Ulcerative Bullosis Diabeticorum in a Man With Chronic, Uncontrolled Diabetes, Uncontrolled Erectile Dysfunction, and Significant Social Barriers to Care.

BACKGROUND Bullosis diabeticorum (BD) is a dermatologic, often acral, complication of diabetes, with a reported prevalence of approximately 0.16% to 0.5% among diabetic individuals in the United States. This case reports a man whose presentation was atypical in location and severity, progressing to ulceration. CASE REPORT A 41-year-old man with a history of poorly controlled type 2 diabetes mellitus (T2DM) complicated by stage II chronic kidney disease and chronic erectile dysfunction presented for ongoing management. His HbA1c values ranged from >14% to 7.8%, often influenced by social determinants. Two months later, he presented with blisters with a non-erythematous base (no surrounding erythema) that were non-painful, non-itchy, non-pruritic, and easily ruptured, forming scabs. The largest wound measured 7.2×3.6×0.1 cm, containing yellow slough, consistent with ulcerative BD. Labs showed elevated albumin-to-creatinine ratio and decreased estimated glomerular filtration rate, a measure of kidney function. Diabetes management included metformin and basal insulin titration, while erectile dysfunction treatment included phosphodiesterase-5 inhibitors. With no signs of infection, wound cultures were not obtained and antibiotic therapy was not initiated. Testing excluded neuropathy and venous-related ulcerations. However, as no biopsy or direct immunofluorescence testing was performed, the diagnosis was clinical, and based on a history of uncontrolled diabetes. Wound care transitioned the patient to twice daily quarter-strength Dakin's solution moist-to-dry dressings after initial non-adherence. One month later, the patient's wounds and fasting glucose showed improvement. CONCLUSIONS This case highlights the risks of uncontrolled T2DM with complications, particularly when compounded by social determinants.