Bullous Disease of Diabetes
- Author: Maureen B Poh-Fitzpatrick, MD; Chief Editor: Dirk M Elston, MD more...
Background
Bullous disease of diabetes (bullosis diabeticorum) is a distinct, spontaneous, noninflammatory, blistering condition of acral skin that is unique to patients with diabetes mellitus.
Kramer first reported bullous-like lesions in diabetic patients in 1930[1] ; Rocca and Pereyra first characterized this as a phlyctenar (appearing like a burn-induced blister) in 1963.[2] Cantwell and Martz are credited with naming the condition bullosis diabeticorum in 1967.[3] It is also termed bullous disease of diabetes and diabetic bullae.
Bullous disease of diabetes tends to arise in long-standing diabetes or in conjunction with multiple complications. Prominent acral accentuation of bullous disease of diabetes lesions suggests a susceptibility to trauma-induced changes, but the definitive explanation awaits elucidation. (See Etiology.)
In the United States, Bullous disease of diabetes has been reported to occur in approximately 0.5% of diabetic patients. Male patients have twice the risk as female patients. (See Epidemiology.)
While lesions typically heal spontaneously within 2-6 weeks, they often recur in the same or different locations. Secondary infections may also develop; these are characterized by cloudy blister fluid and require a culture. (See Clinical Presentation.)
The clinician should consider direct immunofluorescence studies to exclude histologically similar entities (eg, noninflammatory bullous pemphigoid, epidermolysis bullosa acquisita, porphyria cutanea tarda, other bullous porphyrias). (See Workup.) Pseudoporphyria blistering due to photosensitizing drugs, chronic dialysis regimens, or ultraviolet A tanning devices should also be considered.
Specific treatment is unwarranted unless secondary infections (i.e. staphylococcal) occur, thereby warranting antibiotic therapy. However, aspiration of fluid from lesions using a small-bore needle might help prevent accidental rupture. (See Treatment and Management.)
To see complete information on Diabetes Mellitus, Type 1, please go to the main article by clicking here.
To see complete information on Diabetes Mellitus, Type 2, please go to the main article by clicking here.
Pathophysiology
The pathophysiology of bullous disease of diabetes (bullosis diabeticorum) is likely multifactorial. Patients with diabetes have been shown to have a lower threshold for suction-induced blister formation compared with nondiabetic controls,[4] and because of the acral prominence of diabetic bullae, the role of trauma has been speculated.
Electron microscopic evidence has also suggested an abnormality in anchoring fibrils. However, this alone does not explain the often spontaneous development of multiple lesions at several locations.
In some patients, blisters are related to UV exposure, especially in those with nephropathy. Glycemic control does not appear to have a direct correlation with blister formation .
Etiology
The etiology of bullous disease of diabetes (bullosis diabeticorum) is unknown. Prominent acral accentuation of bullous disease of diabetes lesions suggests a susceptibility to trauma-induced changes, but the definitive explanation awaits elucidation.
Many, but not all, patients with bullous disease of diabetes have nephropathy or neuropathy; some authors have hypothesized an etiologic association, possibly related to a local subbasement membrane-zone connective-tissue alteration. Hyalinosis of small vessels noted on biopsy specimens has led some authorities to speculate microangiopathy-associated blister induction. In some, especially in patients with neuropathy, UV exposure is also thought to play a role.[5]
Epidemiology
Bullous disease of diabetes (bullosis diabeticorum) tends to arise in patients with long-standing diabetes mellitus or with multiple complications of the disease. In the United States, bullous disease of diabetes has been reported to occur in approximately 0.5% of diabetic patients, although its frequency may actually be higher due to underreporting of blistering. Patients with uncomplicated or newly diagnosed disease, including type 2 diabetes, may also be affected.
The age of onset of bullous disease of diabetes ranges from 17 to 84 years, and the condition has been reported to be twice as prevalent in men as in women.
Prognosis
Bullous disease of diabetes (bullosis diabeticorum) blisters typically heal spontaneously, within 2-6 weeks, but lesions often recur in the same or a different location. Although secondary infection may develop, the prognosis for bullous disease of diabetes is typically good.
Although bullous disease of diabetes lesions often heal without significant scarring, they may be recurrent and also may lead to ulceration.[5] There have also been reports of osteomyelitis arising at a site of bullous disease of diabetes[6] and reports of amputation due to infection.[7]
Patient Education
For excellent patient education resources for bullous disease of diabetes (bullosis diabeticorum), visit eMedicine's Diabetes Center.
Kramer DW. Early or warning signs of impending gangrene in diabetes. Med J Rec. 1930;132:338-42.
Rocca FF, Pereyra E. Phlyctenar lesions in the feet of diabetic patients. Diabetes. May-Jun 1963;12:220-2. [Medline].
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Scheinfeld N. A review and report of blistering distal dactylitis due to Staphylococcus aureus in two HIV-positive men. Dermatol Online J. May 1 2007;13(2):8. [Medline]. [Full Text].
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