Case Study by Spencer McClure ; Sandra Marchese Johnson , MD , FAAD
Drug-Induced Bullous Pemphigoid
We present a 76-year-old white man with a history of gastroesophageal reflux disease and type two diabetes ( last A1C was 7.3 in August 2018 ) who presented with pruritic erythematous patches and plaques on his scalp , back , and arms . The patient had a tonsillectomy in 1950 , an appendectomy in 1960 , and two carpal tunnel operations , with the first in 2007 and the second in 2014 . Other medical history of note is he received a tetanus and pneumococcal vaccination in 2014 , a varicella vaccination in 2015 , an influenza vaccination in 2017 , and he suffered from a deep vein thrombosis in June of 2018 . His medication regimen consists of Atorvastatin 10mg at night , Finasteride 0.5 mg in the morning , Glyburide / Metformin 10mg / 1000mg bid , Losartan / HCTZ 50mg / 12.5mg in the morning , Metanx bid , Tamsulosin HCL 0.4mg at night , and Warfarin 1mg at night .
On physical exam , patient had erythematous papules , some of which were urticarial in nature scattered on the back , scalp , and upper extremities bilaterally . ( Photo 1 ). Skin biopsies were performed that revealed superficial perivascular infiltrate with eosinophils and sub epidermal detachment . Direct immunofluorescence of perilesional skin revealed linear IgG and C3 deposits at the basement membrane zone without IgA , IgG or fibrin . Serum tests revealed BP 180s to be 31 U ( normal less than 9U ) and BP 230s to be 16
U ( normal is less than 9 ). The diagnosis of bullous pemphigoid was determined . The patient would get relief while taking oral prednisone with a minimum of 20 mg in the morning . Attempts at steroid-sparing agents were not successful including doxycycline , niacinamide , methotrexate ,
cyclosporine , ultraviolet light and mycophenolate mofetil . A second opinion was obtained from the UAMS Department of Dermatology . It was determined that the patient could be experiencing drug-induced bullous pemphigoid from his omeprazole for GERD or his underlying diabetes as well as diabetes treatments . The patient is still suffering with poorly controlled diabetes and poorly controlled bullous pemphigoid .
Bullous pemphigoid is the most common autoimmune blistering disorder , and it has become increasingly common over
Photo 1 : Erythematous papules , some of which are urticarial in nature scattered on the back .
the past decade . 1 It is part of a group of “ pemphigoid diseases ” that are defined by autoantibodies against the dermal-epidermal junction . It is predominantly associated with a more elderly patient population with onset usually occurring in the eighth decade . 2 Clinical presentation most commonly is described by tense , fluid-filled blisters and erythema . Severe pruritus is observed in almost all patients . Mild oral lesions can be observed in 10-20 % of patients but other mucosal surfaces are rarely effected . 3 Bullous pemphigoid has been commonly associated in literature with different conditions , but up to half of all patients with bullous pemphigoid also have a neurological disease with Parkinson ’ s , cerebrovascular disease , epilepsy , and multiple sclerosis being among the most common . 4 , 5 , 6 , 7 Onset of bullous pemphigoid is often variable . Occasionally trauma , burns , UV radiation , and drugs
92 • The Journal of the Arkansas Medical Society www . ArkMed . org