation of latent virus
–More common in adults
–Presents as painful vesicles on an
erythematous base in a dermatomal distribution, beginning with fever, dysesthesia, and/or malaise -
Herpes simplex virus
–Herpetic lesions present as painful, recurrent vesicles on an erythematous base
–Type 1 usually affects oral mucosa and vermilion border
–Genital HSV (most commonly HSV-2) may manifest as nonspecific symptoms (e.g., dysuria, urethritis)
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Bullous impetigo
–Most common in children
–Presents as flaccid vesicles and bullae with honey-colored crust
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Bites from many insects
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Many viral infections of childhood can present with focal vesicles, especially hand-foot-andmouth disease
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Burns and friction blisters
–Common causes of bullae, especially on hands
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Diabetics can develop bullae on the legs
- Dyshidrotic eczema (pompholyx)
–Causes itching, scaling, and erythema, and minute vesicles and painful fissures
Diffuse
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Polymorphous light eruption
–Common reaction to ultraviolet light
–Presents as itchy vesicles or erythematous papules on sun-exposed areas
-
Varicella or “chicken pox”
–Presents with vesicles in crops, and in many stages of evolution
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Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN)
–Most commonly caused by medications
–TEN is life threatening
-
Blistering diseases like bullous pemphigoid, pemphigus vulgaris, and porphyria cutanea tarda present with coalescing vesicles and bullae
Workup and Diagnosis
-
History and physical examination
–Determine whether the lesions are focal or diffuse
–Thorough review of systems
-
Culture from bullous lesions is not usually indicated, because most bullous reactions to bacteria are due to toxin production; thus, the bacteria are not commonly found within the bulla itself
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If HSV-2 (genital herpes) is the suspected etiology of a vesicular eruption, viral culture is the gold standard for diagnosis; obtain a culture by lancing an intact vesicle and swabbing the contents and floor of the erosion; serum IgM and IgG antibodies can also aid in the diagnosis
-
Suspected orolabial HSV-1 infection is diagnosed on the basis of a history of similar recurrent episodes
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Consider a viral etiology if the patient has low-grade fevers, myalgias, pharyngitis, or other systemic symptoms
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Skin biopsy is indicated if an autoimmune blistering disease is suspected. PCT, pemphigus, and pemphigoid have distinct microscopic features
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In patients with widespread bullae, also consider incipient toxic epidermal necrolysis. Drugs such as sulfonamides, certain antibiotics, and several anticonvulsants are the most likely causative agents. Skin biopsy may also aid in this diagnosis, but frozen sections must be examined urgently, since this disease can quickly prove fatal
Treatment
-
HSV-1, HSV-2, and HZV can be effectively treated with antiviral medication (e.g., acyclovir, famciclovir). Early antiviral therapy may decrease the risk of post-herpetic neuralgia. HSV is infectious until all cutaneous lesions have crusted over
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Bullous impetigo can be treated with topical mupirocin, or systemic antibiotics (e.g., erythromycin, cephalexin)
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Dyshidrotic eczema can be difficult to treat. It is not curable, but can be controlled with high-potency topical steroid ointments and heavy emollients
-
PMLE is preventable with sun avoidance and zinc- or titanium-based sun blocks. Topical steroids can diminish the pruritus that accompanies an episode
-
SJS/TEN treatment consists of supportive care and discontinuing the offending drug, often requiring a burn center; IVIG and systemic steroids are sometimes used.
-
Systemic immunosuppressants (e.g., prednisone, cyclosporin, azathioprine) are often necessary to control autoimmune bullous diseases like pemphigus
Book Source Details
- Book Title: In a Page: Signs and Symptoms
- Author(s): Scott Kahan, Ellen G. Smith
- Year of Publication: 2004
- Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.
More About Bullous Pemphigoid
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Medical Books Excerpts
- Dermatitis
- "Professional Guide to Diseases (Eighth Edition)" (2005)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X
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» Next page: Atopic dermatitis (Professional Guide to Diseases (Eighth Edition))
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