Case records of the Massachusetts General Hospital. Case 32-2008. A 10-year-old girl with recurrent oral lesions and cutaneous bullae.

Dr. Melissa M. Burnett (Pediatric Dermatology): A 10.8-year-old girl was seen in the Pediatric Dermatology Clinic of this hospital because of recurrent oral ulcers and cutaneous bullae. The patient was well until 2 years of age, when white lesions developed in the mouth that were followed by vesicles and bullae on the dorsal and plantar surfaces of the feet and, to a lesser degree, on the knees and hands. The white lesions on the buccal mucosa became ulcerated and painful; the other lesions were occasionally painful and pruritic. The lesions lasted 4 days to 2 weeks. Similar lesions recurred intermittently thereafter, at intervals of approximately 3 to 4 months, without seasonal variation or precipitant trauma. At age 6.9 years, she saw her pediatrician because of recurrent blisters on her feet, left knee, and both hands. A swab from a lesion on the toe was sent for culture, and antibiotics were prescribed; the culture was sterile. During the following week, a pink rash developed under the arms and on the inner thighs. The patient saw a dermatologist at another facility. On examination, there were white, slightly oval plaques on the buccal mucosa that were approximately 2 to 3 cm in diameter. Tense bullae, containing clear to slightly cloudy fluid and measuring 3 to 8 mm in diameter, were located on the dorsum of all toes, extending slightly onto the feet (Fig. 1A); on the plantar surfaces of the toes and feet; and on the fingers and palms. Several lesions were confluent. There were resolving bullae with minimal overlying erythema and a slight hemorrhagic crust on the toes, and there was a resolving bulla approximately 1 cm in diameter on the left knee (Fig. 1B). There were multiple pink-to-tan hyperkeratotic papules, 2 to 3 mm in diameter, on the upper thighs and arms (Fig. 1C). There were no nail changes or scarring of the skin. Nikolsky’s sign (ready removal of the epidermis with slight tangential pressure) was negative. Skin care to decrease local trauma and biopsy of a skin lesion for pathological examination were recommended. Two months later, a punch biopsy of the skin of the left inner arm was performed. Pathological examination revealed a subepidermal microvesicle. The results of imCase 32-2008: A 10-Year-Old Girl with Recurrent Oral Lesions and Cutaneous Bullae