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2003:69:4;294-295
PMID: 17642917

Non-bullous variant of bullous pemphigoid: Role of immunofluorescence in diagnosis

A Goel, C Balchandran, SD Shenoi, SB Pai
 Department of Skin and STD, Kasturba Medical College, Manipal - 576119, India

Correspondence Address:
C Balchandran
Department of Skin and STD, Kasturba Medical College, Manipal - 576119
India
How to cite this article:
Goel A, Balchandran C, Shenoi S D, Pai S B. Non-bullous variant of bullous pemphigoid: Role of immunofluorescence in diagnosis . Indian J Dermatol Venereol Leprol 2003;69:294-295
Copyright: (C)2003 Indian Journal of Dermatology, Venereology, and Leprology

Abstract

An elderly lady presented with persistent and unexplained excoriated lesions on trunk and limbs of 4 years duration. No vesicles or bullae ever developed during the course of the disease. Histopathology showed nonspecific dermatitis. The diagnosis of bullous pemphigoid was confirmed by immunofluorescence. The patient responded well to topical steroids and dapsone.
Keywords: Bullous pemphigoid, Non-bullous variant, Immunofluorescence
INTRODUCTION

Bullous pemphigoid (BP) is a subepidermal blistering disease of the elderly, presenting as tense bullae with flexural predominance and variable pruritus. Unusual variants include vegetating, localized, childhood, urticarial and nodular types. BP can thus mimic a variety of clinical conditions. Due to the nzonvesicular nature of the disease in these forms, the presence of itching and nonspecific histopathology, these cases present a diagnostic problem. We report a case of bullous pemphigoid with itchy excoriated papular lesions who was diagnosed by immunofluorescence.

CASE REPORT

A 72-year-old lady presented with itchy, erythematous papules, plaques and excoriations with crusting of 4 years′ duration over the trunk, abdomen and extremities [Figure - 1]. The lesions had started on the upper limb and then progressed to involve the lower limb and the lower abdomen. There was flexural predominance, with sparing of the palms, soles, face and mucosae. Lesions on the extremities showed crusting. She also developed dermatitic changes to a plaster cast that had been applied to a leg 6 weeks earlier.

Differential diagnoses of dermatitis, scabies and dermatitis herpetiformis were considered. A therapeutic trial with antibiotics, anti-scabietics and antihistamines showed only mild and temporary improvement. Histopathology from lesional skin showed features of dermatitis with intraepidermal vesiculation. On direct immunofluorescence, strong IgG and C3 deposits at the dermoepidermal junction were seen. Salt split skin sections showed localizaion of immunoreactants to the roof [Figure - 2]. Thus the diagnosis of bullous pemphigoid was confirmed. The patient was started on topical steroids and dapsone 100 mg daily. Within a month, her itching totally subsided and the lesions healed with residual hyperpigmentation. Subsequently the patient was lost for follow up.

DISCUSSION

Bullous pemphigoid can present as urticarial papules, plaques and excoriations that can precede the onset of blisters by weeks, months or even longer. Later, blistering may arise on normal skin as well as the sites of previous lesions.[1] These cases are usually associated with peripheral blood eosinophilia.[2] Immunofluorescence of the lesional skin is usually positive in such cases. Unusual forms of pemphigoid are vegetating, nodular, hyperkeratotic, localized, childhood, polymorphic and urticarial.[2],[3] BP can also present as erythematous and eczematous lesions.[4] Clinically it can simulate subacute prurigo,[5] scabies,[6] dermatitis herpetiformis or prurigo nodularis.

This case highlights the need to consider the possibility of bullous pemphigoid when an elderly patient presents with persistent, unexplained, excoriated papules. A high index of suspicion coupled with appropriate investigations like immunofluorescence may be required as histopathology is usually nonspecific. Also, follow up of such cases is important as frank vesicobullous lesions could develop later.[4]

References
1.
Ross JS, Mckee PH, Smith NP, et al. Unusual variants of pemphigoid: from pruritus to pemphigoid nodularis. J Cut Path 1992;19:212-6.
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Strohal R, Rappersberger K, Pehamberger H, et al. Nonbullous pemphigoid: Prodome of bullous pemphigoid or a distinct pemphigoid variant? J Am Acad Dermatol 1993;29:293-9.
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Bourke, et al. Pemphigoid nodularis: a report of 2 cases. Clin Exp Dermatol 1994;19:496-9.
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Wolf, et al. Nonbullous bullous pemphigoid. Int J Dermatol 1992;31:498-500.
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Amato DA, Silverstein J, Zitelli J. The prodome of bullous pemphigoid. Int J Dermatol 1988;27:560-3.
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Bhawan J, Milestone E, Malhotra R, et al. Scabies presenting as bullous pemphigoid-like eruption. J Am Acad Dermatol 1991;24:179.
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