Case by Dr. Nancy Burnside.
28 year old diabetic with Hyperpigmentation of the face, erosions and bulla of the
bilateral dorsal hands and forearms, associated hypertrichosis, hyperpigmentation, and skin
The duration of symptoms is unknown. On examination, the patient has new blisters today on
the right hand. Examination also shows hyperpigmented macules and violaceous papules and
plaques, some with crusted erosions. Three intact clear tense bulla of the third dorsal
digit and dorsal hand from 4- 6 mm. Two without erythema of the base, and one, which was
biopsied,approximating a crusted violaceous plaque.
IMPRESSION AND PLAN: Hyperpigmentation and blistering disorder of unknown etiology.
Suggestion of hypertrichosis and skin fragility. Differential diagnosis is broad and
includes PCT versus pseudoporphyria , although the patient does not have any history of
liver or renal disease, traumatic blisters with post inflammatory hyperpigmentation and
diabetic ulcers (and bullous disorder of diabetes) are in the differential (although this
would be an unusual presentation). Discoid lupus is not likely, but he does have
hyperpigmentation and scarring on the face.
PROCEDURES: 4 mm punch biopsy and perilesional skin biopsy for immunofluorescence.