Intended for healthcare professionals

Endgames Picture Quiz

An 81 year old man with a blistering rash

BMJ 2013; 346 doi: (Published 31 January 2013) Cite this as: BMJ 2013;346:f522

This article has a correction. Please see:

  1. Sophie Noel, foundation year 2 trainee,
  2. Janet Dua, specialist registrar,
  3. Ghazia Kaushal, consultant
  1. 1Department of Dermatology, Royal Berkshire Hospital, Reading RG1 5AN, UK
  1. Correspondence to: J Dua Janetdua3000{at}

An 81 year old man presented with a 10 day history of an extensive blistering rash that was profoundly itchy. He had a history of hypothyroidism and a deep vein thrombosis. He was receiving carbimazole and warfarin and denied any recent changes in medication.

On examination he had more than 100 blisters over his whole body, although his face was spared (fig 1). Some of the blisters formed a circinate pattern. Nikolsky’s sign was negative. The mucous membranes were not affected.

Fig 1 Rash on patient’s torso

Blood tests including full blood count, urea and electrolytes, and liver function tests were within normal ranges. He had a C reactive protein of 28.8 mg/L (reference range 0-4.9; 1 mg/L=9.52 nmol/L).


  • 1 What are the possible causes of this man’s blisters?

  • 2 Which investigations would you do to confirm your diagnosis?

  • 3 What comorbidities are associated with this condition?

  • 4 What is the best treatment for this condition?


1 What are the possible causes of this man’s blisters?

Short answer

The main differential diagnoses are bullous pemphigoid, linear IgA disease, and epidermolysis bullosa acquisita.1 This patient had bullous pemphigoid, the most common autoimmune subepidermal blistering disorder. It mainly affects older patients and presents with tense fluid filled blisters that can appear anywhere on the body, including the mucous membranes. It typically occurs over the limbs, groin, and abdomen.1 2

Long answer

Differential diagnoses for skin blistering disorders include bullous pemphigoid, epidermolysis bullosa acquisita, linear IgA disease, and a bullous drug reaction.1 Localised blisters, particularly those on the feet, may be caused by infections such as bullous tinea pedis. Superficial pemphigus vulgaris can usually be discounted because it rarely leaves more than erosions.3

Linear IgA disease typically produces symmetrical annular collections of papules and bullae on the extensor surfaces.2 It is a rare autoimmune condition. Linear depositions of IgA are seen …

View Full Text

Log in

Log in through your institution


* For online subscription