A 70-year-old man comes to the office due to a skin rash. He has widespread redness and blistering across his neck and trunk, which are associated with severe itching. The rash was preceded by 4 weeks of widespread pruritus and occasional urticaria. The patient has a history of hypertension controlled with amlodipine for 2 years and lisinopril for the last 6 months. Vital signs are within normal limits. On examination, he has scattered vesicles and bullae with underlying erythema and urticaria, as shown in the image below: Which of the following is the most appropriate next step in management of this patient's condition?

Question

A 70-year-old man comes to the office due to a skin rash.  He has widespread redness and blistering across his neck and trunk, which are associated with severe itching.  The rash was preceded by 4 weeks of widespread pruritus and occasional urticaria.  The patient has a history of hypertension controlled with amlodipine for 2 years and lisinopril for the last 6 months.  Vital signs are within normal limits.  On examination, he has scattered vesicles and bullae with underlying erythema and urticaria, as shown in the image below:  Which of the following is the most appropriate next step in management of this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be71_00fd_8f63_9db1ddb8a1fc_MD0005_00 This older patient with pruritus and bullae has the typical features of bullous pemphigoid, an autoimmune blistering disease that most commonly affects individuals age >60. A prodromal phase of pruritic, eczematous or urticarial rash may proceed the development of bullae by weeks to months, as in this patient. Bullae are typically tense, have erythematous bases, and may rupture to form erosions. Lesion distribution can be localized or diffuse, involving the trunk and extremities; mucosal involvement is rare. Associated pruritus can be disabling. autoimmune blistering disease Bullae The diagnosis must be confirmed with skin biopsy before starting therapy, which is often chronic and can involve agents with significant toxicity (eg, systemic corticosteroids). A biopsy sample is obtained from the edge of an intact blister for routine histology and from perilesional skin for direct immunofluorescence. Subepidermal cleavage and linear deposition of IgG and/or C3 along the basement membrane are found on biopsy. Serology for antibodies against bullous pemphigoid antigens (ie, hemidesmosomes) can further support the diagnosis. Subepidermal cleavage (Choice A) Bullous pemphigoid is usually idiopathic, although certain drugs (eg, lisinopril) can cause drug-induced bullous pemphigoid. A suspected drug can be temporarily stopped pending definitive diagnosis, but stopping the medication without performing a biopsy for confirmation is insufficient for management of suspected bullous pemphigoid. (Choice B) Prednisone is a treatment option for bullous pemphigoid. Although therapy may be initiated pending biopsy results when symptoms are disabling (eg, severe pruritus), empiric treatment alone (ie, without biopsy) is not appropriate because the diagnosis must be confirmed. (Choice C) Valacyclovir is used to treat herpes zoster (shingles), which presents with acute, burning (neuropathic) pain and grouped vesicles on erythematous bases in a unilateral, dermatomal distribution. Bilateral distribution and a chronic course are not characteristic. grouped vesicles (Choice E) High-potency (eg, clobetasol), not medium-potency (eg, triamcinolone), corticosteroids are used to treat bullous pemphigoid even when widespread lesions are present because it has fewer adverse effects compared to systemic corticosteroids. Educational objective: Bullous pemphigoid is a pruritic, autoimmune blistering disorder that typically occurs in patients age >60. Diagnosis must include skin biopsy (ie, routine histology, direct immunofluorescence), which shows subepidermal cleavage and deposition of IgG and/or C3 along the basement membrane. References: Bullous pemphigoid. (http://www.ncbi.nlm.nih.gov/pubmed/31090818)

A 70-Year-Old Man Comes to the Office Due to a Skin