Blistering Disorders

Question 1

What causes blistering disorders?

Answer 1

• Fragility of blisters depends on the level of split within the skin – an intra- epidermal split (a split within the epidermis) causes blisters to rupture easily; whereas a sub-epidermal split (a split between the epidermis and dermis) causes blisters to be less fragile.

Question 2

What are examples of blistering disorders?

Answer 2

Impetigo

Insect bites

Herpes simplex infection

Herpes zoster infection

Acute contact dermatitis

Pompholyx (vesicular eczema of the hands and feet) and burns.

Question 3

What is a bullous pemphigoid?

Answer 3

Blistering skin disorder which usually affects the elderly

Question 4

What is the cause of Bullous Pemphigoid?

Answer 4

Autoantibodies against antigens between the epidermis and

dermis causing a sub-epidermal split in the skin

Question 5

What is the presentation of Bullous Pemphigoid?

Answer 5

• Tense, fluid-filled blisters on an erythematous base usually affecting the trunk and limbs (mucosal involvement less common)
• Lesions are often itchy but may be preceded by a non-specific itchy rash

Question 6

What is the management of Bullous Pemphigoid?

Answer 6

• General measures: wound dressings where required, monitor for signs of infection
• Topical therapies for localised disease: topical steroids
• Oral therapies for widespread disease: oral steroids, combination of oral tetracycline and nicotinamide, immunosuppressive agents (e.g. azathioprine, mycophenolate mofetil, methotrexate, and other)

Question 7

What is Pemphigus Vulgaris?

Answer 7

A blistering skin disorder which usually affects the middle-aged

Question 8

What is the cause of Pemphigus Vulgaris?

Answer 8

Autoantibodies against antigens within the epidermis causing an intra-epidermal split in the skin

Question 9

What is the presentation of Pemphigus Vulgaris?

Answer 9

• Flaccid, easily ruptured blisters forming erosions and crusts
• Lesions are often painful
• Usually affects the mucosal areas (can precede skin involvement) - example shown

Question 10

What is the management of Pemphigus Vulgaris?

Answer 10

• General measures: wound dressings where required, monitor for signs of infection, good oral care (if oral mucosa is involved)
• Oral therapies: high-dose oral steroids, immunosuppressive agents (e.g. methotrexate, azathioprine, cyclophosphamide, mycophenolate mofetil, and other)

Question 11

What is Vitiligo?

Answer 11

An acquired depigmenting disorder, where there is complete loss of pigment cells (melanocytes)

Question 12

What is the cause of Vitiligo?

Answer 12

• Thought to be an autoimmune disorder, where the innate immune system causes destruction or loss of melanocytes, leading to loss of pigment formation in the skin

Question 13

What is the presentation of Vitiligo?

Question 14

What is the management of Vitiligo?

Answer 14

• Minimise skin injury as a cut, graze, or sunburn can potentially trigger a new patch of vitiligo
• Topical treatments: topical steroids and calcineurin inhibitors (such as topical tacrolimus and pimecrolimus)
• Phototherapy: UVB therapy, excimer laser
• Oral immunosuppressants: methotrexate, ciclosporin and mycophenolate mofetil

Question 15

What is Melasma?

Answer 15

An acquired chronic skin disorder, where there is increased pigmentation in the skin

Question 16

What is the cause of Melasma?

Question 17

What is the presentation of Melasma?

Answer 17

• Brown macules (freckle-like spots) or larger patches with an irregular border. Has a symmetrical distribution
• Common sites are forehead, cutaneous upper lips and cheeks, rarely can occur on neck, shoulders and upper arms

Question 18

What is the management of Melasma?

Answer 18

• Lifelong sun protection
• Discontinuation of hormonal contraceptive pills
• Cosmetic camouflage
• Topical treatments that aim at inhibiting the formation of new melanin such as hydroquinone, azelaic acid, kojic acid (a chelating agent) and vitamin C
• Laser treatments need to be used with caution as the heat generated by lasers can potentially cause post-inflammatory hyperpigmentation.

Question 19

What is a Keloid Scar?

Answer 19

An overgrowth of scar tissue, which tends to be larger than the original wound itself

Question 20

What is presentation of Keloid Scars?

Answer 20

• Firm, smooth, hard nodule which can be itchy or painful
• Common sites are chest and shoulders

Question 21

What is the cause of Keloid Scars?

Answer 21

• Thought to be due to overproduction of collagen during wound healing after minor injuries, skin surgery, insect bites and acne spots in genetically predisposed individuals
• More commonly seen in darker skin types

Question 22

What is the management of Keloid Scars?

Answer 22

• Avoidance of further trauma to the skin such as scratching
• Topical treatments such as topical steroids and silicone gel can potentially flatten the scar, and improve the symptoms
• Intralesional steroid injection if topical treatments are not effective
• Surgery such as excision needs to be carried out only as the last resort and with caution as the new wound may cause a larger keloid scar