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Vesiculobullous
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Newborn (0-1 month)
Infant / child
Adult
Tense
Flaccid / fragile
Mucosa involved
Mucosa spared
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NO FILTER · 40 CANDIDATES · DON'T-MISS ALWAYS SHOWN
COMMON (10)
Bullous fixed drug eruption
Recurs at the same site; dusky violaceous patch evolves into a bulla and resolves with hyperpigmentation; NSAIDs, sulfonamides, tetracyclines, allopurinol
Phototoxic bullous drug reaction
Sunburn-like with bullae on photodistributed sites; psoralens, tetracyclines, voriconazole, BRAF inhibitors
Erythema multiforme minor
Typical 3-zone targets, sometimes papular atypical 2-zone lesions, on extremities (elbows, knees, wrists, hands) and face; no epidermal detachment; mucosal involvement absent or mild; HSV and other infections
Bullous pemphigoid
Generalized tense bullae on trunk and flexures, age over 60; itch may precede bullae by weeks to months, so consider it in any elderly patient with refractory pruritus and urticarial plaques
Dermatitis herpetiformis
Grouped vesicles on extensors (elbows, knees, buttocks, scalp), age 30-40s; gluten sensitive and almost always reflects underlying celiac disease, so check TTG-IgA even without GI symptoms
Grover disease
Discrete pruritic crusted papulovesicles on the trunk in sun-exposed or occluded sites, after heat or sweating; acquired and sporadic, typically older men
Neonatal staphylococcal impetigo / bullous impetigo
Days to weeks; flaccid pustules and bullae with honey crust, periumbilical, diaper and face; the most common neonatal pyoderma
Erythema toxicum neonatorum
Onset 24-72 hours; yellow papulopustules on an erythematous wheal over trunk and proximal extremities, SPARES palms and soles; eosinophils on Wright stain; resolves in 5-7 days
Transient neonatal pustular melanosis
Present at birth; superficial pustules leaving collarettes then hyperpigmented macules on forehead, chin, neck and trunk, can involve palms and soles; neutrophils on Wright stain; more common in darker skin
Sucking blister
Solitary flaccid bulla or erosion present at birth on forearm, wrist or thumb, at a site sucked in utero; resolves spontaneously
DON'T MISS (15) - ALWAYS SHOWN
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Stevens-Johnson syndrome
Macular atypical 2-zone targets plus bullae on trunk and face, under 10% BSA epidermal detachment, severe involvement of 2 or more mucosal sites in over 90%; fever, lymphadenopathy, hepatitis, cytopenias; drugs, occasionally Mycoplasma
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Toxic epidermal necrolysis
Widespread confluent atypical macular targets with over 30% BSA epidermal detachment on trunk, face and neck; severe mucosal involvement including respiratory and GI mucosa; drugs
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TEN-like lupus (Rowell syndrome)
Usually resembles erythema multiforme but can have a TEN-like presentation; appears de novo or as therapy is tapered; ANA, SS-A, SS-B positive
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Purpura fulminans / DIC
Hemorrhagic bullae; acral ischemia and necrosis
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Staphylococcal scalded skin syndrome
Children under 5, less often adults with renal failure or immunocompromise; perioral and periocular crusting with radial fissuring and mild facial swelling; Nikolsky positive widely, even on normal-appearing skin; skin lesions sterile, culture the primary focus (nasopharynx, conjunctiva, umbilicus)
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Pemphigus vulgaris
Peak 50-60 years; initially painful mucosal erosions, then fragile cutaneous blisters and erosions
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Mucous membrane (cicatricial) pemphigoid
Middle-aged to older; anogenital erosions with scarring, rarely blisters; oral and ocular involvement. Often indistinguishable from erosive lichen planus, so biopsy plus DIF is essential
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Paraneoplastic pemphigus
Severe recalcitrant erosive mucosal involvement; adults much more than children
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Neonatal herpes simplex
Days 5-14; grouped vesicles on erythema on the scalp (vertex, fetal monitor sites), eye and mouth; SEM vs CNS vs disseminated; start acyclovir empirically while PCR is pending
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Neonatal varicella
Day 5-10; crops of vesicles on erythema, generalized; maternal VZV from 5 days before to 2 days after delivery carries high mortality
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Congenital candidiasis
Present at birth from intrauterine infection; diffuse erythematous papulopustules on the trunk with palms and soles INVOLVED; maternal chorioamnionitis, preterm infants at risk for systemic disease
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Congenital syphilis
Bullae on palms and soles with condylomata and snuffles at birth; syphilitic pemphigus is pathognomonic; RPR/VDRL and dark-field
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Epidermolysis bullosa
Tense bullae and erosions at trauma sites (hands, feet, knees, mouth) from birth; subtype with IF mapping plus genetics, since clinical phenotype alone cannot reliably subtype EB; consult an EB center
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Acrodermatitis enteropathica
Weeks to months; erosive periorificial, acral and diaper dermatitis with diarrhea, alopecia and failure to thrive; low zinc and low alkaline phosphatase, and responds to zinc; check urine organic acids to rule out organic acidemias
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Invasive fungal dermatitis
Premature NICU infants; erosions and necrotic plaques at catheter, tape and diaper sites; Candida, Aspergillus, zygomycetes on biopsy and culture
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