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Patient Case: Bullous Pemphigoid

Patient Case: Bullous Pemphigoid

Discussion

A 72-year-old man presents to the dermatology clinic with a three-month history of itchy, tense blisters on his arms, abdomen, and thighs. He initially noticed red, raised patches that later developed into large, fluid-filled blisters. Unlike previous skin rashes he has had, these blisters do not rupture easily. He denies any fever, mouth ulcers, or new medications.

His past medical history includes hypertension and osteoarthritis, and he has been on amlodipine and ibuprofen for several years.

On examination, the patient has multiple tense bullae on an erythematous base, primarily on the trunk and extremities, with some areas of crusting. Mucosal involvement is absent, and a Nikolsky sign is negative (blisters do not shear off with slight pressure).

A clinical diagnosis of bullous pemphigoid is suspected. A skin biopsy with direct immunofluorescence confirms the presence of linear IgG and C3 deposition along the basement membrane, supporting the diagnosis. The patient is started on high-dose topical corticosteroids and systemic immunosuppressive therapy to control the disease.

Questions
  1. What is the most likely diagnosis in this patient?
    a) Pemphigus vulgaris
    b) Bullous pemphigoid
    c) Dermatitis herpetiformis
    d) Stevens-Johnson syndrome
  2. Which of the following clinical features helps differentiate bullous pemphigoid from pemphigus vulgaris?
    a) Presence of oral mucosal erosions
    b) Positive Nikolsky sign
    c) Tense bullae on an erythematous base with negative Nikolsky sign
    d) Presence of pruritic urticarial plaques without blisters
  3. Which diagnostic test is most useful for confirming bullous pemphigoid?
    a) Direct immunofluorescence of skin biopsy
    b) Bacterial culture of blister fluid
    c) Tzanck smear of the blister base
    d) Complete blood count (CBC)
  4. What is the first-line treatment for localized bullous pemphigoid?
    a) High-dose systemic corticosteroids
    b) Topical corticosteroids
    c) Oral antibiotics
    d) Antihistamines only
Reveal answers

Answers

  1. (b) Bullous pemphigoid
    • The patient’s tense, fluid-filled bullae, absence of mucosal involvement, and negative Nikolsky sign suggest bullous pemphigoid, an autoimmune blistering disease.
  2. (c) Tense bullae on an erythematous base with negative Nikolsky sign
    • Bullous pemphigoid presents with tense blisters that do not rupture easily and has a negative Nikolsky sign, while pemphigus vulgaris has flaccid blisters and a positive Nikolsky sign.
  3. (a) Direct immunofluorescence of skin biopsy
    • Direct immunofluorescence showing linear IgG and C3 deposition along the basement membrane is the gold standard for diagnosing bullous pemphigoid.
  4. (b) Topical corticosteroids
    • For localized bullous pemphigoid, high-potency topical corticosteroids (e.g., clobetasol) are the first-line treatment. Severe cases may require systemic corticosteroids or immunosuppressants.