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Trauma-induced bullous pemphigoid on pre-existing urticarial bullous pemphigoid (worsening): case report A 61-year-old man exhibited trauma-induced bullous pemphigoid (BP) on pre-existing urticarial bullous pemphigoid (worsening) following application of lidocaine, epinephrine and isopropyl alcohol. The man presented with multiple red pruritic papules and nodules on his chest, lower limbs and back from 2 years. A punch biopsy was performed from a representative lesion on his right forearm with differential diagnosis of erythema multiforme, urticarial vasculitis, sarcoidosis and urticarial BP. The biopsy procedure comprised of physical trauma induced by the punch and needle prick with lidocaine [lignocaine] injection and epinephrine [adrenaline] injection as local anaesthetics along with isopropyl alcohol swab for cleansing the skin [routes and dosages not stated]. After 48 hours, he returned with multiple new blisters confined to his right forearm around the site of biopsy. The bullae were tense, filled with serous fluid and variably sized. Remarkably, the bullae adjacent to the site of the biopsy were the largest. An additional perilesional biopsy was performed for direct immunofluorescence. Histopathology showed mild acanthosis, subtle spongiosis, eosinophilic exocytosis and an upper dermal eosinophilic infiltrate distributed along the basal layer and forming an occasional microabscess in dermal papilla, indicative of urticarial stage of BP (underlying condition). Direct immunofluorescence revealed a strong linear band of C3 along the dermo-epidermal junction, thereby confirming the diagnosis of BP. Direct immunofluorescence ruled out epidermolysis bullosa acquisita. Routine blood biochemistry was normal except for peripheral eosinophilia and around 15 times elevated serum IgE levels. The additional blisters were found to be trauma-induced BP on pre-existing urticarial BP, which was attributed to the skin biopsy and chemical agents i.e. lidocaine, epinephrine and isopropyl alcohol used in skin biopsy procedure. The man was treated with unspecified topical steroids. After 1 month, he developed multiple new blisters over pre-existing urticarial plaques as well as normal skin. He was treated with dapsone, azathioprine and unspecified antihistamines to which he responded well and subsequently recovered within a year. Arshdeep, et al. Skin biopsy-induced blistering in urticarial bullous pemphigoid. Indian Journal of Dermatology, Venereology and Leprology 86: 552-555, No. 5, Sep-Oct 803519552 2020. Available from: URL: http://doi.org/10.4103/ijdvl.IJDVL_453_18

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Reactions 5 Dec 2020 No. 1833