Pruritic Vesicular Eruption on the Lower Legs in a Diabetic Female

Abstract

A 50-year-old diabetic female presented with highly pruritic vesicles and excoriated lesions over the anterior aspect of both lower legs. The lesions were recurrent over the last two years. She received a lot of medications with partial response. Hb A1c was 10.8% (normal up to 7%). CBC showed microcytic, hypochromic anemia. Serum zinc, folate, IgE, TSH and T4 were all within normal ranges. Biopsy showed epidermal separation secondary to keratinocyte necrosis and minimal monocytic, perivascular infiltrate. Direct immunofluorescence was negative for intraepidermal and subepidremal deposition of immunoglobulin. The dermis was positive for mucin deposition stainable by both PAS and Alcian blue while it was negative for Congo red and APC immunoperoxidase staining for amyloid material. In conclusion, the case was diagnosed as bullosis diabeticorum by distinctive clinical and pathological features and after exclusion of other possible differentials. Pruritus was partially controlled by topical potent steroid and the case was resolved spontaneously after eight months.

Bullosis Diabeticorum: Rare Presentation in a Common Disease

“…Bullosis diabeticorum (BD) or diabetic bulla is a spontaneous, recurrent, noninflammatory, and blistering condition usually affecting acral and distal skin of lower extremities [ 1 – 3 ]. The blisters are usually large and asymmetrical in shape [ 4 ].…”

“…These serous fluid filled tense bullae (sized few mm to cm) may even sometimes be hemorrhagic [ 5 ]. The condition occurs in about 0.5% of diabetics in the USA [ 1 ]. They are seen in patients from 17 to 80 years of age and are more frequent in adult men suffering from long standing uncontrolled diabetes with peripheral neuropathy [ 6 , 7 ].…”

“…Diabetes mellitus is associated with cutaneous manifestations including diabetic thick skin, acanthosis nigricans, necrobiosis lipoidica diabeticorum, and diabetic dermopathy in about one-third of patients [ 1 – 3 ].Bullosis diabeticorum is a spontaneous, noninflammatory, and blistering condition, that is, uniquely affects patients with diabetes mellitus. We present a case of bullosis diabeticorum in a patient with a history of diabetes mellitus type 1 who presented with a sudden onset of blisters that were diagnosed as diabetic bullae.…”

Cutaneous Manifestations of Diabetes Mellitus and Prediabetes

“…Bullosis diabeticorum (BD) or diabetic bulla is a noninflammatory blistering condition of unknown aetiology that occurs in about 0.5% of diabetics in the USA. 55 The blisters are usually large and asymmetrical and commonly affect acral and distal skin of lower extremities. 55,56 The diagnosis of BD involves skin biopsies with subsequent histopathologic examination and immunofluorescence in order to rule out other immune bullous disorders such as bullous pemphigoid, epidermolysis bullosa acquisita, traumatic blisters, bullae due to drug reactions, insect bites, and bullous SLE.…”

“…55 The blisters are usually large and asymmetrical and commonly affect acral and distal skin of lower extremities. 55,56 The diagnosis of BD involves skin biopsies with subsequent histopathologic examination and immunofluorescence in order to rule out other immune bullous disorders such as bullous pemphigoid, epidermolysis bullosa acquisita, traumatic blisters, bullae due to drug reactions, insect bites, and bullous SLE. [56][57][58] Although spontaneous healing without scarring frequently occurs in a few weeks and the blisters should be left intact to serve as a sterile dressing, close monitoring for secondary bacterial infection or haemorrhage is warranted.…”