Bullous Disease of Diabetes - Causes, Symptoms, Diagnosis, and Treatment

Introduction

The bullous disease of diabetes is a skin condition characterized by the sudden or overnight development of bullae on the distal parts of the body in patients with long-standing diabetes mellitus. The condition is more prevalent in males than females. These skin lesions are generally asymptomatic. However, they may cause some symptoms in the case of secondary infections. The bullous disease of diabetes occurs in both insulin-dependent and insulin-non-dependant diabetics. These skin lesions may be diagnosed with the help of a biopsy or culture.

What Is the Bullous Disease of Diabetes?

The bullous disease of diabetes, also known as bullosis diabeticorum, is a medical skin condition typically seen in patients with diabetes mellitus. It is a specific kind of skin lesion that is recurrent, distinctive, non-inflammatory, and blistering in nature. It is prevalent in people with diabetes mellitus with peripheral neuropathy, and these bullae usually develop on the legs, feet, hands, and toes (distal distribution). Diabetes bullous disease typically develops in people with chronic and long-standing diabetes mellitus or in conjunction with other comorbidities. These lesions usually cure on their own over two to six weeks. However, they frequently return to the same or different areas. Additionally, secondary infections are common. Kramer first reported the bullous disease of diabetes in 1930. The term “bullosis diabeticorum” was coined in 1967 by Cantwell and Martz.

What Are the Other Names of the Bullous Disease of Diabetes?

Other names of the condition are:

• Bullosis diabeticorum.

• Diabetic bullae.

• Bullous eruption of diabetes mellitus.

• BD (bullous disease).

What Causes Bullous Disease of Diabetes?

• The exact cause of the bullous disease of diabetes is unknown, and the condition is thought to arise due to multiple factors.

• Lesions developing in bullous disease of diabetes have an acral prominence and reveal a vulnerability to changes induced by microtrauma (commonly noticed in chronic diabetes). However, the majority of individuals experience blister development without any prior trauma.

• Many patients with the bullous disease of diabetes also have nephropathy (deterioration of kidney function) and neuropathy (dysfunction of peripheral nerves). Hence some studies suggest that microangiopathy (changes in small blood vessels) may contribute to the early aging of connective tissue and the development of diabetic bullae.

• Disturbances in the metabolism of calcium, magnesium, and carbohydrates (commonly seen in diabetes) have also been suggested as potential causes of the bullous disease of diabetes.

Who Is Affected by Bullous Disease of Diabetes?

• It is reported that abound 0.5 % of all diabetes patients in the United States of America develop the bullous disease of diabetes.

• Patients between the ages of 17 and 80 were reported to have the bullous disease of diabetes, and the mean age of occurrence is 55 years.

• Males with uncontrolled and long-standing diabetes are more frequently affected by the bullous disease of diabetes than females.

• The male-to-female ratio of occurrence is reported to be 2:1.

What Are the Symptoms of Bullous Disease of Diabetes?

The common signs and symptoms of the bullous disease of diabetes include:

• One or multiple painless bullae suddenly develop in normal-looking, uninflamed skin, usually on the distal parts of the body.

• These skin lesions are commonly seen on hands, forearms, feet, legs, toes, and the bottom of the foot (plantar surface).

• Diabetic bullae are rarely noticed on the trunk portion of the body.

• The skin lesions of the bullous disease of diabetes are generally asymptomatic.

• In rare cases, the patient may report mild discomfort and a burning sensation.

• The bullae are variable in size.

• Lesions often begin as tight blisters that grow to become flaccid and uneven in appearance.

• They contain a transparent, sterile fluid that can occasionally be hemorrhagic. Additionally, if a secondary bacterial infection develops, lesions may become pus-filled.

• The development of bullae is associated with both insulin-dependent as well as non-insulin-dependent patients.

• These bullae may develop in longstanding diabetes cases and may also be a symptom of the onset of diabetes mellitus.

• Lesions of the bullous disease of diabetes heal on their own within two to six weeks.

How Is Bullous Disease of Diabetes Diagnosed?

The diagnosis of the bullous disease of diabetes is made in the following ways:

• A detailed medical history of the patient is required to determine the presence of long-standing diabetes. Moreover, in the case of known diabetes patients, medical history is necessary to determine the presence of other comorbidities.

• Physical examination is crucial to determine the location and extent of the skin lesions. If the lesions are present on the distal parts of the body, it suggests the presence of bullous disease of diabetes.

• The bullous disease of diabetes has a relatively simple clinical workup. Diagnostic methods ranging from culture to skin biopsy are employed to distinguish the condition from other clinically comparable conditions and confirm the presence of any secondary infections that need to be treated.

• Ophthalmological and neurological examinations are advised due to the prevalence of microangiopathic complications in patients with diabetes mellitus with bullae.

• The lesions of bullous disease of diabetes can be distinguished from other disorders with similar clinical characteristics using shave biopsy or excisional and incisional biopsy. The biopsy sample should include the blister along with the underlying dermis of the lesion.

How Is Bullous Disease of Diabetes Treated?

The treatment and management of the bullous disease of diabetes include:

• Most of the lesions of the bullous disease of diabetes are self-limiting, and they subside on their own within two to six weeks; therefore, they do not require any treatment.

• Lesions with secondary infections require treatment and management.

• There is no definitive treatment plan for managing the bullous disease of diabetes.

• The skin of the lesion serves as an adequate and sterile cover for the underlying wound; hence several clinicians have recommended that it be left undisturbed. At the same time, others recommend applying topical antibiotics or antiseptics to the blister roof or aspirating the blister with the help of a needle to relieve the tension and pain and avoid secondary infections.

• Surgical management, if required, in case of soft tissue infection and other complications.

• Bone marrow mesenchymal cell transplantation therapy has been found helpful in the case of recurrent lesions.

• Along with treating the bullae, it is extremely crucial to control the blood sugar levels of the affected individual. Guidelines for diabetes control and foot care should be followed.

Conclusion

Although the bullous disease of diabetes is usually a self-limiting condition; it may require treatment and management in some instances. In most cases, lesions recover without leaving behind scarring or post-inflammatory discoloration. In secondary or soft tissue infections, the lesions may be aspirated and treated with topical antibiotics. The condition has a good prognosis and does not cause any long-term or life-threatening complications with proper management.