Blister

Aka: Blister, Vesiculobullous, Vesiculobullous Rash, Vesicle, Bulla, Bullous Disease, Bullous Condition, Autoimmune Bullous Dermatoses, Acantholysis, Acantholytic

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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

IX. Differential Diagnosis: Bullous Lesions

  1. Autoimmune
    1. Pemphigus Vulgaris
    2. Bullous Pemphigoid
    3. Dermatitis Herpetiformis
    4. Paraneoplastic Pemphigus
    5. Cicatricial Pemphigoid (Scarring Pemphigoid)
    6. Dermatitis Herpetiformis
    7. Linear IgA Dermatosis (LAD)
    8. Chronic Bullous Disease of Childhood (CBDC)
    9. Epidermolysis Bullosa Acquisita (rare)
    10. Systemic Lupus Erythematosus
  2. Other Bullous Conditions
    1. Drug-Induced Bullous Disease
    2. Bullous Impetigo
    3. Bullae in Diabetes Mellitus
    4. Herpes Gestationis

X. Differential Diagnosis: Vesicular Lesions

  1. Drug Eruption (e.g. Drug-Induced Bullous Disease)
  2. Atopic Dermatitis
  3. Contact Dermatitis
  4. Erythema Multiforme
  5. Herpes Simplex Virus
  6. Herpes Zoster
  7. Scabies
  8. Cat Scratch Disease
  9. Varicela Zoster Virus
  10. Dermatitis Herpetiformis
  11. Lichen Planus
  12. Porphyria cutania tarda

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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