A 63-year-old man presented with rapidly spreading pruritic blisters on his upper and lower extremities, chest, and back. The blisters initially appeared three to four weeks earlier on the dorsal aspect of both feet and hands. The large blisters waxed and waned and were filled with clear fluid. A dermatologist had recently biopsied the lesions and prescribed clobetasol cream and oral doxycycline. Three days after starting the medications, the lesions rapidly progressed to include his back and chest. The patient did not have pain, fever, mucosal blisters, or swelling of his lips or tongue. He reported having a similar blistering episode one year prior that was successfully treated with steroids. His medical history included non–insulin-dependent diabetes mellitus and tobacco use.

Physical examination revealed bullae the same color as the patient's skin on an erythematous base (Figure 1 and Figure 2). The bullae were in different stages, with some tense and filled with fluid and others flaccid and drained. The lesions varied in size from 1 to 10 cm and were located across the body, with the largest clusters on his arms, legs, chest, and back. No bullae were present on the patient's face, mouth, mucosa, or anal and genital areas. No excoriations were noted.