Case for Diagnosis
Blistering Lesions Involving the Palms
Lesiones ampollosas en las palmas
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Conde-Ferreirós, Á. Santos-Briz Terrón, J. Cañueto" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Conde-Ferreirós" "email" => array:1 [ 0 => "alconfe25@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Á." "apellidos" => "Santos-Briz Terrón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Cañueto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología Médico-Quirúrgica y Venereología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Clínico Universitario de Salamanca, Salamanca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesiones ampollosas en las palmas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 627 "Ancho" => 856 "Tamanyo" => 227822 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification, ×20.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0005" class="elsevierStylePara elsevierViewall">An 88-year-old man with no history of interest came to the clinic with pruritus and vesicles on both hands that had first appeared 5 days earlier. He had not previously experienced insect bites or injury and had had no previous history of lesions of this type. Physical examination revealed the presence of multiple, tense vesicles that were round-oval in shape and contained a serous or serosanguineous fluid. They were scattered over the palms and wrists, although the thenar and hypothenar eminences were spared (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The vesicles were frequently on areas of erythematous-edematous skin. No similar lesions were found on other areas of the body or on the mucous membranes.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">We therefore decided to order a biopsy. We obtained 2 skin fragments for study with hematoxylin-eosin staining and direct immunofluorescence. Examination of the biopsy specimen revealed an orthokeratotic epidermis with irregular acanthosis, marked exocytosis of eosinophils, and spongiosis with spongiotic vesicles. The superficial and mid dermis revealed perivascular dermatitis comprising a mixed infiltrate that was mainly lymphocytic with abundant eosinophils (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What is your diagnosis?</span></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Dyshidrosiform bullous pemphigoid (DBP).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical Course and Comment</span><p id="par0025" class="elsevierStylePara elsevierViewall">Direct immunofluorescence revealed the presence of linear deposits of immunoglobulin (Ig) G and complement component C3 (C3) in the basement membrane. The clinical and pathological findings enabled us to confirm a diagnosis of DBP. We initiated treatment with oral prednisone (0.5<span class="elsevierStyleHsp" style=""></span>mg/kg), together with topical zinc sulfate 1/1000 and clobetasol dipropionate cream, once per day. The lesions improved significantly after 5 days.</p><p id="par0030" class="elsevierStylePara elsevierViewall">DBP is a rare variant of bullous pemphigoid that was first described in 1979 by Levine et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> It most commonly affects elderly patients, and its etiology is unknown. DBP is characterized by tense blisters with clear and often hemorrhagic content, which are found initially or exclusively on the palms and soles. In some cases, the blisters develop after pruritic eczematous or urticarial lesions, whereas in others, the urticarial lesions persist without formation of blisters. Bullous pemphigoid is characterized by subepidermal blisters with abundant eosinophils in histopathology. However, intradermal spongiotic vesicles with eosinophils in the interior may also be present.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> This phenomenon, which is known as eosinophilic spongiosis, is characterized by intercellular edema composed of an inflammatory eosinophilic infiltrate. It constitutes a reactive pattern in the epidermis that is observed in a wide range of skin conditions.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> According to Crotty et al.,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> this histopathological finding is very frequently associated with bullous pemphigoid. Nevertheless, additional histopathological criteria must be fulfilled before the diagnosis of bullous pemphigoid can be confirmed.</p><p id="par0035" class="elsevierStylePara elsevierViewall">As with bullous pemphigoid, DBP is characterized by linear deposits of IgG and C3 in the basement membrane. The lesions frequently resolve with residual hyperpigmentation, although without scarring or milia.