A case report on Bullous Pemphigoid(BP)

Gracelin Jebamalar1, Arputha Mary2

1Senior staff nurse, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

2Assistant Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

Background

Bullous pemphigoid is a rare skin condition causing large, fluid – filled blisters.  It is an autoimmune pruritic skin disease that most commonly affects people over 60 years old. But it may appear in younger people, too. It is more common in the Western world, and uncommon in the Far East. Bullous pemphigoid affects men and women equally. That involves the formation of blisters (bullae) in the space between the epidermal and dermal skin layers.

Bullous pemphigoid is relatively rare. There are between 2.4 and 23 cases per 1 million people in the general population. Bullous pemphigoid usually appears on the stomach, chest, arms, legs, groin or armpits. It may occur in the mouth as sores. The risk of developing this condition increases with age.

Who does bullous pemphigoid affect?

Bullous pemphigoid may affect those with a neurological disorder, including:

  • Dementia.
  • Parkinson’s disease.
  • Stroke
  • Epilepsy.
  • Multiple sclerosis.

Bullous pemphigoid is not contagious. It cannot spread to another person through skin-to-skin contact.

Case Presentation

A 67 years aged male was admitted with the complaints of generalized ulcerated lesions for twenty days, initially as blister that spontaneously ruptured (scab formation). History of burning micturition for 20 days, and of fever for 20 days, high grade, not associated with chills.  Also, history of two episodes of loose stools, not blood stained., and history of vomiting 10 days back. No history of bladder disturbances or bleeding manifestations.

Initially he was admitted in JIPMER hospital and found to have increased sodium, deranged RFT, decreased albumin, and increased IgE. Treated with oral steroids, antihistamines and then came here for further management.

Patient had history of diabetes mellitus, systemic hypertension, and coronary artery disease. Surgical history of PTCA (2012).

The Bullous pemphigoid had a remitting and relapsing course, and was on irregular treatment.

On examination

On examination, patient was conscious and oriented, afebrile

PR: 90 b/min, RR: 22 b/min. SpO2: 100% in Room air, BP: 170/70 mmhg

CVS: S1 S2 (+), RS: NVBS, PA: Soft

GRBS: 115 mg/dl

Blood investigations were done like CBC, Electrolytes, LFT, RFT, PT/INR, APTT, Serology, Ca125, AFP, and Blood grouping & typing. ECG & chest X-ray were also taken.

Management

Lab investigations showed neutrophil predominant leukocytosis, elevated ESR, hyperalbuminemia and hyponatremia.

Dermatologist opinion was Bullous pemphigoid. He was initiated on systemic corticosteroids and advised to undergo further definitive investigations to confirm the diagnosis and to guide long-term management.

BPAg 180 was positive. When BPAg180 is “positive” in a test, it usually indicates the presence of autoantibodies (antibodies that mistakenly attack the body’s own tissues) in BP. He was continued on current line of management.

Plastic surgeon’s opinion was obtained for new onset larger lesions, he advised conservative management. Applied hydro heal and bactigrass dressing. Serial monitoring of serum electrolytes done, corrections given appropriately.

Blood and urine cultures were sterile. He was managed with IV antibiotics

  • Cefoperazone & Sulbactum 1.5 gm BD).
  • Systemic steroids (Tab. Wysolone 10 mg 2-0-0).
  • Daily basis given saline soaks,
  • Proper cleaning, liquid paraffin application,
  • Hydroheal am cream was applied for erosions.
  • Then dermatologist advised to give Diprobate ointment and increase steroids as Tab. Wysolone 10 mg 2 ½ -0-0 (if new blisters developed).

He improved symptomatically and was carefully mobilized. The ulcerated lesions subsided well.  Finally, the patient was discharged in stable condition

Dietary Recommendations

Soft, bland foods: Patients are advised soft foods like soups, mashed potatoes, and yogurt to minimize irritation to oral blisters. Dermatologists suggest avoiding crunchy, sharp, acidic, or hot foods, as these can exacerbate discomfort.

Life styles and home remedies

The following wound care advice was given,

  • Limiting activities. Blisters on the feet and hands can make it difficult to walk or to go about daily tasks. The itching may make it hard to sleep. Advised the patient to change the routine until the blisters are under control.
  • Protecting the skin, advised not try to scratch the affected area. And protect the skin from too much heat and sun, even on cool, cloudy or hazy days.
  • Wear loose-fitting cotton clothes to protect the skin.
  • Do not eat hard and crunchy foods if there are blisters in their mouth.

Psychological support

  • Psychological support is important for bullous pemphigoid patients The disease causes emotional distress, impacts on daily life and on self-esteem, Treatment-related anxiety needs coping strategies
  • Seeking psychological support, including therapy and support groups, can help patients cope with the emotional challenges associated with BP.

Conclusion

Early recognition and accurate diagnosis are crucial for preventing complications. Supportive care, patient education, and multidisciplinary management improve quality of life. With timely intervention, disease progression can be controlled, and prognosis is generally favorable.

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