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I had a referral from dermatology recently for consideration of possible mechanical cause for episodic bullous reaction in 66 yo female.


I was unable to find any likely cause of friction or stress from abnormal foot behavior during stance or gait and footwear fits well.
There was no prodromal itching or pain and lesion started at apex of the toe. The lesion base is sensitive but painless without pressure. Problem has been episodic approximately annually for several consecutive years; there is no interesting medical history, known drug allergies or unusual medications. She had her annual episode 2 days ago.

Some pics to look at below.

If this was a more widespread distribution or constant problem I might be suspicious for some kind of bullous pemphigoid reaction but not aware that this might present in such an episodic way. Not sure if she has been assayed for autoantibodies.
I aspirated the bulla and sent fluid for culture to rule out dermatophytes or other micro-orgs.

Anyone care to comment, speculate etiology or further diagnostic approach?











Cheers
Martin
The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

If the blisters dont occur anywhere else, then I would think Pemphigoid unlikely- even less likely if it happens "annually".

Annually suggests fungal or else perhaps a reaction to the nail art ingredients? It would be interesting to see whats under the nail polish

Any one else?

 

All,
I would speculate either,

1. Bullous pemphigiod (limited presentation) or

2. Allergic reaction, caused by something that she only comes into contact with yearly, say on her annual holiday.

This is Blinda's area of expertise, maybe she can throw some light on this ?

CF

 

Thanks for comments. I checked back on my notes; she reported 5 previous episodes all in August on yearly basis except one in Feb.

In Winnipeg you dont venture outdoors barefoot in Feb unless bonkers and she isn't; I think this makes outdoor environmental allergen unlikely.
Nail polish? I thought about. If this were likely why only single toe? Also I am pretty sure this was not present in previous episode.

Will post any diagnostic progress.

cheers

Martin

The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

No, not an expert, just an interest in dermatology.

Nice pics :drinks

I would imagine that as the referral was FROM dermatology they would have ruled out BP as they would probably have performed blood tests and checked for antibodies along the basement membrane.

You say she has unremarkable meds and no known drug allergies, but there are some `regular` meds that are capable of causing fixed eruptions (FE). Such as paracetamol, A/B`s, NSAIDS, some sedatives and even quinine.

That said, I`m with the others, I reckon it`s probably a reaction to the nail art....she only has jewels and stuff on that toe. Cant think of reason for
annual episodes other than she has pedicures/art work during August?

I`d be very interested to know the results of the culture.

Cheers,
Bel

 

Nice nail art. There's a nasty chemical used in fake acrylic nails, MDMA? Also a swop with acetone, And she went to a foot spa? YUK!! Since I did the manicure and pedicure course, subjecting myself to the misplaced humor on this site, I would never go near one...Bug heaven The episode inFeb? Did she take a cruise that year?

 

Thanks Bel . . . . good points....... I check her for any recollection for prior spa use or associated episodic drug use.


cheers

Martin


The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

Hya,
I beleive it could well be reaction to insect bites, i know of two people in england that have very similar reactions, and i think local circulation causes hallux to be the weaker point. (As for feb outbreak, although cold in your area is it possible that the odd insect survives?)
jane