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Treatment consists of topical or systemic corticosteroids according to the severity and/or extension of the process and the disease. The disease can progress via 3 different pathways: (<span class="elsevierStyleItalic">a</span>) the bullous lesions remain confined to the palms and soles; (<span class="elsevierStyleItalic">b</span>) onset is in acral regions of the palms and soles, with subsequent extension to the rest of the skin; and (<span class="elsevierStyleItalic">c</span>) concomitant appearance of lesions on the palms and soles, together with generalized lesions.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The patient in the present case is in complete remission, with no new vesicles on the palms or soles or on other areas. Residual hyperpigmentation persisted for several weeks.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Diagnosis" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinical Course and Comment" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of Interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Conde-Ferreirós A, Santos-Briz Terrón Á, Cañueto J. Lesiones ampollosas en las palmas. Actas Dermosifiliogr. 2020;111:321–322.</p>" ] ] "multimedia" => array:2 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 638 "Ancho" => 1306 "Tamanyo" => 121114 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 627 "Ancho" => 856 "Tamanyo" => 227822 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification, ×20.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Localized pemphigoid simulating dyshidrosiform dermatitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N. Levine" 1 => "A. Freilich" 2 => "P. Barland" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1979" "volumen" => "115" "paginaInicial" => "320" "paginaFinal" => "321" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/373634" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spongiotic intra-epidermal blister: a pitfall in the histopathologic diagnosis of bullous pemphigoid" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. 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Dash" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/2229-5178.142509" "Revista" => array:6 [ "tituloSerie" => "Indian Dermatol Online J" "fecha" => "2014" "volumen" => "5" "paginaInicial" => "482" "paginaFinal" => "484" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25396135" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dyshidrosiform pemphigoid: a well-defined clinical entity?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Caldarola" 1 => "L. Fania" 2 => "E. Cozzani" 3 => "C. Feliciani" 4 => "C. de Simone" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1684/ejd.2010.1172" "Revista" => array:7 [ "tituloSerie" => "Eur J Dermatol" "fecha" => "2011" "volumen" => "21" "paginaInicial" => "112" "paginaFinal" => "113" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21224186" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0264410X14009451" "estado" => "S300" "issn" => "0264410X" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011100000004/v1_202006060751/S1578219020300792/v1_202006060751/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000011100000004/v1_202006060751/S1578219020300792/v1_202006060751/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219020300792?idApp=UINPBA000044" ]
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| 2023 September | 81 | 29 | 110 |
| 2023 August | 68 | 12 | 80 |
| 2023 July | 83 | 36 | 119 |
| 2023 June | 83 | 19 | 102 |
| 2023 May | 89 | 28 | 117 |
| 2023 April | 66 | 25 | 91 |
| 2023 March | 94 | 21 | 115 |
| 2023 February | 56 | 22 | 78 |
| 2023 January | 54 | 25 | 79 |
| 2022 December | 55 | 45 | 100 |
| 2022 November | 47 | 24 | 71 |
| 2022 October | 47 | 26 | 73 |
| 2022 September | 38 | 36 | 74 |
| 2022 August | 54 | 30 | 84 |
| 2022 July | 50 | 41 | 91 |
| 2022 June | 41 | 35 | 76 |
| 2022 May | 59 | 47 | 106 |
| 2022 April | 57 | 41 | 98 |
| 2022 March | 66 | 57 | 123 |
| 2022 February | 42 | 27 | 69 |
| 2022 January | 46 | 41 | 87 |
| 2021 December | 56 | 37 | 93 |
| 2021 November | 39 | 34 | 73 |
| 2021 October | 40 | 48 | 88 |
| 2021 September | 39 | 37 | 76 |
| 2021 August | 33 | 32 | 65 |
| 2021 July | 34 | 23 | 57 |
| 2021 June | 21 | 20 | 41 |
| 2021 May | 32 | 40 | 72 |
| 2021 April | 57 | 99 | 156 |
| 2021 March | 56 | 26 | 82 |
| 2021 February | 32 | 18 | 50 |
| 2021 January | 26 | 17 | 43 |
| 2020 December | 25 | 16 | 41 |
| 2020 November | 18 | 9 | 27 |
| 2020 October | 35 | 13 | 48 |
| 2020 September | 32 | 14 | 46 |
| 2020 August | 34 | 16 | 50 |
| 2020 July | 50 | 18 | 68 |
| 2020 June | 77 | 35 | 112 |
| 2020 May | 28 | 20 | 48 |
| 2020 April | 6 | 2 | 8 |
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