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Bullous Disease of Diabetes Clinical Presentation

  • Author: Maureen B Poh-Fitzpatrick, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Aug 24, 2015
 

History

Bullous disease of diabetes (bullosis diabeticorum) blisters occur spontaneously and abruptly, often overnight, and usually without known antecedent trauma.

These blisters tend to be asymptomatic, although mild discomfort or burning has been described.

Bullous disease of diabetes blisters heal spontaneously within 2-6 weeks of onset.

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Physical Examination

The goals of the physical examination should include determining the location and physical characteristics of lesions, developing a useful differential diagnosis, and determining the need for biopsy to secure a correct diagnosis and for culture to identify secondary infections that may require treatment.

Common findings of bullous disease of diabetes (bullosis diabeticorum) include tense, nontender blisters arising on nonerythematous skin (see the image below).

Tense noninflammatory bulla on the leg. Tense noninflammatory bulla on the leg.

Blisters tend to be large (from 0.5-17 cm in diameter), often with an irregular shape, simulating a burn. Some blisters may also be flaccid. Although blisters typically occur on the feet or lower legs, they also may occur on fingers, toes, hands, and arms. (See the image below.)

Unroofed blister on the leg. Note the irregular shUnroofed blister on the leg. Note the irregular shape.

Rarely, nonacral sites (eg, trunk) may be involved.

To see complete information on Diabetic Ulcers, please go to the main article by clicking here.

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Contributor Information and Disclosures
Author

Maureen B Poh-Fitzpatrick, MD Professor Emerita of Dermatology and Special Lecturer, Columbia University College of Physicians and Surgeons

Maureen B Poh-Fitzpatrick, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, New York Dermatological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jacqueline M Junkins-Hopkins, MD Associate Professor, Director, Division of Dermatopathology and Oral Pathology, Department of Dermatology, Johns Hopkins Medical Institutions

Jacqueline M Junkins-Hopkins, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Dermatopathology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Michael J Wells, MD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

References
  1. Kramer DW. Early or warning signs of impending gangrene in diabetes. Med J Rec. 1930. 132:338-42.

  2. Rocca FF, Pereyra E. Phlyctenar lesions in the feet of diabetic patients. Diabetes. 1963 May-Jun. 12:220-2. [Medline].

  3. Cantwell AR Jr, Martz W. Idiopathic bullae in diabetics. Bullosis diabeticorum. Arch Dermatol. 1967 Jul. 96(1):42-4. [Medline].

  4. Bernstein JE, Levine LE, Medenica MM, Yung CW, Soltani K. Reduced threshold to suction-induced blister formation in insulin-dependent diabetics. J Am Acad Dermatol. 1983 Jun. 8(6):790-1. [Medline].

  5. Larsen K, Jensen T, Karlsmark T, Holstein PE. Incidence of bullosis diabeticorum--a controversial cause of chronic foot ulceration. Int Wound J. 2008 Oct. 5(4):591-6. [Medline].

  6. Wilson TC, Snyder RJ, Southerland CC. Bullosis diabeticorum: is there a correlation between hyperglycemia and this symptomatology?. Wounds. 2012 Dec. 24 (12):350-5. [Medline].

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  8. Lipsky BA, Baker PD, Ahroni JH. Diabetic bullae: 12 cases of a purportedly rare cutaneous disorder. Int J Dermatol. 2000 Mar. 39(3):196-200. [Medline].

  9. James WD, Odom RB, Goette DK. Bullous eruption of diabetes mellitus. A case with positive immunofluorescence microscopy findings. Arch Dermatol. 1980 Oct. 116(10):1191-2. [Medline].

  10. Basarab T, Munn SE, McGrath J, Russell Jones R. Bullosis diabeticorum. A case report and literature review. Clin Exp Dermatol. 1995 May. 20(3):218-20. [Medline].

  11. Toonstra J. Bullosis diabeticorum. Report of a case with a review of the literature. J Am Acad Dermatol. 1985 Nov. 13(5 Pt 1):799-805. [Medline].

  12. [Guideline] Bantle JP, Wylie-Rosett J, Albright AL, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2008 Jan. 31 Suppl 1:S61-78. [Medline].

  13. [Guideline] American Diabetes Association. Standards of medical care in diabetes. I. Classification and diagnosis. Diabetes Care. 2008 Jan. 31(Suppl 1):S12-3.

  14. [Guideline] American Diabetes Association. Standards of medical care in diabetes. V. Diabetes care. Diabetes Care. 2008 Jan. 31(Suppl 1):S16-24.

  15. Centers for Disease Control and Prevention. National Diabetes Fact Sheet. United States. Atlanta, Ga: Centers for Disease Control and Prevention; 2003. [Full Text].

  16. Goodfield MJ, Millard LG, Harvey L, Jeffcoate WJ. Bullosis diabeticorum. J Am Acad Dermatol. 1986 Dec. 15(6):1292-4. [Medline].

  17. Phillips P, Weightman W. Diabetes and the skin. Correspondence. Aust Fam Physician. 2005 Oct. 34(10):48.

  18. Scheinfeld N. A review and report of blistering distal dactylitis due to Staphylococcus aureus in two HIV-positive men. Dermatol Online J. 2007 May 1. 13(2):8. [Medline]. [Full Text].

  19. Zhang AJ, Garret M, Miller S. Bullosis diabeticorum: case report and review. N Z Med J. 2013 Mar 15. 126 (1371):91-4. [Medline].

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Tense noninflammatory bulla on the leg.
Unroofed blister on the leg. Note the irregular shape.
Histology of bullosis diabeticorum showing a noninflammatory blister with a subepidermal and focally intraepidermal separation (hematoxylin and eosin stain).
High-power view of the dermis beneath the blister showing capillary wall thickening (hematoxylin and eosin stain).
 
 
 
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