The store-and-forward feature of teledermatology allows patient medical information (including history and visual data) obtained from one provider's location to be electronically transferred to a provider in another location (Roman & Jacob, 2014). The construct of the Teledermatology Viewpoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
HISTORY
Chief complaint: blisters that break open and leave sores.
History of present illness
A 55-year-old man presents with "sores" that he believes started as blisters that quickly ruptured. The patient also notes the onset of scaly, erythematous lesions on his chest and upper back. Prior treatment: none. His primary symptom: burning pain and pruritus. He has no personal or family history of skin cancer or melanoma. Other significant laboratory/study findings: none.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT1
One image was provided that depicts well-demarcated, round flaccid bullae with an overlying yellow-brown crust on an erythematous base. There is no evidence of purulence. Scattered, round erythematous patches of varying sizes are also observed (Figure 1).
INTERPRETATION OF IMAGES
Lesion A
Findings
The presented lesions are consistent with an autoimmune blistering disease in the pemphigus group.
RECOMMENDATIONS
Other Recommendations
Two skin biopsies are recommended. One stained with hematoxylin and eosin and the other processed for antibody-antigen reaction by direct immunofluorescence are strongly recommended for all blistering disorders of unknown etiology.
RECOMMENDED FOLLOW-UP
Type of Visit
Refer to dermatology clinic for evaluation and follow-up of biopsy results (face-to-face).
CLINICAL PEARL
Pemphigus is a rare autoimmune blistering skin disease caused by separation of keratinocytes in the upper epidermis due to antibodies against the adhesion molecule desmoglein (Emery et al., 1995). The blister roof consists of a very thin portion of the superficial epidermis, making it easily prone to rupture and leakage of serum that desiccates into an overlying crust. Intact blisters are rarely seen, in contrast with bullous pemphigoid, and crusted patches and erosions instead appear as the predominant lesion (Bolognia, Jorizzo, & Schaffer, 2012). Pemphigus foliaceus is typically limited to the skin, and the lack of mucous membrane involvement helps distinguish it from pemphigus vulgaris. Diagnosis requires skin biopsy and direct immunofluorescence that will show intercellular deposition of immunoglobulin G and frequently complement C3 in the upper epidermis (Habif, Campbell, Chapman, Dinulos, & Zug, 2011).
Pemphigus typically affects middle-aged and elderly individuals, with associated symptoms of localized pain and burning occurring more commonly than pruritus (Bolognia et al., 2012). A characteristic finding in this condition is the incidence of lesions in a "seborrheic distribution" including the scalp, face, and upper trunk. In fact, early pemphigus foliaceus may be initially misdiagnosed as seborrheic dermatitis. Interestingly, an increased incidence of other autoimmune diseases such as myasthenia gravis has been noted in these patients (Kim, Kim, Kim, Kim, & Lee, 1995).
The course of pemphigus can vary tremendously, with some cases remaining localized and others rapidly progressing into a generalized exfoliative dermatitis (Bolognia et al., 2012). The index of suspicion for cutaneous infections should be high, as the impetiginization of erosions may occur. The management team should include a dermatologist, as control of the disease is difficult to attain and mismanagement is associated with morbidity and mortality. Localized disease may be treated with topical steroids, but more widespread involvement often requires complicated regimens of systemic immunosuppressive agents.
REFERENCES