Hypopyon sign in pemphigus vulgaris

A 50-year-old man presented to our clinic with oral erosions and vesiculobullous lesions over the body in a generalized distribution for 5 years. Few of these bullae had a bottom layer of pus and clear fluid on the top [Figure 1], demonstrating the “hypopyon sign.” Histopathology and direct immunofluorescence revealed features of pemphigus vulgaris. “Hypopyon sign” or “half-half blister” describes bullae with pus accumulating in the bottom half, especially when the patient stands upright. It is hypothesized that the hypopyon sign results from neutrophil accumulation inside the bullae, which accumulates in its bottom half. While classically described in subcorneal pustular dermatosis, dermatologists need to remember that the morphology can also be seen in other bullous disorders.^[1]

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Figure 1:

A flaccid blister with a collection of pus in the lower half and clear fluid on the top, demonstrating hypopyon sign.

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