Bullous Pemphigoid in a 49-Year-Old Woman

August 1, 2006

For several weeks, a 49-year-old woman had had large, tense, persistent blisters on the arms and trunk. She also had annular papulovesicular and urticarial lesions in these areas.

For several weeks, a 49-year-old woman had had large, tense, persistent blisters on the arms and trunk. She also had annular papulovesicular and urticarial lesions in these areas.

Hematoxylin and eosin staining and direct immunofluorescence of biopsy specimens from perilesional and uninvolved skin confirmed the diagnosis of bullous pemphigoid. This autoimmune disease generally affects persons older than 60 years. It is associated with presumably causative autoantibody production, as manifested by either the deposition of IgG along the basement membrane zone or, as in this patient, the deposition of C3.

The main condition in the differential diagnosis is pemphigus, which is characterized by weakness and malaise and by flaccid blisters that break easily. Obtaining biopsy specimens from both perilesional and uninvolved skin is necessary to distinguish bullous pemphigoid from its other mimics, such as erythema multiforme, acquired epidermolysis bullosa, bullosa diabeticorum, and dermatitis herpetiformis.

This patient was treated with prednisone, 40 mg twice a day for a week, which was tapered over a 3-week period and then replaced with dapsone. The prognosis is usually excellent, because the disorder is often self-limited.

(Case and photograph courtesy of Joe R. Monroe, PA-C, MPAS.)