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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Ontology: Acantholysis (C0000887)

Definition (MSH) Separation of the prickle cells of the stratum spinosum of the epidermis, resulting in atrophy of the prickle cell layer. It is seen in diseases such as pemphigus vulgaris (see PEMPHIGUS) and DARIER DISEASE.
Concepts Pathologic Function (T046)
MSH D000051
SnomedCT 43327007
English Acantholyses, Acantholysis, Acantholysis [Disease/Finding], acantholysis, Acantholysis (morphologic abnormality)
Japanese 棘融解, キョクユウカイ
Swedish Akantolys
Czech akantolýza, Akantolýza
Finnish Akantolyysi
Polish Akantoliza
Hungarian Acantholysis
Norwegian Akantolyse
Spanish acantólisis (anomalía morfológica), acantólisis, Acantolisis, Acantólisis
Dutch acantholyse, Abces, Acantholysis
French Acantholyse
German Akantholyse
Italian Acantolisi
Portuguese Acantólise

Ontology: Bulla (C0005758)

Definition (MSHCZE) Viditelné nahromadění tekutiny uvnitř nebo pod pokožkou.
Definition (SCTSPA) Lesión sobreelevada, llena de líquido, generalmente translúcida, mayor de 1 cm de diámetro
Definition (SNOMEDCT_US) A fluid-filled, raised, often translucent lesion, greater than 1 cm in diameter
Definition (NCI) A large (greater than 5-10 mm) intraepidermal/subepidermal cavity filled with clear, serosanguineous or cloudy fluid.
Definition (NCI) An intraepidermal/subepidermal cavity filled with clear, serosanguineous or cloudy fluid.(NICHD)
Definition (NCI_NCI-GLOSS) A fluid-filled sac in the outer layer of skin. It can be caused by rubbing, heat, or diseases of the skin.
Definition (CSP) visible accumulations of fluid within or beneath the epidermis.
Definition (MSH) Visible accumulations of fluid within or beneath the epidermis.
Concepts Pathologic Function (T046)
MSH D001768
SnomedCT 287129000, 271208000, 210984001, 339008, 247464001
English Bleb, Blister, Bulla, Bullae, Vesication, Vesications, Blebs, BLISTERS, Blistering eruption, Blister NOS, bulla, vesication, blister, blister (diagnosis), Bullous lesions, Blister [Disease/Finding], bullous lesions, bullous lesion, bullae, Bullous Lesion, Bullous Lesions, Lesion, Bullous, Lesions, Bullous, Blister NOS (disorder), Blister: NOS, Blisters, Blistering, Blister (morphologic abnormality), Blister, NOS
Dutch bulleuze laesies, blaren, bullae, blaarvorming, blaar, Blaar, Bulla, Vesica
French Ampoules, Bulles, Lésions bulleuses, Vésication, VESICULES, Vésicule cutanée, Phlyctène, Vésicule, Bulle, Ampoule, Cloque, Lésion bulleuse
German Blasen, Bullae, blasige Laesionen, BLAESCHENAUSSCHLAG, Blasenbildung, Blase, Bulla
Italian Lesioni bollose, Vescicole, Vescicolazione, Bolle, Lesione bollosa, Vescicazione, Bolla, Vescichetta, Vescicola
Portuguese Formação de bolhas, Lesões bolhosas, Ampolas, VESICULAS, Bolhas, Bolha, Vesícula
Spanish Lesiones ampollosas, Vesiculación, AMPOLLAS, Bulla, ampolla, SAI, ampolla, SAI (trastorno), Ampolla, Ampollas, Bullas, ampolla (anomalía morfológica), ampolla, flictena (trastorno), flictena, ampolla filtrante (anomalía morfológica), ampolla filtrante, Vesicación, Vesícula
Japanese 皮膚水疱, 水疱性病変, 水疱形成, ヒフスイホウ, スイホウ, スイホウセイビョウヘン, スイホウケイセイ, 水疱, 発疱疹, ブラ
Swedish Blåsa
Czech puchýř, Bulózní léze, Puchýř, Buly, Puchýřnatění, Puchýře, bula, bulla
Finnish Rakkula
Polish Pęcherz, Pęcherz skórny, Pęcherz śluzówkowy, Pęcherze
Hungarian Hólyag, Bullosus laesiók, Hólyagosodó, Bullák, Hólyagok
Norwegian Blemme, Vable, Vesikkel, Blære, Bulla, Bulløs skade, Gnagsår

Ontology: Skin Diseases, Vesiculobullous (C0037275)

