“It all began with blisters behind my ears five months ago,” a sixty-nine-year-old woman told us on her first visit. It would be many visits later before we could find the cause.
She described the blisters as initially being small and very itchy. As the months went by, new blisters appeared on her face, chest and, most dramatically, over her left thigh. She had always been in good health with no prior skin disease. But two years ago she had fractured her left hip. This required extensive orthopedic care, involving screws, bone grafting with a buttress plate, and the implant of an osteogenic bone growth stimulator.
On examination the blisters were large, tense, and filled with a clear fluid, while the surrounding skin was red and slightly elevated. Rubbing the skin firmly did not produce any new blisters. This simple sign (Nikolsky) helped rule out the grave diagnosis of pemphigus.
Clinically, her problem appeared to be the blistering eruption called “bullous pemphigoid,” usually seen in older individuals. However, skin biopsies did not confirm this diagnosis, showing only that the epidermis was lifted off of the dermis by the blister fluid. Extensive blood studies told us that she had a very high serum level of the immune protein, IgE, seen in allergic individuals.
We were able to suppress the blisters with intramuscular cortisone shots and an oral antibiotic, but the problem was not really solved.