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Bullous Pemphigoid Workup

  • Author: Lawrence S Chan, MD; Chief Editor: Dirk M Elston, MD  more...
Updated: Oct 14, 2015

Laboratory Studies

To establish a diagnosis of bullous pemphigoid, the following tests should be performed: histopathologic analysis from the edge of a blister and DIF studies on normal-appearing perilesional skin. If the DIF result is positive, indirect immunofluorescence (IDIF) is performed using the patient's serum. The preferred substrate for IDIF is salt-split normal human skin substrate.

Direct immunofluorescence studies

DIF studies demonstrate in vivo deposits of antibodies and other immunoreactants, such as complement. DIF tests usually demonstrate IgG (70-90% of patients) and complement C3 deposition (90-100% of patients) in a linear band at the dermal-epidermal junction. This pattern of immunoreactants is not specific for bullous pemphigoid and may be seen in cicatricial pemphigoid and epidermolysis bullosa acquisita. Bullous pemphigoid can be differentiated from these conditions by incubating the patient's skin biopsy sample in 1 mol/L salt prior to performing the DIF technique. This process induces cleavage through the lamina lucida. DIF on salt-split skin reveals IgG on the blister roof (epidermal side of split skin) in patients with bullous pemphigoid, while, in CP and EBA, the IgG localizes to the blister floor (dermal side of split skin).

The optimal location for DIF testing is normal-appearing perilesional skin. False-positive results can be observed when it is performed on lesional skin. Rarely, skin biopsy samples placed in transport media may yield false-negative results. This observation makes the use of fresh tissue the preferred substrate for DIF studies. See the image below.

Direct immunofluorescence study performed on a per Direct immunofluorescence study performed on a perilesional skin biopsy specimen from a patient with bullous pemphigoid detects a linear band of immunoglobulin G deposit along the dermoepidermal junction.

Indirect immunofluorescence

IDIF studies document the presence of IgG circulating autoantibodies in the patient's serum that target the skin basement membrane component. Seventy percent of patients with bullous pemphigoid have circulating autoantibodies that bind to split skin. The titer of circulating antibody is not correlated with the disease course.

IDIF studies can be used to detect the patient's IgG circulating autoantibodies that bind to the epidermal roof (upper part) of the salt-split skin substrate. See the image below.

Indirect immunofluorescence study performed on sal Indirect immunofluorescence study performed on salt-split normal human skin substrate with the serum from a patient with bullous pemphigoid detects immunoglobulin G class circulating autoantibodies that bind to the epidermal (roof) side of the skin basement membrane.

Other Tests

Experimental procedures available in research laboratories include direct and indirect immunoelectron microscopy, immunoblotting, immunoprecipitation, and enzyme-linked immunosorbent assay (ELISA), as follows:

  • Direct and indirect immunoelectron microscopy: Direct and indirect immunoelectron microscopy (immunoEM) ultrastructurally localize in vivo–bound IgG autoantibodies (direct immunoEM) or the binding site of circulating IgG autoantibodies (indirect immunoEM) at the basement membrane. IgG autoantibodies are detected at the hemidesmosome/upper lamina lucida areas of the skin basement membrane.
  • Immunoblotting [39] : Immunoblotting or Western blotting demonstrates reactivity of IgG in the sera of patients with proteins extracted from healthy human skin. The sensitivity of immunoblotting varies. In 75% of patients, a reaction occurs with the BP230 antigen, while, in 50% of patients, a reaction occurs with the BP180 antigen.
  • Immunoprecipitation: Like immunoblotting, immunoprecipitation demonstrates reactivity with BP230 and BP180. Unlike immunoblotting, immunoprecipitation is performed with native, rather than denatured, protein and is more sensitive. Immunoprecipitation is more difficult to perform and generally less available than immunoblotting. In most cases, immunoprecipitation detects autoantibodies specific for BP230 and BP180.
  • Enzyme-linked immunosorbent assay: The ELISA technique analyzes the bullous pemphigoid antigen-specific IgG autoantibodies in the patients' sera by using various lengths of recombinant proteins of the BPAg1 or BPAg2 antigens. In several reports, ELISA has been demonstrated to be highly sensitive and specific. [40] ELISA kits for testing bullous pemphigoid antigen-specific IgG autoantibodies are now available commercially. However, only a few medical centers currently offer this service. ELISAs based on recombinant proteins encoded by BP230 and BP180 have been developed. [41] These assays are not commercially available, but they offer promise as investigational tools. An ELISA based on BP180 demonstrates sera reactivity with more than 90% of patients with bullous pemphigoid.
  • Immunohistochemistry: If freshly frozen tissue is not available for direct immunofluorescence microscopy, formalin-fixed skin sections from patients with bullous pemphigoid may be used to examine the presence of C3 deposition along the epidermal basement membrane zone, for the confirmation of the diagnosis. [42]

Histologic Findings

The histopathologic examination demonstrates a subepidermal blister. The inflammatory infiltrate is typically polymorphous, with an eosinophil predominance. Mast cells and basophils may be prominent early in the disease course. Lesional skin biopsy specimens may reveal a predominantly neutrophilic infiltrate or minimal inflammation (pauci-inflammatory or cell-poor bullous pemphigoid).

