Approach to the patient with cutaneous blisters
- Christopher Hull, MD
Christopher Hull, MD
- Associate Professor, Department of Dermatology
- University of Utah
- John J Zone, MD
John J Zone, MD
- Section Editor — Bullous Disease
- Professor and Chairman, Department of Dermatology
- University of Utah
Cutaneous blisters occur in a wide variety of clinical settings, including autoimmune disorders, drug reactions, infections, genetic disorders, and physical injury. The ability to narrow the differential diagnosis for patients with blistering skin lesions is essential for the prompt recognition of life-threatening disorders and the appropriate management of other blistering diseases (algorithm 1).
The clinical approach to the diagnosis of disorders that present with cutaneous blisters and a summary of common investigative tests used to assist with diagnosis is discussed here. Blistering disorders in the newborn infant and specific blistering disorders are discussed in greater detail separately. (See "Vesiculobullous and pustular lesions in the newborn".)
Blistering skin disorders are characterized by the presence of fluid-filled lesions on the skin that occur as a result of a loss of adhesion between cells within the epidermis (acantholysis), edema between epidermal cells (spongiosis), or disassociation of the epidermis and dermis. Pathologic events that may lead to the formation of blisters include the following:
●Disruption of cellular or extracellular adhesion molecules (eg, autoimmune blistering disorders, congenital epidermolysis bullosa)
●Epidermal cell injury or death (eg, toxic epidermal necrolysis, erythema multiforme)
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- LIFE-THREATENING EMERGENCIES
- PATIENT ASSESSMENT
- Lesion distribution
- - Generalized distribution
- Generalized blisters with systemic illness
- Other generalized blistering disorders
- - Localized distribution
- Dependent areas
- Hands or feet
- Linear distribution
- Other localized blistering disorders
- - Mucous membrane involvement
- Additional clinical features
- - Patient age
- - Blister configuration
- - Blister size
- - Blister quality
- - History of drug exposure
- Nikolsky sign
- DIAGNOSTIC TESTS
- Skin biopsy
- - Light microscopy
- - Direct immunofluorescence
- Serologic tests
- - Indirect immunofluorescence
- - Antigen-specific serologic testing
- Basement membrane zone-split skin technique
- Microbiologic studies
- INDICATIONS FOR REFERRAL
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS