Bullous pemphigoid

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Bullous pemphigoid
Specialty Dermatology Edit this on Wikidata

Bullous pemphigoid is an acute or chronic autoimmune skin disease, involving the formation of blisters, more appropriately known as bullae, at the space between the epidermis and dermis skin layers. It is classified as a type II hypersensitivity reaction, with the formation of anti-hemidesmosome antibodies.

Signs and symptoms[edit]

Clinically, the earliest lesions may appear urticarial (like hives), but could also appear dermatitic, targetoid, lichenoid, nodular, or even without visible rash (essential pruritus)[1]. Tense bullae eventually erupt, most commonly at the inner thighs and upper arms, but the trunk and extremities are frequently both involved. Any part of the skin surface can be involved. Oral lesions are present in a minority of cases.[2] The disease may be acute, but typically will wax and wane. Several other skin diseases may have similar symptoms. However, milia are more common with epidermolysis bullosa acquisita, because of the deeper antigenic targets. A more ring-like configuration, with a central depression or centrally collapsed bullae may indicate linear IgA disease. Nikolsky's sign is negative unlike pemphigus vulgaris where it is positive.


In most cases of bullous pemphigoid, no clear precipitating factors are identified.[2] Potential precipitating events that have been reported include exposure to ultraviolet light and radiation therapy.[2][3] Onset of bullous pemphigoid has also been associated with certain drugs, including furosemide, nonsteroidal anti-inflammatory agents, DPP-4 inhibitors, captopril, penicillamine, and antibiotics.[3]


The bullae are formed by an immune reaction, initiated by the formation of IgG[4] autoantibodies targeting Dystonin, also called Bullous Pemphigoid Antigen 1,[5] and/or type XVII collagen, also called Bullous Pemphigoid Antigen 2,[6] which is a component of hemidesmosomes. A different form of dystonin is associated with neuropathy.[5] Following antibody targeting, a cascade of immunomodulators results in a variable surge of immune cells, including neutrophils, lymphocytes and eosinophils coming to the affected area. Unclear events subsequently result in a separation along the dermoepidermal junction and eventually stretch bullae.


A photo of legs covered in popped blisters caused by bullous pempigoid. The blisters cover his entire body, but subject preferred to stay clothed.

Diagnosis is based on two biopsies of the skin, one submitted for routine H&E staining and one for immunofluorescence studies.


Treatments include class I topical steroids (clobetasol, halobetasol, etc.) which in some studies have proven to be equally effective as systemic, or pill, therapy and somewhat safer.[2] However, in difficult-to-manage or widespread cases, systemic prednisone and powerful steroid-free immunosuppressant medications, such as methotrexate, azathioprine or mycophenolate mofetil, may be appropriate.[2][7] Some of these medications have the potential for severe adverse effects such as kidney and liver damage, increased susceptibility to infections, and bone marrow suppression.[8] Antibiotics such as tetracycline or erythromycin may also control the disease, particularly in patients who cannot use corticosteroids.[7] The anti-CD20 monoclonal antibody rituximab has been found to be effective in treating some otherwise refractory cases of bullous pemphigoid.[citation needed] A 2010 meta-analysis of 10 randomized controlled trials showed that oral steroids and potent topical steroids are effective treatments though their use may be limited by side-effects, while lower doses of topical steroids are safe and effective for treatment of moderate bullous pemphigoid.[8]

IgA-mediated pemphigoid can often be difficult to treat even with usually effective medications such as rituximab.[9]


Bullous pemphigoid may be self-resolving in a period ranging from several months to many years even without treatment.[2] Poor general health related to old age is associated with a poorer prognosis.[2]


Very rarely seen in children, bullous pemphigoid most commonly occurs in people 70 years of age and older.[2] Estimated frequency is seven to 14 cases per million per year, but has been reported to be as high as 472 cases per million per year in Scottish men older than 85.[2] At least one study indicates the incidence might be increasing in the United Kingdom.[10] Some sources report it affects men twice as frequently as women,[7] while others report no difference between the sexes.[2]

Many mammals can be afflicted, including dogs, cats, pigs, and horses, as well as humans. It is very rare in dogs; on average, three cases are diagnosed around the world each year.[citation needed]


Animal models of bullous pemphigoid have been developed using transgenic techniques to produce mice lacking the genes for the two known autoantigens, dystonin and collagen XVII.[5][6]

See also[edit]


  1. ^ Cozzani, Emanuele, et al. "Atypical presentations of bullous pemphigoid: Clinical and immunopathological aspects." Autoimmunity reviews 14.5 (2015): 438-445.
  2. ^ a b c d e f g h i j Wolff K, Goldsmith L, Gilchrest B, Stephen Katz, Amy Paller, David Leffell (17 October 2007). "Chapter 54. Bullous Pemphigoid". In Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ. Fitzpatrick's Dermatology In General Medicine, Two Volumes (7th ed.). Mcgraw-hill. ISBN 978-0-07-146690-5. Retrieved July 21, 2012. 
  3. ^ a b Lawrence S. Chan (2011). "Bullous Pemphigoid". eMedicine Reference. 
  4. ^ "Dorlands Medical Dictionary:bullous pemphigoid". Retrieved 2010-06-24. 
  5. ^ a b c "OMIM Entry - *113810 - DYSTONIN; DST". [permanent dead link]
  6. ^ a b "OMIM Entry - *113811 - COLLAGEN, TYPE XVII, ALPHA-1; COL17A1". [permanent dead link]
  7. ^ a b c ""Bullous Pemphigoid." Quick Answers to Medical Diagnosis and Therapy". Retrieved 2012-07-21. 
  8. ^ a b Kirtschig, Gudula; Middleton, Philippa; Bennett, Cathy; Murrell, Dedee F; Wojnarowska, Fenella; Khumalo, Nonhlanhla P (2010-10-06). "Interventions for bullous pemphigoid". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD002292.pub3. ISSN 1465-1858. 
  9. ^ He Y, Shimoda M, Ono Y, Villalobos IB, Mitra A, Konia T, Grando SA, Zone JJ, Maverakis E (2015). "Persistence of Autoreactive IgA-Secreting B Cells Despite Multiple Immunosuppressive Medications Including Rituximab". JAMA Dermatol. 151 (6): 646–50. doi:10.1001/jamadermatol.2015.59. PMID 25901938. 
  10. ^ Langan SM, Smeeth L, Hubbard R, Fleming KM, Smith CJ, West J (2008). "Bullous pemphigoid and pemphigus vulgaris--incidence and mortality in the UK: population based cohort study". BMJ. 337: a180. doi:10.1136/bmj.a180. PMC 2483869Freely accessible. PMID 18614511. 

Further reading[edit]

  • Wojnarowska, F; Kirtschig, G; Highet, AS; Venning, VA; Khumalo, NP; British Association of, Dermatologists (Aug 2002). "Guidelines for the management of bullous pemphigoid". The British Journal of Dermatology. 147 (2): 214–21. doi:10.1046/j.1365-2133.2002.04835.x. PMID 12174090. 

External links[edit]

External resources