Diabetic bullae: A case series and a new model of surgical management
Bullosis diabeticorum is considered a rare skin manifestation of diabetes mellitus. Tense blisters appear rapidly, mostly on the feet, the cause of which is unclear, with multiple pathophysiologies hypothesised. This is a retrospective review of 4 diabetic patients who presented over six months with diabetic bullae; the condition may therefore not be as rare as commonly believed. All the patients had early surgical debridement followed by topical negative pressure wound dressings. A multidisciplinary team that included vascular surgeons, diabetologists, diabetic foot care team, wound care team, physiotherapists and occupational therapists managed the patients and none of them required amputations. We propose an alternative way of managing these patients with early surgical debridement followed by topical negative pressure wound dressing.
Diabetic bullae were first observed by Kramer in 1930.1 In a case series by Rocca and Pereyra in 1963,2 the lesions were termed ‘phlyctenar’ to express their resemblance to blisters created by burns. It was four years later that the term ‘bullosis diabeticorum’3 was first coined and this remains the common nomenclature today.
Cutaneous manifestations are estimated to be present in 30% of diabetics,10 the most common including acanthosis nigricans, skin tags, yellow nails, necrobiosis lipoidica diabeticorum, xerosis (dry skin) and granuloma annulare. Diabetic bullae are, however, considered the rarest cutaneous manifestations of diabetes.4 They usually present as tense, painless blisters on acral areas, most commonly present on the feet, although they have also been reported on legs and occasionally even on the upper limb.5 The bullae appear to form spontaneously, vary in size and evolve rapidly (sometimes within an hour)6 with no obvious precipitating trauma or inoculation. The bullae contain serous, often thick or ‘syrupy’ fluid,6,7 and are occasionally blood stained (haemorrhagic bullae).4
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