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Blistering Skin Eruptions. Jill Tichy, PGY III February 15 th , 2010. Causes of Vesicles/Bullae.

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Blistering skin eruptions

Blistering Skin Eruptions

Jill Tichy, PGY III

February 15th, 2010

Causes of vesicles bullae
Causes of Vesicles/Bullae

  • Primary Cutaneous Disease: Pemphigus, Bullous Pemphigus, Dermatitis Herpatiformis, Contact Dermatitis, Erythema Multiforme, Stevens-Johnson syndrome, Toxic Epidermal Necrolysis, VZV, HSZ, Hand-foot-and-mouth disease, Staphylococcal scalded-skin syndrome, Scarlet Fever, Toxic Shock Syndrome, Exfoliative Erythroderma Syndrome

  • Systemic Diseases: Paraneoplastic pemphigus, Porphyria Cutanea Tarda, Porphyria Variegata

Nikolsky s sign
Nikolsky’s Sign

  • Staphylococcal Scalded Skin Syndrome


  • Positive when slight rubbing of the skin results in exfoliation of the skin's outermost layer

  • A "positive" Nikolsky's sign is associated with pemphigus vulgaris.

  • Nikolsky's sign is useful in differentiating between pemphigus vulgaris (where it is present or positive) and bullous pemphigoid (where it is absent)

Toxic epidermal necrolysis
Toxic Epidermal Necrolysis

  • Bullae that arise on the widespread areas of erythema and then slough

  • The result is large areas of denuded skin

  • Sepsis and Respiratory Failure

  • Involvement of mucous membranes and intestinal tract

  • Drugs are primary offenders (95%): phenytoin, barbituates, tegretol, sulfonamides, PCN, steroids

Ten cont d scorten
TEN- cont’d. SCORTEN

  • A score of 0-1 indicates a mortality risk of 3.2%; score of 2, 12.1%; score of 3, 35.3%; score of 4, 58.3%; and a score of 5 or more, 90%. Each of the following independent prognostic factors is given a score of one:

  • Age older than 40 years

  • Heart rate of greater than 120 beats per minute

  • Cancer/hematologic malignancy

  • Involved body surface area of greater than 10%

  • Serum urea level of more than 10 mmol/L

  • Serum bicarbonate level of less than 20 mmol/L

  • Serum glucose level of more than 14 mmol/L

Mechanism of tens
Mechanism of TENS

  • Delayed Hypersensitivity

  • Antigen native drug

  • Accumulation of interstitial fluid under necrotic epidermis; T lymphocytes that are able to kill autologous lymphocytes and keratinocytes in a drug specific, HLA-restricted mediated pathway

  • Epidermis overexpresses TNF-alpha  stimulates cytotoxic T lymphocytes  Apoptosis

Tegretol and ten
Tegretol and TEN

  • Strongly associated with HLA-B*1502

  • Commonly reaction seen within two months of drug initiation

  • However can be seen in long-term use

Steven johnson syndrome
Steven-Johnson Syndrome

  • Widespread dusky macules and mucosal involvement

  • Due to drugs

  • Limited to < 10% of BSA

  • SJS/TENs overlap 10-30% BSA

  • TEN > 30% BSA

Sjs and ten

  • Acute symptoms, painful skin lesions, fever > 39, pharyngitis, visual impairment

  • Mortality 10-30%

  • No treatment of proven efficacy

  • Early diagnosis, immediate discontinuation of any offending drug

  • No RCT exist but IVIG is second line

  • G-CSF if leukopenia exists (again no data)

  • Early retrospective studies suggested that corticosteroids increased hospital stays and complication rates.

Erythema multiforme
Erythema Multiforme

“Dusky” violet color or petechiae in the center of the lesions

  • Target or iris lesions

  • Symmetric on palms, soles, knees, elbows

  • Mycoplasma, HSV, idiopathic, rarely drugs; PCN, sulfa, phenytoin

  • May involve of mucous membranes, Hemorrhagic crusts of the lips (SJS, HSV, PV, Paraenoplastic)

  • Fever, malaise, myalgias, sore throat, and cough may accompany the eruption

  • Resolve over 3-6 weeks but may recur

  • Can follow vaccinations, XRT, exposure to environmental toxins

Drug rash with eosinophilia and systemic symptoms dress
Drug Rash with Eosinophilia and Systemic Symptoms (DRESS)

  • Widespread erythematous eruption

  • Fever, facial/periorbital edema, tender generalized lymphadenopathy (atypical lymphocytes and eosinophils), leukocytosis, hepatitis, nephritis, pneumonitis

  • Eruption recur with re-challenge

  • Onset 2-8 weeks after drug is started and lasts longer

  • Mortality 10%

Staphylococcal scalded skin syndrome ssss
Staphylococcal Scalded Skin Syndrome (SSSS)

  • Redness or tenderness of the face, trunk, intertriginous zones

  • Short lived flaccid bullae and a slough of superficial epidermis

  • Crusted areas develop around the mouth

  • Distinguishing features: young age group (infants), more superficial, no oral lesions, shorter course

  • Associated with Staph exfoliative toxin

  • Lesions are sterile vs bullous impetigo

  • Conjuctivitis, rhinorrhea, Otitis media, pharyngitis

Porphyria cutanea tarda
Porphyria Cutanea Tarda

  • Sun exposed areas mainly hands and face

  • Skin is fragile which leads to tense vesicles => milia => epidermoid inclusion cysts

  • Hypertrichosis

  • Porphyria Variegata: PCT + systemic findings

  • Drug-induced psuedoporphyria: Naproxen, Lasix, tetracycline, Tegretol is porphyrinogenic

  • Attacks can be precipitated by infections, surgery, ETOH

Blistering metabolic disorders
Blistering Metabolic Disorders

  • Comatose patients and decreased cutaneous blood flow; pressure points

  • Diabetes Mellitus; distal extremities


  • Harrison’s Internal Medicine 17 th ed.

  • Google Images