Contributor Information and Disclosures

Lawrence S Chan, MD Dr Orville J Stone Professor of Dermatology, Head, Department of Dermatology, University of Illinois College of Medicine

Lawrence S Chan, MD is a member of the following medical societies: American Medical Association, Illinois State Medical Society, Society for Investigative Dermatology, Association of Professors of Dermatology, Chicago Dermatological Society, Dermatology Foundation, Microcirculatory Society, Alpha Omega Alpha, American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Julia R Nunley, MD Professor, Program Director, Dermatology Residency, Department of Dermatology, Virginia Commonwealth University Medical Center

Julia R Nunley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Nephrology, International Society of Nephrology, Medical Dermatology Society, Medical Society of Virginia, National Kidney Foundation, Phi Beta Kappa, Women's Dermatologic Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Board of Dermatology<br/>Co-Editor for the text Dermatological Manifestations of Kidney Disease .

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Russell Hall, MD J Lamar Callaway Professor And Chair, Department of Dermatology, Duke University Medical Center, Duke University School of Medicine

Russell Hall, MD is a member of the following medical societies: American Academy of Dermatology, American Federation for Medical Research, American Society for Clinical Investigation, Society for Investigative Dermatology

Disclosure: Received consulting fee from Novan for consulting; Received consulting fee from Stieffel, a GSK company for consulting; Received salary from Society for Investigative Dermatology for board membership.

  1. Waisbourd-Zinman O, Ben-Amitai D, Cohen AD, et al. Bullous pemphigoid in infancy: Clinical and epidemiologic characteristics. J Am Acad Dermatol. 2008 Jan. 58(1):41-8. [Medline].

  2. Terra JB, Potze WJ, Jonkman MF. Whole body application of a potent topical corticosteroid for bullous pemphigoid. J Eur Acad Dermatol Venereol. 2013 Apr 3. [Medline].

  3. Gual A, Iranzo P, Mascaró Jr JM. Treatment of bullous pemphigoid with low-dose oral cyclophosphamide: a case series of 20 patients. J Eur Acad Dermatol Venereol. 2013 Apr 13. [Medline].

  4. Iwasaki T, Olivry T, Lapiere JC, et al. Canine bullous pemphigoid (BP): identification of the 180-kd canine BP antigen by circulating autoantibodies. Vet Pathol. 1995 Jul. 32(4):387-93. [Medline].

  5. Xu L, O'Toole EA, Olivry T, et al. Molecular cloning of canine bullous pemphigoid antigen 2 cDNA and immunomapping of NC16A domain by canine bullous pemphigoid autoantibodies. Biochim Biophys Acta. 2000 Jan 3. 1500(1):97-107. [Medline].

  6. Olivry T, Borrillo AK, Xu L, et al. Equine bullous pemphigoid IgG autoantibodies target linear epitopes in the NC16A ectodomain of collagen XVII (BP180, BPAG2). Vet Immunol Immunopathol. 2000 Jan 31. 73(1):45-52. [Medline].

  7. Olivry T, Mirsky ML, Singleton W, et al. A spontaneously arising porcine model of bullous pemphigoid. Arch Dermatol Res. 2000 Jan. 292(1):37-45. [Medline].

  8. Chen R, Ning G, Zhao ML, et al. Mast cells play a key role in neutrophil recruitment in experimental bullous pemphigoid. J Clin Invest. 2001 Oct. 108(8):1151-8. [Medline].

  9. Hall RP 3rd, Murray JC, McCord MM, Rico MJ, Streilein RD. Rabbits immunized with a peptide encoded for by the 230-kD bullous pemphigoid antigen cDNA develop an enhanced inflammatory response to UVB irradiation: a potential animal model for bullous pemphigoid. J Invest Dermatol. 1993 Jul. 101(1):9-14. [Medline].

  10. Liu Z, Giudice GJ, Swartz SJ, et al. The role of complement in experimental bullous pemphigoid. J Clin Invest. 1995 Apr. 95(4):1539-44. [Medline]. [Full Text].