Definition (MSH) Skin diseases characterized by local or general distributions of blisters. They are classified according to the site and mode of blister formation. Lesions can appear spontaneously or be precipitated by infection, trauma, or sunlight. Etiologies include immunologic and genetic factors. (From Scientific American Medicine, 1990)
Concepts Disease or Syndrome (T047)
MSH D012872
English Dermatoses, Vesiculobullous, Skin Disease, Vesiculobullous, Skin Diseases, Vesiculobullous, Vesiculobullous Dermatoses, Vesiculobullous Skin Disease, Vesiculobullous Skin Diseases, SKIN DIS VESICULOBULLOUS, VESICULOBULLOUS SKIN DIS, Skin Diseases, Vesiculobullous [Disease/Finding]
Swedish Hudsjukdomar, vesikulobullösa
Czech kůže - nemoci bulózní
Finnish Rakkulaihotaudit
Japanese 角層下膿疱症, スネドン・ウィルキンソン病, 皮膚疾患-水疱性, スネドン-ウィルキンソン病, 水疱性皮膚疾患, 小胞水疱性皮膚疾患, 膿疱症-角層下, Sneddon-Wilkinson病, 皮膚疾患-小胞水疱性
Spanish Dermatopatías Vesiculoampollosas, Enfermedades Cutáneas Vesiculoampollosas, Dermatopatías Vesiculobullosas, Enfermedades Ampollosas de la Piel, Dermatopatías Bullosas, Dermatopatías Bulosas, Enfermedades Bullosas de la Piel
Italian Dermatosi vescicolobollosa, Malattie vescicolobollose della pelle
Croatian Not Translated[Skin Diseases, Vesiculobullous]
Polish Choroby skóry pęcherzowe
Norwegian Vesikulobulløse dermatoser, Vesikulobulløse hudsykdommer, Vesikulobulløse utslett
French Dermatoses vésiculo-bulleuses, Dermatoses vésiculobulleuses
German Hautkrankheiten, vesikulobullöse, Vesikulobullöse Hautkrankheiten
Dutch Huidziekte, vesiculobulleuze, Huidziekten, vesiculobulleuze, Vesiculobulleuze huidziekte, Vesiculobulleuze huidziekten
Portuguese Dermatopatias Vesiculobolhosas

Ontology: Vesiculobullous rash (C0151883)

Concepts Finding (T033)
SnomedCT 14912003
English VESICULOBULLOUS RASH, VESICULOPUSTULAR RASH, Vesiculo-bullous eruption, Rash vesiculo-bullous, Vesiculo-bullous rash, Rash vesiculobullous, Vesiculo-pustular rash, Rash vesiculopustular, Rash vesiculo-pustular, Vesiculopustular rash, Vesiculobullous rash, Vesiculobullous rash (morphologic abnormality)
Dutch vesiculobulleuze rash, vesiculobulleuze uitslag, vesiculobulleuze eruptie, rash vesiculopustulair, vesiculo-pustulaire rash
French Rash vésiculo-bulleux, Rash vésiculobulleux, Eruption vésiculobulleuse, ERUPTION VESICULO BULLEUSE, ERUPTION VESICULO PUSTULEUSE, Rash vésiculo-pustulaire, Rash vésiculopustuleux
German Ausschlag vesikulo-bulloes, vesikulo-bulloeser Ausschlag, vesikulobulloeser Ausschlag, Ausschlag vesikulobulloes, EXANTHEM VESICULOBULLOES, EXANTHEM VESIKULOPUSTULOES, vesikulo-pustuloeser Ausschlag, Ausschlag vesikulo-pustuloes, Ausschlag, vesikulo-pustuloes
Italian Eruzione vescico-bollosa, Esantema vescicolo-bolloso, Esantema vescicolo-pustoloso, Eruzione vescico-pustolosa
Portuguese Exantema vesiculobolhoso, Erupção vesiculobolhosa, ERUPCAO VESICO-BOLHOSA, ERUPCAO VESICO-PUSTULOSA, Exantema vesiculopustuloso, Erupção vesiculopustulosa
Spanish Erupción vesiculoampollar, Erupción vesicoampollar, ERUPCION VESICULOAMPOLLOSA, ERUPCION VESICULOPUSTULAR, Erupción vesiculopustular, Erupción vesicopustular, erupción vesicoampollosa (anomalía morfológica), erupción vesicoampollosa, rash vesicoampolloso, salpullido vesicoampolloso, sarpullido vesicoampolloso
Japanese 小水疱水疱性皮疹, 小胞水疱性皮疹, ショウホウスイホウセイヒシン, ショウスイホウスイホウセイヒシン, 水疱膿疱性皮疹, スイホウノウホウセイヒシン
Czech Vezikulobulózní výsev, Vezikulobulózní erupce, Vezikulobulózní vyrážka, Vezikulopustulózní vyrážka
Hungarian Apró- és nagyhólyagos kiütés, Kiütés vesiculo-pustulosus, Vesiculo-pustulosus exanthema, exanthema vesiculo-bullosa, Vesiculo-pustulosus kiütés, vesiculobullosus kiütés, Kiütés, vesiculo-bullosus, exanthema vesiculo-pustulosa, vesiculo-bullosus kiütés

Ontology: Vesicle (morphologic abnormality) (C0333262)

Definition (CHV) a small liquid filled sac
Definition (CHV) a small liquid filled sac
Definition (SCTSPA) Lesión pequeña (de menos de 1 cm de diámetro) llena de líquido, sobreelevada con respecto al plano de la piel circundante
Definition (SNOMEDCT_US) A small (less than 1 cm) fluid-filled lesion, raised above the plane of surrounding skin
Concepts Acquired Abnormality (T020)
SnomedCT 82515000
English vesicle, vesicles, Vesicle formation, Vesicle, Vesicle (morphologic abnormality)
Spanish vesícula (anomalía morfológica), vesícula

Ontology: Acantholytic (C0443130)

Concepts Qualitative Concept (T080)
SnomedCT 263655009
English acantholytic, Acantholytic, Acantholytic (qualifier value)
Spanish acantolítico (calificador), acantolítico

Ontology: Bullous conditions (C0851664)

Concepts Disease or Syndrome (T047)
Italian Condizioni bollose
Japanese 水疱形成, スイホウケイセイ
Czech Bulózní stavy
English Bullous conditions
Hungarian Bullózus állapotok
Portuguese Patologias bolhosas
Spanish Enfermedades ampollosas
Dutch blaarvormingen
French Affections bulleuses
German Blasige Erkrankungen