Bullous pemphigoid

Also called BP

The elderly patient's autoimmune blistering disease: autoantibodies against hemidesmosomes split skin BELOW the epidermis, producing tense, sturdy bullae on urticarial bases, usually sparing the mouth.

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How it looks

Multiple tense, fluid-filled bullae arising on urticarial erythematous plaques over the flexural trunk and thighs of an elderly patient, with intact blisters and no mucosal erosions.

Bulla Wheal Erythema Discrete Flexural Truncal

Rose is the lesion, grey the pattern the lesions make, green where on the body it lives.

Across skin tones

The urticarial pre-bullous phase may read violaceous or hyperpigmented; tense bullae look similar across skin tones.

Symptoms & course

Itch, often intense and preceding blisters by weeks
Blisters are tense and may be tender

Diagnostic approach

Biopsy of blister edge for histology (subepidermal split, eosinophils)
Perilesional biopsy for direct immunofluorescence, linear IgG/C3 at the basement membrane
Serum anti-BP180/230 antibodies

Differential, and how to separate them

Pemphigus vulgaris
Favours it: Flaccid fragile blisters, prominent mouth erosions, younger
Against it: BP's blisters are tense and the mouth usually escapes
Contact dermatitis
Favours it: Exposure geometry, vesicles over bullae
Against it: BP is widespread, elderly, and biopsy-proven subepidermal

Management principles

Potent topical or systemic corticosteroids to gain control
Steroid-sparing agents for maintenance
Wound care for eroded areas

Clinical pearl: Tense blister + old age + itchy urticarial background + spared mouth: the four-legged table BP stands on.

Keep going

Try the case: Blisters that will not break Compare with Pemphigus vulgaris Back to the Atlas