  11. Olivry T, Chan LS, Xu L, et al. Novel feline autoimmune blistering disease resembling bullous pemphigoid in humans: IgG autoantibodies target the NC16A ectodomain of type XVII collagen (BP180/BPAG2). Vet Pathol. 1999 Jul. 36(4):328-35. [Medline].

  12. Xu L, Robinson N, Miller SD, Chan LS. Characterization of BALB/c mice B lymphocyte autoimmune responses to skin basement membrane component type XVII collagen, the target antigen of autoimmune skin disease bullous pemphigoid. Immunol Lett. 2001 Jun 1. 77(2):105-11. [Medline].

  13. Liu Z, Diaz LA, Troy JL, et al. A passive transfer model of the organ-specific autoimmune disease, bullous pemphigoid, using antibodies generated against the hemidesmosomal antigen, BP180. J Clin Invest. 1993 Nov. 92(5):2480-8. [Medline]. [Full Text].

  14. Sitaru C, Schmidt E, Petermann S, Munteanu LS, Brocker EB, Zillikens D. Autoantibodies to bullous pemphigoid antigen 180 induce dermal-epidermal separation in cryosections of human skin. J Invest Dermatol. 2002 Apr. 118(4):664-71. [Medline].

  15. Thoma-Uszynski S, Uter W, Schwietzke S, Schuler G, Borradori L, Hertl M. Autoreactive T and B cells from bullous pemphigoid (BP) patients recognize epitopes clustered in distinct regions of BP180 and BP230. J Immunol. 2006 Feb 1. 176(3):2015-23. [Medline].

  16. Schmidt E, Obe K, Brocker EB, Zillikens D. Serum levels of autoantibodies to BP180 correlate with disease activity in patients with bullous pemphigoid. Arch Dermatol. 2000 Feb. 136(2):174-8. [Medline].

  17. Kiss M, Perenyi A, Marczinovits I, et al. Autoantibodies to human alpha6 integrin in patients with bullous pemphigoid. Ann N Y Acad Sci. 2005 Jun. 1051:104-10. [Medline].

  18. Bekou V, Thoma-Uszynski S, Wendler O, et al. Detection of laminin 5-specific auto-antibodies in mucous membrane and bullous pemphigoid sera by ELISA. J Invest Dermatol. 2005 Apr. 124(4):732-40. [Medline].

  19. Ujiie H, Shibaki A, Nishie W, Sawamura D, Wang G, Tateishi Y, et al. A novel active mouse model for bullous pemphigoid targeting humanized pathogenic antigen. J Immunol. Feb/2010. 184:2166-74. [Medline].

  20. Schachter M, Brieva JC, Jones JC, Zillikens D, Skrobek C, Chan LS. Pemphigoid nodularis associated with autoantibodies to the NC16A domain of BP180 and a hyperproliferative integrin profile. J Am Acad Dermatol. 2001 Nov. 45(5):747-54. [Medline].

  21. Frezzolini A, Cianchini G, Ruffelli M, Cadoni S, Puddu P, De Pita O. Interleukin-16 expression and release in bullous pemphigoid. Clin Exp Immunol. 2004 Sep. 137(3):595-600. [Medline].

  22. Echigo T, Hasegawa M, Shimada Y, Inaoki M, Takehara K, Sato S. Both Th1 and Th2 chemokines are elevated in sera of patients with autoimmune blistering diseases. Arch Dermatol Res. 2006 Jun. 298(1):38-45. [Medline].

  23. Niimi Y, Pawankar R, Kawana S. Increased expression of matrix metalloproteinase-2, matrix metalloproteinase-9 and matrix metalloproteinase-13 in lesional skin of bullous pemphigoid. Int Arch Allergy Immunol. 2006. 139(2):104-13. [Medline].

  24. Asashima N, Fujimoto M, Watanabe R, et al. Serum levels of BAFF are increased in bullous pemphigoid but not in pemphigus vulgaris. Br J Dermatol. 2006 Aug. 155(2):330-6. [Medline].

  25. Iwata Y, Komura K, Kodera M, et al. Correlation of IgE autoantibody to BP180 with a severe form of bullous pemphigoid. Arch Dermatol. 2008 Jan. 144(1):41-8. [Medline].

  26. Di Zenzo G, Calabresi V, Olasz EB, Zambruno G, Yancey KB. Sequential Intramolecular Epitope Spreading of Humoral Responses to Human BPAG2 in a Transgenic Model. J Invest Dermatol. 2009 Oct 8. [Medline].

