Bullous Pemphigoid: A case report

A. Mahalakshmi

Physician assistant – Department of General Medicine, Kauvery Hospital, Cantonment, Trichy

Abstract

Bullous pemphigoid is an autoimmune skin disease. It is most commonly found in the elderly and immunological criteria. It presents clinically with consists of fluid filled blisters which are large size that develop on areas of skin such as trunk, lower abdomen, upper arm, upper thighs.

We report our patient who had developed fluid filled lesions over trunk, upper arm, abdomen, chest and back, which on scratching, lead to erosion and healed with milia. Efforts were made to prevent bullae on skin surface by treating the patient with systemic corticosteroids, antibiotics and topical creams. Bullous pemphigoid is caused by autoantibodies to IgG & IgE. This article will discuss about a case on bullous pemphigoid.

Case Presentation

A 76 years aged female patient was admitted in dermatology department with chief complaints of blisters associated with severe itching all over the body- neck, chest, trunk, back, and upper arm, for past  one month.

H/o Decreased activity, mostly bedridden for past 1 year. No h/o fever/vomiting

On examination

GCS – E4V2 M5

Patient was vocalizing, conscious, respond to commands, Severe bradykinesia +

BP – 100/60 mmHg

PR- 87/min

SPO2- 99% in RA

Physical Examination

GRBS – 124 mg/dl

CVS- S1 S2 +

RS- B/LAE +

PA – Soft

Past Medical History

Parkinsonism – 1 year on tab. Syndopa 275mg TDS. All blood investigations were normal.

Diagnosis

Patient was diagnosed with Bullous Pemphigoid; the patient was treated with the following, which included:

Inj. Dexamethasone IV – 1-0-1

Inj. Cefoperazone + Sulbactam IV – 1-0-1 and other supportive measures.

Discussion

Bullous pemphigoid is the most frequent autoimmune disease which is more often seen in the older age group. It is characterized by large tense blisters filled with clear fluid but may be hemorrhagic. arising on erythematous base or normal skin. In general, it  occurs in lower abdomen, upper arm, upper thighs and trunk.

The exact etiology is unknown but some predisposing genetic factor, viral infection, physical agent like radiation therapy, or light, electrical burns and other environmental conditions have been involved in the induction of bullous pemphigoid. Bullous pemphigoid is  an autoantibody (IgG) mediated blistering skin disease in which basal keratinocytes and mucosal membrane loss occurs. Cell adhesion to the basement membrane, triggering inflammatory response by releasing chemokines and cytokines like IL I6 and IL2 with the characteristic blistering lesion is thought to be the pathology. The mechanism involved could be  the production of autoantibodies and increased blood glucose levels causing increased skin fragility.

Patients are treated depending upon the symptoms of the disease, mostly systemic corticosteroids are the first choice of drug. Antibiotics, antihistamines, and topical ointment are used to avoid re-occurrence of disease. Treatment with corticosteroids may need to be maintained for a long period, avoiding side effects.

Before Treatment

After Treatment

Conclusion

Bullous pemphigoid is a rare autoimmune life-threatening disease which can lead to significant morbidity and mortality. The patient responded well to the use of systemic corticosteroids, antihistamines, antibiotics and topical ointment. Hence it was proved that the treatment is safe and effective in alleviating the clinical manifestations of disease. Counselling  the patient regarding appropriate use of drugs and maintaining good hygienic condition of skin may avoid re-occurance of bullous pemphigoid and achieve better clinical outcomes for  the patient.

 

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