Tense Bullae on Erythematous Base

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The patient is a 79 year old female who has multiple asymptomatic erythematous targetoid lesions on the chest, abdomen, and extremities, along with tense bullae. Nikolsky’s sign is negative.

Diagnosis: Bullous pemphigoid, likely drug-induced.

Histology: Sections in this biopsy of peribullous skin did not show a subepidermal split but did show an infiltrate of eosinophils, consistent with the so-called “prebullous phase” of bullous pemphigoid.

Direct Immunofluorescence (DIF): Direct immunofluorescence with C3 (shown above) demonstrated a linear-granular fluorescence at the basement membrane zone.