  27. Iwata H, Kamio N, Aoyama Y, et al. IgG from patients with bullous pemphigoid depletes cultured keratinocytes of the 180-kDa bullous pemphigoid antigen (type XVII collagen) and weakens cell attachment. J Invest Dermatol. 2009 Apr. 129(4):919-26. [Medline].

  28. Marzano AV, Tedeschi A, Fanoni D, et al. Activation of blood coagulation in bullous pemphigoid: role of eosinophils, and local and systemic implications. Br J Dermatol. 2009 Feb. 160(2):266-72. [Medline].

  29. Wieland CN, Comfere NI, Gibson LE, Weaver AL, Krause PK, Murray JA. Anti-bullous pemphigoid 180 and 230 antibodies in a sample of unaffected subjects. Arch Dermatol. Jan/2010. 146:21-5. [Medline].

  30. Stausbol-Gron B, Deleuran M, Sommer Hansen E, Kragballe K. Development of bullous pemphigoid during treatment of psoriasis with adalimumab. Clin Exp Dermatol. Oct/2009. 34:e285-6. [Medline].

  31. Langan SM, Smeeth L, Hubbard R, Fleming KM, Smith CJ, West J. Bullous pemphigoid and pemphigus vulgaris--incidence and mortality in the UK: population based cohort study. BMJ. 2008 Jul 9. 337:a180. [Medline]. [Full Text].

  32. Gajic-Veljic M, Nikolic M, Medenica L. Juvenile bullous pemphigoid:the presentation and follow-up of six cases. J Eur Acad Dermatol Venereol. Jan/2010. 24:69-72. [Medline].

  33. Parker SR, Dyson S, Brisman S, et akl. Mortality of bullous pemphigoid: an evaluation of 223 patients and comparison with the mortality in the general population in the United States. J Am Acad Dermatol. 2008 Oct. 59(4):582-8. [Medline].

  34. Cortes B, Marazza G, Naldi L, Combescure C, Borradori L. Mortality of bullous pemphigoid in Switzerland: a prospective study. Br J Dermatol. 2011 Aug. 165(2):368-74. [Medline].

  35. Bakker CV, Terra JB, Pas HH, Jonkman MF. Bullous pemphigoid as pruritus in the elderly: a common presentation. JAMA Dermatol. 2013 Aug. 149(8):950-3. [Medline].

  36. Baykal C, Okan G, Sarica R. Childhood bullous pemphigoid developed after the first vaccination. J Am Acad Dermatol. 2001 Feb. 44(2 Suppl):348-50. [Medline].

  37. Sun C, Chang B, Gu H. Non-bullous lesions as the first manifestation of bullous pemphigoid: a retrospective analysis of 24 cases. J Dermatolog Treat. 2009. 20(4):233-7. [Medline].

  38. Chan LS, Dorman MA, Agha A, Suzuki T, Cooper KD, Hashimoto K. Pemphigoid vegetans represents a bullous pemphigoid variant. Patient's IgG autoantibodies identify the major bullous pemphigoid antigen. J Am Acad Dermatol. 1993 Feb. 28(2 Pt 2):331-5. [Medline].

  39. Labib RS, Anhalt GJ, Patel HP, Mutasim DF, Diaz LA. Molecular heterogeneity of the bullous pemphigoid antigens as detected by immunoblotting. J Immunol. 1986 Feb 15. 136(4):1231-5. [Medline].

  40. Roussel A, Benichou J, Randriamanantany ZA, Gilbert D, Drenovska K, Houivet E, et al. Enzyme-linked immunosorbent assay for the combination of bullous pemphigoid antigens 1 and 2 in the diagnosis of bullous pemphigoid. Arch Dermatol. 2011 Mar. 147(3):293-8. [Medline].

  41. Charneux J, Lorin J, Vitry F, Antonicelli F, Reguiai Z, Barbe C, et al. Usefulness of BP230 and BP180-NC16a Enzyme-Linked Immunosorbent Assays in the Initial Diagnosis of Bullous Pemphigoid: A Retrospective Study of 138 Patients. Arch Dermatol. 2011 Mar. 147(3):286-91. [Medline].

  42. Pfaltz K, Mertz K, Rose C, Scheidegger P, Pfaltz M, Kempf W. C3d immunohistochemistry on formalin-fixed tissue is a valuable tool in the diagnosis of bullous pemphigoid of the skin. J Cutan Pathol. 2009 Oct 15. [Medline].

