History: I must admit my first thought when I looked at this rash and the history and the distribution of this rash was that he had a severe phytophotodermatitis but the more I looked at the nature of the bullae the more it looked like the bullous variant of Sweet's syndrome.
Phytophotodermatitis and Sweet's syndrome were the two differentials I gave to the pathologist when I submitted a biopsy specimen.The histo is shown below.
This condition is a Pyoderma gangrenosum variant .Weedon described Pustular Vasculitis of the hands which looks very similar to this man's presentation.He was treated with high dose steroids.There was no response to iv antibiotics.The last photo shows his hands after 10 days treatment.