Bullous pemphigoid

Diagnosis: Bullous pemphigoid

Bullous pemphigoid

Clinical Presentation

Bullous pemphigoid

Clinical History

Elderly patient with pruritic urticarial plaques progressing to tense bullae. May be preceded by eczematous or urticarial phase without blisters. Medication history for potential drug triggers.

Treatment

Localized: potent topical corticosteroids (clobetasol). Generalized: systemic corticosteroids + steroid-sparing agent (dapsone, doxycycline, mycophenolate, azathioprine, rituximab for refractory cases). Anti-BP180 titers for monitoring.

Differential Diagnosis

• Pemphigus vulgaris • Linear IgA bullous dermatosis • Dermatitis herpetiformis • Epidermolysis bullosa acquisita • Bullous drug eruption • Erythema multiforme • Bullous lupus erythematosus

Key Learnings

• Most common autoimmune blistering disease — IgG against BP180 and BP230 (hemidesmosomes) • Subepidermal blister — tense bullae that are less fragile than pemphigus • Nikolsky sign is negative (positive in pemphigus) • DIF shows linear IgG and C3 at the dermal-epidermal junction • Salt-split skin: antibodies bind to the epidermal (roof) side • Drug-induced BP: DPP-4 inhibitors (gliptins), PD-1 inhibitors, diuretics • Often occurs in elderly patients (>60 years)

Tags: Bullous pemphigoid, dermatologist, dermatology