  43. American College of Rheumatology. Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. American College of Rheumatology Task Force on Osteoporosis Guidelines. Arthritis Rheum. 1996 Nov. 39(11):1791-801. [Medline].

  44. Joly P, Roujeau JC, Benichou J, et al. A comparison of oral and topical corticosteroids in patients with bullous pemphigoid. N Engl J Med. 2002 Jan 31. 346(5):321-7. [Medline].

  45. Spivey J, Nye AM. Bullous pemphigoid: corticosteroid treatment and adverse effects in long-term care patients. Consult Pharm. 2013 Jul. 28(7):455-62. [Medline].

  46. Ahmed AR, Spigelman Z, Cavacini LA, Posner MR. Treatment of pemphigus vulgaris with rituximab and intravenous immune globulin. N Engl J Med. 2006 Oct 26. 355(17):1772-9. [Medline].

  47. Dupuy A, Viguier M, Bedane C, et al. Treatment of refractory pemphigus vulgaris with rituximab (anti-CD20 monoclonal antibody). Arch Dermatol. 2004 Jan. 140(1):91-6. [Medline].

  48. Morrison LH. Therapy of refractory pemphigus vulgaris with monoclonal anti-CD20 antibody (rituximab). J Am Acad Dermatol. 2004 Nov. 51(5):817-9. [Medline].

  49. Reguiaï Z, Tchen T, Perceau G, Bernard P. [Efficacy of rituximab in a case of refractory bullous pemphigoid]. Ann Dermatol Venereol. 2009 May. 136(5):431-4. [Medline].

  50. Peterson JD, Chan LS. Effectiveness and side effects of anti-CD20 therapy for autoantibody-mediated blistering skin diseases: A comprehensive survey of 71 consecutive patients from the Initial use to 2007. Ther Clin Risk Manag. 2009 Feb. 5(1):1-7. [Medline]. [Full Text].

  51. Schmidt E, Seitz CS, Benoit S, Brocker EB, Goebeler M. Rituximab in autoimmune bullous diseases: mixed responses and adverse effects. Br J Dermatol. 2007 Feb. 156(2):352-6. [Medline].

  52. Schulze J, Bader P, Henke U, Rose MA, Zielen S. Severe bullous pemphigoid in an infant--successful treatment with rituximab. Pediatr Dermatol. 2008 Jul-Aug. 25(4):462-5. [Medline].

  53. Shetty S, Ahmed AR. Treatment of bullous pemphigoid with rituximab: critical analysis of the current literature. J Drugs Dermatol. 2013 Jun 1. 12(6):672-7. [Medline].

  54. Zhou XP, Liu B, Xu Q, Yang Y, He CX, Zuo YG, et al. Serum levels of immunoglobulins G1 and G4 targeting the non-collagenous 16A domain of BP180 reflect bullous pemphigoid activity and predict bad prognosis. J Dermatol. 2015 Aug 24. [Medline].

  55. Cugno M, Marzano AV, Bucciarelli P, Balice Y, Cianchini G, Quaglino P, et al. Increased risk of venous thromboembolism in patients with bullous pemphigoid. The INVENTEP (INcidence of VENous ThromboEmbolism in bullous Pemphigoid) study. Thromb Haemost. 2015 Aug 6. 114 (6):[Medline].

  56. Langan SM, Groves RW, West J. The relationship between neurological disease and bullous pemphigoid: a population-based case-control study. J Invest Dermatol. 2011 Mar. 131(3):631-6. [Medline].

  57. Taghipour K, Chi CC, Bhogal B, Groves RW, Venning V, Wojnarowska F. Immunopathological characteristics of patients with bullous pemphigoid and neurological disease. J Eur Acad Dermatol Venereol. 2013 Mar 26. [Medline].

  58. Jedlickova H, Hlubinka M, Pavlik T, Semradova V, Budinska E, Vlasin Z. Bullous pemphigoid and internal diseases - A case-control study. Eur J Dermatol. 2009 Oct 2. [Medline].

  59. Bernard P, Reguiai Z, Tancrede-Bohin E, et al. Risk factors for relapse in patients with bullous pemphigoid in clinical remission: a multicenter, prospective, cohort study. Arch Dermatol. 2009 May. 145(5):537-42. [Medline].

Direct immunofluorescence study performed on a perilesional skin biopsy specimen from a patient with bullous pemphigoid detects a linear band of immunoglobulin G deposit along the dermoepidermal junction.
Indirect immunofluorescence study performed on salt-split normal human skin substrate with the serum from a patient with bullous pemphigoid detects immunoglobulin G class circulating autoantibodies that bind to the epidermal (roof) side of the skin basement membrane.
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