Blisters tell the story

This patient has both intact blisters occurring on a red base (seen centrally) and ruptured blisters showing a superficial peeling of the skin (see bottom left). The diagnosis was thought to be bullous pemphigoid, which was supported by the intact blisters but not by the superficial skin peeling. In bullous pemphigoid the separation occurs at the dermo-epidermal junction and the overlying epidermis is thick and intact hence the blisters do not rupture easily. This patient had early toxic epidermal necrolysis due to a drug reaction. The diagnosis was confirmed by skin biopsy and negative immunofluorescence.
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