Bullous Pemphigoid (Hemorrhagic)

This lesion erupted on a 58-year-old man's right palm, and several tense bullae also were visible on the trunk. The patient complained of mild pruritus. He had no history of similar lesions. A routine skin biopsy was performed, and the diagnosis of hemorrhagic bullous pemphigoid was made.

Drs Charles E. Crutchfield III and Eric J. Lewis of Minneapolis write that bullous pemphigoid is more common in the geriatric population, often beginning with pruritic, urticaria-like lesions that develop into tense bullae. It is a blistering disorder in which autoantibodies bind to proteins in the basement membrane of the skin, producing subepidermal splits or blisters. Because the split is deep, the blisters do not fracture easily and are often firm or tense, unlike the flaccid blisters and erosion seen in pemphigus vulgaris, where the splits occur much higher in the skin. As in this patient, hemorrhage can occur into the bullae, resulting in hemorrhagic bullous pemphigoid.

Anti-inflammatory medications, including corticosteroids and tetracycline (with inherent anti-inflammatory properties), and immunosuppressives are used to treat bullous pemphigoid. This patient's disease was successfully managed with a combination of tetracycline and niacinamide, a relatively new and effective treatment for bullous pemphigoid.