Bullosis diabeticorum (BD) is an uncommon dermatologic complication occurring in people with diabetes. In the United States its reported prevalence is approximately 0.16%–0.5% among diabetic individuals. BD classically produces tense blisters, often in acral locations, but presentations can be variable. This report documents an atypical case in which BD progressed to ulceration in the setting of chronic, poorly controlled type 2 diabetes mellitus (T2DM) and important social barriers to care.
The patient was a 41-year-old man with long-standing, poorly controlled T2DM complicated by stage II chronic kidney disease (CKD) and chronic erectile dysfunction. His glycemic control had been highly variable over time, with documented hemoglobin A1c values ranging from greater than 14% down to 7.8% at different encounters; social determinants were noted to influence these fluctuations. His diabetes regimen included metformin and titration of basal insulin. For erectile dysfunction he received phosphodiesterase-5 inhibitors. The case emphasizes multimorbidity and social factors contributing to disease trajectory and adherence.
Approximately two months after an initial visit for ongoing management, the patient developed blisters characterized by a non-erythematous base, without surrounding redness. The lesions were described as nonpainful and nonpruritic, and they ruptured easily, leaving scabs. The largest lesion was measured at 7.2 × 3.6 × 0.1 cm and contained yellow slough, features interpreted as ulcerative bullosis diabeticorum in this clinical context. No clinical findings suggesting local infection were reported.
Laboratory evaluation demonstrated renal involvement: the patient had an elevated albumin-to-creatinine ratio and a decreased estimated glomerular filtration rate, consistent with CKD. The clinical team performed testing that excluded peripheral neuropathy and venous-related causes of ulceration. However, no skin biopsy or direct immunofluorescence testing was performed; therefore the diagnosis remained clinical and was supported primarily by the history of uncontrolled diabetes and the characteristic lesion morphology.
Management of the patient included optimization of diabetes medications with continued metformin and titration of basal insulin. Erectile dysfunction was managed with phosphodiesterase-5 inhibitors as noted. Because there were no clinical signs of infection, wound cultures were not obtained and systemic antibiotic therapy was not initiated.
Initial wound care adherence was suboptimal. After re-engagement with wound management, care was transitioned to twice-daily moist-to-dry dressings using quarter-strength Dakin's solution. The report describes this topical wound-care approach as part of the conservative management strategy for the ulcerative lesions.
One month after implementing the Dakin's solution dressings and after improved adherence, the patient demonstrated clinical improvement in wound appearance and a reduction in fasting glucose values. These outcomes were reported in the clinical follow-up cited in the case. The absence of treatment for infection was based on lack of clinical indicators and the decision not to obtain cultures.
The diagnosis in this case was clinical. Although neuropathy and venous ulcers were tested for and excluded, the authors explicitly reported that no biopsy or direct immunofluorescence studies were performed. Because those diagnostic modalities were not obtained, histopathologic confirmation and exclusion of other vesiculobullous disorders using immunofluorescence were not available. The report therefore acknowledges the limitation that the diagnosis rests on clinical features combined with the context of poorly controlled diabetes rather than on tissue-based confirmation.
This case highlights several clinically relevant points: BD can present atypically and progress to ulceration, especially in the context of long-standing, poorly controlled T2DM and concomitant organ dysfunction such as CKD. Social determinants of health may substantially influence glycemic control and adherence to wound care, affecting clinical outcomes. Conservative wound management with topical antiseptic dressings (quarter-strength Dakin's solution moist-to-dry dressings, in this case) was associated with improvement when adherence improved. The report underscores the importance of comprehensive care that addresses metabolic control, wound management, and social barriers; it also notes diagnostic limitations when biopsy and immunofluorescence are not performed.
Limitations in the available data include lack of histologic confirmation and absence of wound cultures because clinical infection was not suspected. Details such as the timeline of all HbA1c measurements, specific social barriers encountered, and long-term follow-up beyond the one-month improvement were not reported in the source material.
Overall, the case serves as a reminder that dermatologic complications of diabetes, though uncommon, can be severe and are influenced by systemic disease control and access to care. Clinicians should consider both clinical features and the broader psychosocial context when diagnosing and managing suspected bullosis diabeticorum.