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Diabetic bullae (Bullosis Diabeticorum) - Clinical essentials

Bullous disease of diabetes (bullosis diabeticorum) is a distinct, spontaneous, noninflammatory, blistering condition of acral skin that is unique to patients with diabetes mellitus. Bullous disease of diabetes tends to arise in long-standing diabetes or in conjunction with multiple complications. The etiology of the disease is yet unknown. In the United States, bullous disease of diabetes has been reported to occur in approximately 0.5% of diabetic patients. Male patients have twice the risk as female patients.

Kramer first reported bullous-like lesions in diabetic patients in 1930 ; Rocca and Pereyra first characterized this as a phlyctenar (appearing like a burn-induced blister) in 1963. Cantwell and Martz are credited with naming the condition bullosis diabeticorum in 1967. It is also termed bullous disease of diabetes and diabetic bullae.

While lesions typically heal spontaneously within 2-6 weeks, they often recur in the same or different locations. Secondary infections may also develop; these are characterized by cloudy blister fluid and require a culture.

The clinician should consider direct immunofluorescence (DIF) studies to exclude histologically similar entities (eg, noninflammatory bullous pemphigoid, epidermolysis bullosa acquisita, porphyria cutanea tarda, other bullous porphyrias), as DIF studies are only rarely positive in bullosis diabeticorum.

Pseudoporphyria blistering due to photosensitizing drugs, chronic dialysis regimens, or ultraviolet A tanning devices should also be considered.

Specific treatment is unwarranted unless secondary infections (eg, staphylococcal) occur, thereby warranting antibiotic therapy. However, aspiration of fluid from lesions using a small-bore needle might help prevent accidental rupture.

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