Clinical features localised blisters

Pompholyx, which means "a bubble", is characterised by persistent, itchy, clear blisters on the fingers, which may extend to the palms, with larger blisters. The feet may be affected. Secondary infection leads to turbid vesicle fluid. Pompholyx may be associated with a number of conditions— atopy, stress, fungal infection elsewhere, and allergic reactions. It may occur as a result of ingesting nickel in nickel sensitive patients and a similar reaction has been reported to neomycin.

Pustular psoriasis is characterised by deep seated sterile blisters, often with no sign of psoriasis elsewhere—hence the term palmopustular pustulosis. Foci of sepsis have long been considered a causative factor and recent studies have shown a definite association with cigarette smoking. The pattern of HLA antigens indicates that this may be a separate condition from psoriasis.

Bullous impetigo is seen in children and adults. Staphylococci are usually isolated from the blister fluid. The blisters are commonly seen on the face and are more deeply situated than in the non-bullous variety.

Herpes simplex. Primary infection with type 1 virus occurs on the face, lips, and buccal mucosa in children and young adults. Type II viruses cause genital infection. Itching may be severe.

Pemphigus vulgaris

Nikolsky sign

Pemphigus vulgaris

Nikolsky sign

Pustular psoriasis

Pompholyx

Pustular psoriasis

Pompholyx

Herpes simplex—type I virus infection

Bullous impetigo

Herpes simplex—type II virus infection

Bullous impetigo

Herpes simplex—type II virus infection

Herpes zoster is due to varicella virus producing groups of vesicles in a dermatome distribution, usually thoracic, trigeminal, or lumbosacral. It is more common after the fourth decade of life.

Insect bite allergy. Large blisters, which are usually not itching, can occur on the legs of susceptible individuals.

Bullous drug eruptions. Fixed drug eruptions can develop bullae, and some drugs can cause a generalised bullous eruption, particularly:

Barbiturates (particularly if taken in overdose) Sulphonamides Penicillins Penicillamine Captopril

Frusemide (may be phototoxic)

Herpes zoster

} pemphigus-like blisters

Remember that there may be an associated erythematous eruption.

Insect bite allergy

Drug reaction to sulfapyridine
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