Bullous Pemphigoid Treatment Modalities and Management

Lo Schiavo et al. describes bullous pemphigoid as the most common of the pemphigoid disorders.1 It is an autoimmune variant condition that typically presents with subepidermal blistering. Major causes include genetic predisposition, age, adverse responses to medication, infections, as well as physical and viral agents. These stimulate an immune response cascade producing the characteristic blistering appearance that patients present with.1 Miyamoto et al. discuss that there is a non-bullous presentation that precedes the manifestation involving intense pruritis followed by urticarial plaques.2 There is rarely mucosal involvement but it has been reported. The current standard of care includes the use of systemic glucocorticoids and potent topical corticosteroids; oral tetracyclines such as Doxycycline are most often used to treat this condition.7 A study comparing oral Doxycycline and oral Prednisolone in treating bullous pemphigoid found that Prednisolone is not superior to Doxycycline for treatment based on a six-week short term trial on blisters and life-threatening events for patients. Doxycycline has also proven to be a safer long-term option.8 First line recommendations include high potency topical steroids such as Clobetasol cream for mild to moderate severity and a systemic steroid such as Prednisone for moderate to severe severity. The second line treatments for mild to moderate include Doxycycline and Dapsone. For moderate to severe disease states Methotrexate, Azathioprine, and Mycophenolate mofetil are recommended. For severe cases intravenous immunoglobulin, Rituximab and Omalizumab are recommended. Combination therapies can improve the quality of life for a patient without impairing the comorbidities.2 Ultimately, the evidence suggests the use of various modalities in treating this condition, leaving the decision of what to prescribe at the discretion of the medical provider in determining best practice for each patient on a case-by-case basis