Coma blisters

A 53-year-old woman presented to our hospital Emergency Department with reduced conscious level, shallow respirations, and miosis. She had a clinical history of diabetes, hypertension, obesity, and sleep apnoea, and had recently been self-administering co-codamol (acetaminophen 500 mg/ codeine 30 mg). Our initial diagnosis was hypoventilatory respiratory failure exacerbated by opiate toxicity, and she was treated with intravenous naloxone and non-invasive ventilatory support. Twenty-four hours later, respiration had improved, but a bullous rash had developed over her right forearm (Fig. 1). There was minimal erythema, and skin involvement was characterized by blisters of varying age that were superficial and burst on minimal abrasion. The rash was confined to the right upper limb, and gradually resolved over 72 h without any specific treatment.