Pruritic Vesicular Eruption on the Lower Legs in a Diabetic Female

A 50-year-old diabetic female presented with highly pruritic vesicles and excoriated lesions over the anterior aspect of both lower legs. The lesions were recurrent over the last two years. She received a lot of medications with partial response. Hb A1c was 10.8% (normal up to 7%). CBC showed microcytic, hypochromic anemia. Serum zinc, folate, IgE, TSH and T4 were all within normal ranges. Biopsy showed epidermal separation secondary to keratinocyte necrosis and minimal monocytic, perivascular infiltrate. Direct immunofluorescence was negative for intraepidermal and subepidremal deposition of immunoglobulin. The dermis was positive for mucin deposition stainable by both PAS and Alcian blue while it was negative for Congo red and APC immunoperoxidase staining for amyloid material. In conclusion, the case was diagnosed as bullosis diabeticorum by distinctive clinical and pathological features and after exclusion of other possible differentials. Pruritus was partially controlled by topical potent steroid and the case was resolved spontaneously after eight months. 1. Introduction Bullosis diabeticorum is a distinct, spontaneous, non-inflammatory, blistering condition of distal and acral skin, unique to patients with diabetes mellitus. Krane first reported this condition in 1930; Cantwell and Martz are credited with naming the condition in 1967 [1]. It also is termed bullous disease of diabetes and diabetic bullae [2]. The etiology of bullosis diabeticorum is unknown. The role of trauma has been speculated; however, this alone does not explain spontaneous development of multiple lesions at different locations. Bullosis diabeticorum is a rare complication of long-standing diabetes mellitus. Patients with this disorder manifest a sudden onset of intraepidermal or subepidermal blisters, which are primarily confined to the extremities. However, it is not correlated with any specific sign of the disease except for its increased incidence with diabetic neuropathy [3–5]. Searching by title on PubMed, there were only 28 published results for bullosis diabeticorum, 2 results were for diabetic bullae, and no study was titled as bullous disease of diabetes. We believe that cases were underreported for many reasons: the benign course of the disease and lack of self-report by the patients. The condition occurs more frequently in middle age males with long-standing diabetes and neuropathy. Male-to-female ratio is 2？:？1, while the incidence among diabetics is 0.5% in the United States and 1% in India [6, 7], which constitutes a large number of patients. The disease is not