Histology: Routine hematoxylin and eosin staining reveals a cell-poor subepidermal blister with scattered eosinophils. The histological differential diagnosis can be between bullous pemphigoid and epidermolysis bullosa acquisita (EBA). Immunofluorescence staining can be used to help differentiate the two. IgG and complement C3 localize to the basement membrane zone and appear as a linear band. The salt-split skin technique can also be used to differentiate the two diseases. This is achieved by incubating skin in a 1M NaCl solution to split the skin through the lamina lucida. When immunofluorescence staining is used on salt-split skin, the immunoreactants localize to the blister roof in bullous pemphigoid and to the dermal base in EBA.
Treatment: The severity of bullous pemphigoid varies. Therapy needs to be tailored to the individual. Many patients are older and have comorbidities that must be taken into account. Mild, localized disease can be treated with high-potency topical steroids. Severe disease is treated initially with oral steroids, and then the patient is transitioned to a steroid-sparing agent. The medications that have been routinely used include mycophenolate mofetil, azathioprine, and the combination of tetracycline and nicotinamide. Newer agents such as intravenous immunoglobulin (IVIG) have been used for severe refractory disease.
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