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Palmoplantar target lesions are another feature Refer to the related chapter Paraneoplastic pemphigus Bullous pemphigoid (figure 37) Mainly affects older patients There may be a prodromal phase with itch and fixed urticarial-like lesions Tense bullae can develop anywhere on the skin and are especially widespread on the trunk, proximal limbs and flexures Mucosal symptoms tend to be mild Refer to the related chapter Bullous pemphigoid Mucous membrane pemphigoid (figure 38) Mainly affects mucosal surfaces , however, the skin is involved in approximately one-quarter of cases In the skin it can cause either a generalised bullous eruption similar to bullous pemphigoid, or localised areas of scarring blisters, predominantly of the scalp and of the skin close to affected mucosal surfaces Refer to the notes below on mucosal surfaces Hands, feet and limbs Hands only Porphyria cutanea tarda and pseudoporphyria (figures 39-40) Causes skin fragility and bullae on the backs of hands and bald areas of the scalp Lesions heal slowly and often scar Milia and areas of hyperpigmentation may develop Pseudoporphyria , in which porphyria-like blistering of exposed skin on the extremities occurs in the absence of abnormal porphyrin metabolism, may be caused by a number of drugs, especially furosemide, nalidix acid and naproxen Refer to the chapter Porphyria Hands and feet Epidermolysis bullosa Epidermolysis bullosa simplex (figure 41) Is characterised by painful blisters on the palms of the hands and soles of the feet that develop after mild or moderate physical activity

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