Blister-associated rashes in children are divided into two groups: vesicular rashes and bullous rashes. By definition, vesicles are fluid-filled lesions that are no more than 0.5 cm in diameter and bullae are blistering lesions that are greater than 0.5 cm in diameter. They may be seen in the skin or mucous membranes and may be round or have irregular borders. Compared with adult skin, that of pediatric patients is very prone to blistering. Vesicular rashes are common in the pediatric population, and are discussed elsewhere. Bullous rashes, on the other hand, are a relatively uncommon class of pediatric skin disorders.

Bullae form secondary to fluid accumulation between cells in the epidermis or between the epidermal and dermal (subepidermal) skin layers. Bullous skin disorders can be divided into congenital disorders, such as congenital epidermolysis bullosa (EB); infectious disorders, such as bullous impetigo and staphylococcal scalded skin syndrome (SSSS), immunologic disorders, such as Stevens–Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), chronic bullous dermatosis/disease of childhood, and toxin-mediated such as phototoxic or venom reactions.

• Systemic symptoms such as fever, fussiness, ill appearance, and diffuse skin involvement are associated with SJS, TEN, and SSSS.

• Congenital blistering diseases, such as EB, are often present at birth or during the newborn period.

• Bullae appearing in the first few days or weeks of life may be secondary to EB, bullous impetigo of the neonate, or SSSS.

• In EB, bullae form at sites of minor skin trauma or friction.

• With the exception of TEN, the more common bullous skin disorders involve only the epidermis and may cause temporary hyperpigmentation and lichenification but do not tend to cause permanent scarring.

• Although many believe SJS and TEN are a continuum of the same disease, one convention is that infectious agents are causally related to SJS, and drugs to TEN.

• Chronic bullous disease of childhood is rare, but it is the most common acquired autoimmune bullous disease in children; it is only rarely present in the neonate.

• Photosensitivity rashes are seen on exposed parts of the body, primarily the face and extremities.

• Bullous impetigo differs from nonbullous impetigo. Distribution is more truncal with a predilection for intertriginous areas, including the diaper area.

• Nikolsky sign—the ability to use gentle traction with a finger to separate the upper epidermis from the underlying skin in bullous lesions—is commonly seen in systemic bullous disorders, including TEN, SSSS, and EB.

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