A bedbound 76-year-old woman with advanced dementia is brought to ED with a six-month history of progressive widespread bullae on the trunk, arms and legs.

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A bedbound 76-year-old woman with advanced dementia is brought to ED with a six-month history of progressive widespread bullae on the trunk, arms and legs. The patient is typically bedbound and is a high-dependency care nursing home resident. The bullae were initially noted on the right leg but slowly progressed to involve the trunk and arms. These lesions are not apparently painful or itchy; however, this is difficult to assess confidently because of her severe cognitive impairment. On examination, there are haemorrhagic bullae over the hands and hips, and clear bullae over the knees. There are also large areas of erosions. There is no mucosal involvement.

The answer is A. Bullous pemphigoid can present as large, tense, fluid-filled blisters, which rupture to form erosions. Typically, the flexural aspects of the limbs are involved, and lesions may either be localised or widespread. Bullous pemphigoid is often associated with urticaria and annular eczematous lesions. Less commonly, there may also be involvement of mucous membranes including the eyes, oral and genital mucosa.