A 63-year-old man is evaluated for a skin eruption that is itchy and worsening over the past several weeks. His medical history is unremarkable, and he takes no medications. On physical examination, vital signs are normal. There are tense bullae on an erythematous base and scattered erosions on the trunk and extremities.

What is the most appropriate diagnostic test to perform next?

1. Biopsy of lesional skin for direct immunofluorescence
2. Biopsy of lesional skin for histology
3. Biopsy of lesional skin for histology and perilesional skin for direct immunofluorescence
4. Biopsy of perilesional skin for histology and direct immunofluorescence

The most appropriate diagnostic test for the man's skin condition is a biopsy of both lesional skin (skin with visible changes in appearance) for histology and perilesional skin (skin close to the lesion) for direct immunofluorescence.

Explanation:

In the case of a 63-year-old man with tense bullae on an erythematous base and scattered erosions on the trunk and extremities, the most appropriate diagnostic test to perform next is a Biopsy of lesional skin for histology and perilesional skin for direct immunofluorescence (Option 3). This combination of tests is vital in helping clinicians definitively diagnose skin conditions.

Biopsy of lesional skin for histology allows for the examination of the cellular structure and arrangement in the affected area, which can point to specific types of skin conditions. The direct immunofluorescence of perilesional skin, on the other hand, helps in the detection of certain immune-mediated skin diseases.

This approach is particularly useful in evaluating for conditions like Bullous Pemphigoid, a blistering skin condition common in the elderly. In this condition, immune cells attack an area just below the outer layer of skin, leading to the tense bullae (blisters) as seen in the patient.

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