Blistering skin disorders: Clinical

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Blistering skin disorders: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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 A 16-year-old boy presents to the emergency department for evaluation of right middle finger pain. Several days ago, the patient noticed small fluid-filled sacs in the right middle finger, which progressed into painful lesions yesterday. His mother, who is accompanying him, states, “He has got a finger infection from chewing on his nails all day.” The patient is otherwise healthy and takes only a multivitamin daily. Temperature is 37.0°C (98.6°F), blood pressure is 115/73 mmHg, and pulse is 78/min. Physical examination is notable for the following finding:

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Which of the following is the most appropriate treatment for this patient’s clinical condition?  


Blistering skin disorders are characterized by the presence of blisters, which are bubbles that pop up when serum collects in pockets under the top layer of the skin.

Blisters occur as a result of a loss of adhesion between cells within the epidermis - called acantholysis; edema between epidermal cells - called spongiosis; and dissociation between the epidermis and dermis.

Blisters that form within the epidermis tend to be more fragile than subepidermal blisters.

Blisters that are smaller than 1 centimeter in diameter are called vesicles, while blisters that are larger than 1 centimeter in size are called bullae.

There are various causes for blistering disorders, including autoimmune disorders, drug reactions, infections, genetic disorders, and traumatic injury. These conditions range from benign to life-threatening conditions.

Life-threatening cutaneous blistering disorders include toxic epidermal necrolysis, staphylococcal scalded skin syndrome, disseminated herpes simplex virus infection, and disseminated herpes zoster.

Broadly speaking, blistering skin disorders may be divided into generalized or localized disorders.

Among generalized blisters, some cause systemic illness, whereas others don’t. Generalized blistering disorders that are not usually associated with systemic illness include miliaria crystallina, bullous impetigo, linear IgA bullous dermatosis, epidermolysis bullosa, pemphigus, pemphigoid, and dermatitis herpetiformis.

Miliaria crystallina typically results in multiple tiny vesicles on the face and trunk, due to obstruction of eccrine sweat gland ducts in the setting of excessive warmth.

Usually, the rash of miliaria resolves on its own, the key is to avoid overheating the body by wearing lighter clothing, staying hydrated, and keeping a cool environment, for instance by using air conditioner. A soothing ointment like calamine lotion can also help.


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