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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, 1 but neither this article nor 3 dermatology textbooks 2-4 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. 3The discussion also addresses the differential diagnosis of bullous lesions and the need for special punch biopsy specimen media if BP is suspected. Case ReportsA 53-year-old woman presented with painless blisters of several days' duration. One month before she sustained a third-degree burn of the right foot requiring a split-thickness skin graft. Her blisters were disproportionately concentrated on the skin graft donor site (Figure 1) but were also present on the left shin (Figure 2). She denied fever and itching and complained only of chronic foot pain ever since skin graft surgery. She denied applying any topical products to the donor site or her legs and denied any recent change in skin care products. The patient had never experienced a similar blistering episode.Her recent medical history included a hospital admission 2 weeks earlier for aspiration pneumonia. Recovery was uneventful apart from Clostridium difficile colitis caused by piperacillin/tazobactam, which was successfully treated with metronidazole. Medical history included insulin-dependent diabetes, chronic renal insufficiency, coronary artery disease, hypertension, and cerebrovascular accident with mild residual right-sided weakness. Medications included oxycodone/acetaminoiphen; lansoprazole; aspirin; atorvastatin; clopidogrel; metoprolol; venlafaxine; albuterol; gabapentin; insulin; Culturelle (an OTC pro-biotic; Amerifit Brands, Inc., Cromwell, CT); and metronidazole.Vital signs were normal during physical examination. The skin graft donor site contained multiple tense bullae with hemorrhagic contents (Figure 1). Similar bullae with clear fluid were seen on the left anterior shin (Figure 2). The bullae were oval to round in shape, 1.5 to 4 cm in diameter, tense, and painless to the touch. There were no lesions in the oral cavity. Gentle pressure applied to the blisters did not cause them to spread outwards, thus yiel...

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