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

fragility.
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.