An 87 year old female with past medical history of Insulin dependent diabetes mellitus type II presented post fall with desquamative blistering lesions over lower extremities bilaterally. She noticed the lesions two days prior to presentation, and described them as fluid filled blisters that were painless. After her fall, the blisters burst from resultant trauma and were painful. She denied starting any new medications recently. On physical exam, there were a few covered blisters and desquamative lesions present bilaterally over lower extremities affecting approximately 6-8% of total body surface area; Nikolsky skin was positive with no mucous membrane lesions. She was normotensive, afebrile with WBC count of 22.2 X 103µL. This patient was admitted to the Intensive Care Unit for aggressive management of desquamative skin lesions with high suspicion of infection and acute kidney injury secondary to rhabdomyolysis. Patient received aggressive hydration, broad spectrum antibiotics, and Dermatology was consulted. After examining the patient, a punch biopsy was ordered to rule out inflammatory etiologies. The biopsy revealed dermoepidermal separation that was negative for all inflammatory markers on immmunofloresence. The patient’s wounds were treated with medihoney and dressing changes three times a week. Her lesions improved over 2 months, with no recurrence.
Discussion:
Bullosis Diabeticorum is a rare condition of Diabetes mellitus Type I and Type II of unknown etiology. Cases have been reported in ages from 17 to 83, with higher incidence in males, 2:1. The blistering lesions are typically asymmetrical and limited to the lower extremities. Its incidence is reported at 0.5% of the diabetic population in the US, however it may be higher as this condition may remain undiagnosed and under reported. Although this condition is relatively benign, life threatening inflammatory etiologies of bullous diseases such as Stevens Johnsons Syndrome, Toxic epidermal necrolysis, Pemphigus vulgaris, Bullous pemphigoid, Epidermolysis bullous simplex, Porphyria cutanea tarda must be ruled out. A throughout history including any new medications, distribution of lesions and systemic signs and symptoms can help narrow the differential. A biopsy with immunofluorescence is gold standard in ruling out inflammatory causes. The etiology of this condition remains unclear. Speculations have been made regarding poorly controlled blood sugars and increased incidence, however further studies are needed to establish a correlation between glycemic control and bullous disease of diabetes.
Conclusions:
Physician surveillance of lower extremities in uncontrolled diabetics should be up to the knees to evaluate for blistering lesions. Patient education of caring for early presentation of covered blisters is key to preventing complications such as infections, and hospitalizations.