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Blisters on an elderly woman’s toes

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Our patient had already been hospitalized out of concern for cellulitis. Her history and lab work proved the cause to be far more benign.


 

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A 69-year-old woman with a history of hypertension, hyperlipidemia, diabetes, osteoarthritis, and depression presented to the emergency department (ED) with a 2-day history of blisters on the dorsal aspect of her toes on both feet. She had been wearing sandals so as not to disrupt them. The bullae appeared over the course of one day and progressively grew. The patient had no fever, chills, pain, or itching. She said she’d never had blisters like these before, and she had no history of cellulitis; she also denied trauma to her feet. There were no recent changes to any prescription or nonprescription medications. She also had not had any prolonged exposure to the sun or anything new that would suggest contact dermatitis.

The physical exam revealed an otherwise healthy woman with multiple, clear, fluid-filled bullae of varying sizes on her toes (FIGURE). There was no erythema, warmth, or tenderness. She could walk without difficulty. Her vital signs were normal. A white blood cell count and differential were normal, as well.

Our patient was admitted because of a mistaken concern for cellulitis, despite the absence of any systemic findings or surrounding erythema. She was discharged the next day with no change in status and without treatment. She returned to the ED several days later with the bullae still intact; a biopsy was performed and sent for immunofluorescence.

The bullae spontaneously resolve over several weeks without treatment, but tend to recur.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

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