Clinicopathologic challenge A tale of an acral bullous eruption Soumaya Gara 1 , MD, Anissa Zaouak 1 , MD, Ehsen Ben Brahim 2 , MD, Fatma Khanchel 2 , MD, Samy Fenniche 1 , MD and Houda Hammami 1 , MD 1 Department of Dermatology, Research Unit “Genodermatoses and cancers” LR12SP03, Habib Thameur Hospital, Tunis, Tunisia, and 2 Department of Pathology, Habib Thameur Hospital, Tunis, Tunisia Correspondence Soumaya Gara, MD Department of Dermatology Habib Thameur Hospital 8 street Ali Ben Ayed Montfleury 1008, Tunis, Tunisia E-mail: Soumayagara33@gmail.com Conflict of interest: None. Funding source: None. doi: 10.1111/ijd.15340 What is your diagnosis? Clinical findings A 74-year-old male patient presented to our clinic for a 1-month history of a localized, itchy bullous eruption of both hands and feet. He had been previously diagnosed with pompholyx and had received topical steroids and antibiotic therapy with no improvement. He did not recall a preceding trauma or specific exposure to allergens or irritant products. His medical history was significant for high blood pressure, chronic obstructive pul- monary disease, and Parkinson’s disease. There was no history of immune blistering disorders. On examination, the patient was found to have multiple and tense bullae, round-oval in shape, some containing hemorrhagic fluid with large eroded and crusted areas on an erythematous skin. The lesions were sym- metrically distributed on the palms (Fig. 1a), soles, and the dorsa of both feet (Fig. 1b). The Nikolsky sign was negative. No other cutaneous or mucosal involvement was noted. Review of systems was otherwise within normal limits. Laboratory studies were remarkable for a moderate peripheral blood eosinophilia. Cultures for fungi and bacteria were negative. Histopathologic and immunopathologic findings Microscopic assessment of skin sections taken from a blister revealed a subepidermal clefting (Fig. 2a) with a focal Figure 1 (a) Bullae and large crusted erosions with hemorrhagic fluid over an erythematous skin of the palms. (b) Well-demarcated erythema with crusted erosions and tense bullae of the dorsal aspect of both feet ª 2020 the International Society of Dermatology International Journal of Dermatology 2020 1