Bullous lesions on a skin graft donor site.

Patients with bullous lesions often present to family physicians. In many cases, the diagnosis is readily apparent based on a focused history and examination. We report a case in which the correct diagnosis, bullous pemphigoid (BP), was obscured by an unusual presentation. Although some lesions were typical of BP, most were clustered on a recent skin graft donor site and some were hemorrhagic. A review of recent family medicine literature revealed one article discussing BP, but neither this article nor 3 dermatology textbooks mentioned this presentation. However, further literature review revealed that this presentation is actually well described and fits nicely with current understanding of the etiology of BP. The review also revealed an important recent change in BP management: the emergence of ultra–high-potency topical steroids as a first line therapy. As recently as 6 years ago, oral steroids were the standard approach for treating most BP patients. The following case provides an opportunity to review recent advances in the understanding and management of BP, a condition most family physicians can expect to encounter. The discussion also addresses the differential diagnosis of bullous lesions and the need for special punch biopsy specimen media if BP is suspected.