Bullous Pemphigoid Medication

Updated: Aug 10, 2018
  • Author: Lawrence S Chan, MD; Chief Editor: Dirk M Elston, MD  more...
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Medication

Medication Summary

Treatment is directed at reducing the inflammatory response and autoantibody production. Although target-specific therapy is the "Holy Grail" for immunodermatologists, non–target-specific treatments are currently used. The most commonly used medications are anti-inflammatory agents (eg, corticosteroids, tetracyclines, dapsone) and immunosuppressants (eg, azathioprine, methotrexate, mycophenolate mofetil, cyclophosphamide). Evidence suggests that strong topical corticosteroid treatment may achieve disease control while avoiding systemic adverse effects from systemic corticosteroids. [4, 3, 63, 64] Omalizumab has been used as a corticosteroid-sparing agent. [65]

Initial treatment with doxycycline was found to be effective and was associated with a lower incidence of adverse effects compared with prednisone. [5, 6, 7]

Proper treatments of bullous pemphigoid depend on the severity of the disease. For localized disease, topical steroids plus the systemic anti-inflammatory (tetracycline and nicotinamide) may be sufficient. Effects of monotherapy with nicotinamide are unknown. For more severe cases, systemic steroids along with immunosuppressives may be needed to control the disease. If the disease is difficult to control, consider treatment with an anti-CD20 antibody (rituximab), which is relatively specific in targeting the antibody-producing B cells. [66, 67, 68, 69, 70, 71, 72, 73, 74]

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Anti-inflammatory agents

Class Summary

These agents inhibit the inflammatory process by inhibiting specific cytokine production and vascular permeability. They may also stabilize granulocyte membranes and prevent release of key enzymes.

Prednisone (Deltasone)

Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. When taken orally, it is used alone or in conjunction with other immunosuppressive agents for treating bullous pemphigoid.

Tetracycline (Sumycin)

Although an antibiotic, tetracycline has proven effective in some cases of bullous pemphigoid either alone or in conjunction with niacinamide (2 g/d). Efficacy may be due to anti-inflammatory properties.

Clobetasol (Temovate)

Clobetasol is a class I superpotent topical steroid; it suppresses mitosis and increases the synthesis of proteins that decrease inflammation and cause vasoconstriction. It is useful in treating localized bullous pemphigoid or in conjunction with low-dose systemic corticosteroids to treat the generalized disease.

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Immunosuppressive agents

Class Summary

For patients in whom steroids or other anti-inflammatory agents have not caused a response or for those unable to tolerate prednisone, immunosuppressants are useful adjuvants.

Azathioprine (Imuran)

Azathioprine antagonizes purine metabolism and inhibits the synthesis of DNA, RNA, and proteins. It may decrease the proliferation of lymphocytes. It is for use alone or in conjunction with prednisone.

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Biologicals

Rituximab (Rituxan)

Rituximab is a genetically engineered chimeric murine/human monoclonal antibody against human CD20, a molecule present in normal and malignant B lymphocytes. It is described in case reports as a promising biological treatment for B-lymphocyte–mediated diseases (eg, pemphigus vulgaris).

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