Dermatology Book

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BlisterAka: Vesiculobullous, Vesicle, Bulla, Bullous Disease, Autoimmune Bullous Dermatoses, Acantholysis, Acantholytic

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  1. Definitions
    1. Vesicle
      1. Raised fluid filled lesion <0.5 cm diameter
    2. Bulla
      1. Raised fluid filled lesion >0.5 cm diameter
  2. Pathophysiology
    1. Develops at intersection of skin levels
      1. Epidermal layers
      2. Epidermal-Dermal junction (Deeper lesions)
  3. 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
  4. Signs
    1. Thin, translucent walls
    2. Contains serum, lymph, blood, or extracellular fluid
    3. Nikolsky's Sign (seen in Pemphigus Vulgaris)
  5. Evaluation of Acute Blistering Condition
    1. Consider Exposures
      1. Insects
      2. Pets
      3. Medications
      4. Contact Dermatitis allergans and irritants
    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
  6. 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
  7. Differential Diagnosis by Vesicle or Bulla Depth
    1. Superficial Vesiculobullous Conditions (Intraepidermal)
      1. Pemphigus
      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
      2. Dermatitis Herpetiformis
      3. Erythema Multiforme
      4. Porphyria cutanea tarda
      5. Diabetes Mellitus associated bullae
      6. Renal disease associated bullae
  8. 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. Bullous Impetigo
      2. Bullae in Diabetes Mellitus
      3. Herpes Gestationis
  9. Differential Diagnosis: Vesicular Lesions
    1. Drug eruption
    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
  10. 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

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