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A Patient With Diabetes and Spontaneous Blistering of the Right Lower Extremity

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 42-year-old man with hypertension, type 2 diabetes diagnosed at age 25 years, and gastroparesis presented to the emergency department with right lower extremity blisters that had developed spontaneously over the prior 36 hours. He reported a tingling sensation in the affected area but no pruritus or pain. He had no history of leg trauma and no chemical or extreme temperature exposure. Medications included insulin lispro (sliding scale 3 times daily) and insulin glargine (20 units nightly). On physical examination, he was afebrile and had normal vital signs. His extremities were warm with palpable distal pulses. Hyperpigmented macules were present on the anterior lower legs below the knees, and tense bullae were present on the anterior aspect of the right lower extremity, dorsal foot surface, and toes (Figure). There was no surrounding erythema or edema, and findings on the remainder of the skin and mucocutaneous examination were unremarkable. Laboratory testing revealed a blood glucose level of 375 mg/dL (20.81 mmol/L) and hemoglobin A1c level of 9.8%. Results of a basic metabolic panel and complete blood cell count were within reference range except for mild anemia (hemoglobin level, 10.9 g/dL).

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A 42-year-old man with hypertension, type 2 diabetes diagnosed at age 25 years, and gastroparesis presented to the emergency department with right lower extremity blisters that had developed spontaneously over the prior 36 hours. He reported a tingling sensation in the affected area but no pruritus or pain. He had no history of leg trauma and no chemical or extreme temperature exposure. Medications included insulin lispro (sliding scale 3 times daily) and insulin glargine (20 units nightly). On physical examination, he was afebrile and had normal vital signs. His extremities were warm with palpable distal pulses. Hyperpigmented macules were present on the anterior lower legs below the knees, and tense bullae were present on the anterior aspect of the right lower extremity, dorsal foot surface, and toes (Figure). There was no surrounding erythema or edema, and findings on the remainder of the skin and mucocutaneous examination were unremarkable. Laboratory testing revealed a blood glucose level of 375 mg/dL (20.81 mmol/L) and hemoglobin A1c level of 9.8%. Results of a basic metabolic panel and complete blood cell count were within reference range except for mild anemia (hemoglobin level, 10.9 g/dL).

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Article Information

Corresponding Author: Daniela Kroshinsky, MD, MPH, Department of Dermatology, Massachusetts General Hospital, 50 Staniford St, Second Floor, Boston, MA 02114 (dkroshinsky@partners.org).

Published Online: March 24, 2023. doi:10.1001/jama.2023.3101

Conflict of Interest Disclosures: Dr DeWane reported having a patent pending for Microneedle patch for immunostimulatory drug delivery. No other disclosures were reported.

Additional Contributions: We thank the patient for providing permission to share his information.

References
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2.
Vangipuram  R , Hinojosa  T , Lewis  DJ ,  et al.  Bullosis diabeticorum: a neglected bullous dermatosis.   Skinmed. 2018;16(1):77-79.PubMedGoogle Scholar
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Svoboda  SA , Shields  BE .  Cutaneous manifestations of nutritional excess: pathophysiologic effects of hyperglycemia and hyperinsulinemia on the skin.   Cutis. 2021;107(2):74-78. doi:10.12788/cutis.0173PubMedGoogle ScholarCrossref
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Larsen  K , Jensen  T , Karlsmark  T , Holstein  PE .  Incidence of bullosis diabeticorum—a controversial cause of chronic foot ulceration.   Int Wound J. 2008;5(4):591-596. doi:10.1111/j.1742-481X.2008.00476.xPubMedGoogle ScholarCrossref
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Braverman  IM , Keh-Yen  A .  Ultrastructural abnormalities of the microvasculature and elastic fibers in the skin of juvenile diabetics.   J Invest Dermatol. 1984;82(3):270-274. doi:10.1111/1523-1747.ep12260279PubMedGoogle ScholarCrossref
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Bernstein  JE , Levine  LE , Medenica  MM , Yung  CW , Soltani  K .  Reduced threshold to suction-induced blister formation in insulin-dependent diabetics.   J Am Acad Dermatol. 1983;8(6):790-791. doi:10.1016/S0190-9622(83)80007-3PubMedGoogle ScholarCrossref
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Lipsky  BA , Baker  PD , Ahroni  JH .  Diabetic bullae: 12 cases of a purportedly rare cutaneous disorder.   Int J Dermatol. 2000;39(3):196-200. doi:10.1046/j.1365-4362.2000.00947.xPubMedGoogle ScholarCrossref
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Hamdan  R , Mihai  AM .  Disabling bullosis diabeticorum despite optimal type 2 diabetes control.   BMJ Case Rep. 2022;15(12):e254182. doi:10.1136/bcr-2022-254182PubMedGoogle ScholarCrossref
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Armanious  M , AbuHilal  M .  Gliptin-induced bullous pemphigoid: Canadian case series of 10 patients.   J Cutan Med Surg. 2021;25(2):163-168. doi:10.1177/1203475420972349PubMedGoogle ScholarCrossref
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Shahi  N , Bradley  S , Vowden  K , Vowden  P .  Diabetic bullae: a case series and a new model of surgical management.   J Wound Care. 2014;23(6):326-330. doi:10.12968/jowc.2014.23.6.326PubMedGoogle ScholarCrossref
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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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