Skill Checkup: A Student With an Inherited Blistering Condition and Painful Bullae on His Feet

William D. James, MD


April 12, 2021

The Skill Checkup series provides a quick, case-style interactive quiz highlighting key guidelines- and evidence-based information to inform clinical practice.

A 19-year-old first-year (freshman) college student presents to the student health center with painful blisters on his feet. He says he's had similar symptoms since early childhood. He develops blisters and erosive skin lesions on his hands and feet, particularly following exposure to trauma or friction. They heal but leave scars, some of which are small and whitish in color. He had been neglectful of some of the usual preventive measures that help reduce the occurrence of these blisters. He reported that his condition was confirmed with genetic testing and he received repeated medical treatment for it. He says he has no itching or other complaints. He does not have difficulty swallowing or moving any parts of his body. He is not a smoker or an alcohol or drug user, and is not sexually active.

His height is 5'4" and weight is 109 lb. Vital signs are within normal range. Physical examination of the lower limbs shows a large (3 x 2 cm) blister on the dorsal left hallux extending an inch into the plantar surface and a similar 1.5 x 1 cm blister on the small toe. The skin appears erythematous and the bullae are intact, flaccid, and fluid filled. Similar blisters are found on the right foot as well as an additional round, 2 x 2 cm blister on the dorsal surface of the heel. Both feet reveal hyperkeratosis and dystrophic toenails. Milia are noted on the dorsal surface of both feet. His hand exam shows dystrophic nails but no blisters. Examination of the head and neck shows no blisters in the oral cavity or abnormal dentition. The ophthalmic exam is unremarkable. Examination of other systems is within normal limits.


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