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We obtained 2 skin fragments for study with hematoxylin-eosin staining and direct immunofluorescence&#46; Examination of the biopsy specimen revealed an orthokeratotic epidermis with irregular acanthosis&#44; marked exocytosis of eosinophils&#44; and spongiosis with spongiotic vesicles&#46; The superficial and mid dermis revealed perivascular dermatitis comprising a mixed infiltrate that was mainly lymphocytic with abundant eosinophils &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What is your diagnosis&#63;</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 &#40;DBP&#41;&#46;</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 &#40;Ig&#41; G and complement component C3 &#40;C3&#41; in the basement membrane&#46; The clinical and pathological findings enabled us to confirm a diagnosis of DBP&#46; We initiated treatment with oral prednisone &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#44; together with topical zinc sulfate 1&#47;1000 and clobetasol dipropionate cream&#44; once per day&#46; The lesions improved significantly after 5 days&#46;</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&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> It most commonly affects elderly patients&#44; and its etiology is unknown&#46; DBP is characterized by tense blisters with clear and often hemorrhagic content&#44; which are found initially or exclusively on the palms and soles&#46; In some cases&#44; the blisters develop after pruritic eczematous or urticarial lesions&#44; whereas in others&#44; the urticarial lesions persist without formation of blisters&#46; Bullous pemphigoid is characterized by subepidermal blisters with abundant eosinophils in histopathology&#46; However&#44; intradermal spongiotic vesicles with eosinophils in the interior may also be present&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> This phenomenon&#44; which is known as eosinophilic spongiosis&#44; is characterized by intercellular edema composed of an inflammatory eosinophilic infiltrate&#46; It constitutes a reactive pattern in the epidermis that is observed in a wide range of skin conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> According to Crotty et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> this histopathological finding is very frequently associated with bullous pemphigoid&#46; Nevertheless&#44; additional histopathological criteria must be fulfilled before the diagnosis of bullous pemphigoid can be confirmed&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As with bullous pemphigoid&#44; DBP is characterized by linear deposits of IgG and C3 in the basement membrane&#46; The lesions frequently resolve with residual hyperpigmentation&#44; although without scarring or milia&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Treatment consists of topical or systemic corticosteroids according to the severity and&#47;or extension of the process and the disease&#46; The disease can progress via 3 different pathways&#58; &#40;<span class="elsevierStyleItalic">a</span>&#41; the bullous lesions remain confined to the palms and soles&#59; &#40;<span class="elsevierStyleItalic">b</span>&#41; onset is in acral regions of the palms and soles&#44; with subsequent extension to the rest of the skin&#59; and &#40;<span class="elsevierStyleItalic">c</span>&#41; concomitant appearance of lesions on the palms and soles&#44; together with generalized lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The patient in the present case is in complete remission&#44; with no new vesicles on the palms or soles or on other areas&#46; Residual hyperpigmentation persisted for several weeks&#46;</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&#46;</p></span></span>"
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Case for Diagnosis
Blistering Lesions Involving the Palms
Lesiones ampollosas en las palmas
A. Conde-Ferreirósa,
Autor para correspondencia
alconfe25@yahoo.com

Corresponding author.
, Á. Santos-Briz Terrónb, J. Cañuetoa
a Servicio de Dermatología Médico-Quirúrgica y Venereología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
b Servicio de Anatomía Patológica, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin&#44; original magnification&#44; &#215;20&#46;</p>"
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    "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&#46; He had not previously experienced insect bites or injury and had had no previous history of lesions of this type&#46; Physical examination revealed the presence of multiple&#44; tense vesicles that were round-oval in shape and contained a serous or serosanguineous fluid&#46; They were scattered over the palms and wrists&#44; although the thenar and hypothenar eminences were spared &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The vesicles were frequently on areas of erythematous-edematous skin&#46; No similar lesions were found on other areas of the body or on the mucous membranes&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">We therefore decided to order a biopsy&#46; We obtained 2 skin fragments for study with hematoxylin-eosin staining and direct immunofluorescence&#46; Examination of the biopsy specimen revealed an orthokeratotic epidermis with irregular acanthosis&#44; marked exocytosis of eosinophils&#44; and spongiosis with spongiotic vesicles&#46; The superficial and mid dermis revealed perivascular dermatitis comprising a mixed infiltrate that was mainly lymphocytic with abundant eosinophils &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What is your diagnosis&#63;</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 &#40;DBP&#41;&#46;</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 &#40;Ig&#41; G and complement component C3 &#40;C3&#41; in the basement membrane&#46; The clinical and pathological findings enabled us to confirm a diagnosis of DBP&#46; We initiated treatment with oral prednisone &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#44; together with topical zinc sulfate 1&#47;1000 and clobetasol dipropionate cream&#44; once per day&#46; The lesions improved significantly after 5 days&#46;</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&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> It most commonly affects elderly patients&#44; and its etiology is unknown&#46; DBP is characterized by tense blisters with clear and often hemorrhagic content&#44; which are found initially or exclusively on the palms and soles&#46; In some cases&#44; the blisters develop after pruritic eczematous or urticarial lesions&#44; whereas in others&#44; the urticarial lesions persist without formation of blisters&#46; Bullous pemphigoid is characterized by subepidermal blisters with abundant eosinophils in histopathology&#46; However&#44; intradermal spongiotic vesicles with eosinophils in the interior may also be present&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> This phenomenon&#44; which is known as eosinophilic spongiosis&#44; is characterized by intercellular edema composed of an inflammatory eosinophilic infiltrate&#46; It constitutes a reactive pattern in the epidermis that is observed in a wide range of skin conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> According to Crotty et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> this histopathological finding is very frequently associated with bullous pemphigoid&#46; Nevertheless&#44; additional histopathological criteria must be fulfilled before the diagnosis of bullous pemphigoid can be confirmed&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As with bullous pemphigoid&#44; DBP is characterized by linear deposits of IgG and C3 in the basement membrane&#46; The lesions frequently resolve with residual hyperpigmentation&#44; although without scarring or milia&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Treatment consists of topical or systemic corticosteroids according to the severity and&#47;or extension of the process and the disease&#46; The disease can progress via 3 different pathways&#58; &#40;<span class="elsevierStyleItalic">a</span>&#41; the bullous lesions remain confined to the palms and soles&#59; &#40;<span class="elsevierStyleItalic">b</span>&#41; onset is in acral regions of the palms and soles&#44; with subsequent extension to the rest of the skin&#59; and &#40;<span class="elsevierStyleItalic">c</span>&#41; concomitant appearance of lesions on the palms and soles&#44; together with generalized lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The patient in the present case is in complete remission&#44; with no new vesicles on the palms or soles or on other areas&#46; Residual hyperpigmentation persisted for several weeks&#46;</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&#46;</p></span></span>"
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