II. Definitions

  1. Vesicle
    1. Raised fluid filled lesion <0.5 cm diameter
  2. Bulla
    1. Raised fluid filled lesion >0.5 cm diameter

III. Pathophysiology

  1. Develops at intersection of skin levels
    1. Epidermal layers
    2. Epidermal-Dermal junction (Deeper lesions)

IV. Types

  1. Subcorneal Vesicle or bulla
    1. Occurs immediately below Stratum Corneum
    2. Examples
      1. Bullous Impetigo
      2. Pemphigus Foliaceus (Superficial Pemphigus)
  2. Spongiosis (e.g. Allergic Contact Dermatitis)
    1. Intracellular edema in epidermal layers
  3. Acantholysis
    1. Occurs in all forms of Pemphigus
    2. Desmosomes (intracellular bridges) disrupted
    3. Results in loss of Keratinocyte cohesion
    4. Acatholytic cells become rounded (from polyhedral)
  4. Viral induced cell destruction (e.g. Varicella)
    1. Epidermal cells expand as they degenerate

V. Signs

  1. Thin, translucent walls
  2. Contains serum, lymph, blood, or extracellular fluid
  3. Nikolsky's Sign
    1. Pemphigus Vulgaris
    2. Stevens-Johnson Syndrome
    3. Toxic Epidermal Necrolysis

VI. Evaluation: Acute Blistering Condition

  1. Consider Exposures
    1. Insects
    2. Pets
    3. Medications (e.g. Drug-Induced Bullous Disease)
    4. Contact Dermatitis allergens and irritants
    5. Infection (e.g. Bullous Impetigo)
  2. Consider Trauma
    1. Burn
    2. Friction injury
  3. Observe for mucosal lesions
  4. Consider systemic causes
    1. Diabetes Mellitus
    2. Systemic Lupus Erythematosus
    3. Thyroid disease
    4. Porphyria
    5. Celiac Sprue

VII. Labs

  1. Tzanck Smear and viral culture
    1. Indicated for grouped herpetiform Vesicles
  2. Biopsy with Immunofluorescence
    1. Indicated for bullae in older patients
    2. Rule-out Pemphigus or Pemphigoid

VIII. Differential Diagnosis: Vesicle or Bulla Depth

  1. Superficial Vesiculobullous Conditions (Intraepidermal)
    1. Pemphigus (e.g. Pemphigus Vulgaris)
    2. Bullous Impetigo
    3. Staphylococcal Scalded Skin Syndrome
    4. Toxic Epidermal Necrolysis
    5. Herpes Simplex
    6. Varicella Zoster Virus
  2. Deep Vesiculobullous Conditions (Dermal-Epidermal)
    1. Pemphigoid (e.g. Bullous Pemphigoid)
    2. Dermatitis Herpetiformis
    3. Erythema Multiforme
    4. Porphyria cutanea tarda
    5. Diabetes Mellitus associated bullae
    6. Renal disease associated bullae

XI. References

  1. Goldman (2000) Cecil Medicine, p. 2283
  2. Habif (1996) Dermatology, Mosby-Year, p. 9-10
  3. Rye (1997) Am Fam Physician 55(8):2709-18 [PubMed]

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