Treating The Acute Onset Of An Asymptomatic Solitary Blister

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M. Joel Morse, DPM

   Bullae are rounded or irregularly shaped blisters containing serous or seropurulent fluid. They are usually unilocular but may be multilocular. The walls of the bulla are flaccid and thin, and subject to spontaneous rupture. Examples include: pemphigus, bullous pemphigoid, poison ivy and second-degree burns.

   Hemorrhagic bullae are common in pemphigus, herpes zoster, severe bullous drug eruptions and lichen sclerosus.

   The fluid in the cavity exerts equal pressure in all directions to give rise to a spherical shape. On the sole, the vesicles may be non-palpable due to the thicker stratum corneum.

   Formation of blisters. Blisters arise from cleavage at various levels of the epidermis (intra-epidermal) or at the dermal-epidermal interface (sub-epidermal). The amount of pressure to collapse the blister may predict whether the blister is intra-epidermal or sub-epidermal. The characteristic of blisters in various dermatoses tends to be uniform and reproducible, which aids in diagnosis.

   Proper diagnosis requires a biopsy from the site with histopathologic examination of the blister cavity edge. One also examines the biopsy specimen for deposits of immune reactants, immunoglobulins and complement components.

   Pathological evaluation. Blisters look similar from afar. However, their assessment is based on the microscopic analysis. The critical assessments are: blister separation plane, the mechanisms of blister formation, the character of the inflammatory infiltrate, its pattern, and the specific cell types involved.8

   Nikolsky’s sign. This is when the intact epidermis shears away from underlying dermis, leaving a moist surface. Slight pressure or rubbing of the blister elicits this sign. Nikolsky’s sign is present in pemphigus vulgaris and is not present in bullous diabeticorum.

   Asboe-Hansen sign or indirect Nikolsky sign (bullae spread phenomenon). This is elicited by pressure on an intact bulla, gently forcing the fluid to spread under adjacent unblistered skin.

   Dr. Morse is the President of the American Society of Podiatric Dermatology. He is a Fellow of the American College of Foot and Ankle Surgeons, and the American College of Foot and Ankle Orthopedics and Medicine. Dr. Morse is board certified in foot surgery. He is on the Podiatric Residency Educational Committee at the Washington Hospital Center in Washington, D.C.

1. James WD, Berger TG, Elston DM (eds). Andrews’ Diseases Of The Skin, 11th edition. Saunders Elsevier, Philadelphia, 2011, p. 2
2. Wolff K, Goldsmith L, (eds). Fitzpatrick’s Dermatology in General Medicine, seventh edition. McGraw-Hill, New York, 2008, pp.1469-70.
3. Ghosh SK, Bandyopadhyay D, Chatterjee G. Bullosis diabeticorum: a distinctive blistering eruption in diabetes mellitus. Int J Diabetes Dev Ctries. 2009; 29(1):41–42.
4. Jacqueline M, Junkins-Hopkins. Bullous Disease of Diabetes. E-Medicine. Available from: , accessed on Nov. 6, 2012.
5. Taylor S, Badreshia-Bansai S, et al. Treatments for Skin of Color. Elseiver-Saunders, Edinburgh, 2011, p. 25.
6. Lee WJ, Lee DW, Kim CH, et al. Pompholyx with bile-coloured vesicles in a patient with jaundice: are sweat ducts involved in the development of pompholyx? J Eur Acad Dermatol Venereol. 2010; 24(2):235-6.
7. Hall BJ, Hall JC. Sauer’s Manual of Skin Disease, 10th edition. Lippincott Williams and Wilkins, Philadelphia, 2011, p. 586.
8. Elder DE. Lever’s Histopathology of the Skin, ninth edition. Lippincott Williams, Philadelphia, 2005, pp. 243-244.

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