Bullous Pemphigoid and Tetracycline



Figure 3.1
Tense bullae on erythematous and normal appearing skin as well as urticarial, eroded and crusted plaques on the inner aspects of bilateral upper arms (a) and extensor surfaces of lower extremities (b)



(A)

Azathioprine

 

(B)

Methotrexate

 

(C)

Rituximab

 

(D)

Tetracycline and Nicotinamide

 

(E)

Prednisone

 




Discussion


Topical and systemic prednisone as well as other steroid sparing systemic immunosuppressive agents have traditionally been used in the treatment of bullous pemphigoid (BP). Since BP typically occurs in elderly patients with various other medical problems as well as co-morbidities, a steroid sparing agent with excellent safety profile is needed for management.

Tetracycline (TCN) was first reported as an effective treatment for BP in the 1980s, either alone or in combination with nicotinamide (niacinamide) [2, 16]. Since that time, many case reports and case series have demonstrated good response in treating both localized and generalized BP with TCN (Table 3.1) or one of its family members of antibiotics (Table 3.2), either alone or in combination with nicotinamide, with or without moderate to high potency topical steroids. The current discussion will focus on TCN, as it has been used most extensively in the treatment of BP.


Table 3.1
Summary of BP treated with TCN +/− Nicotinamide +/− topical steroids




















































































Reference
TCN starting dose
Nicotinamide
Topical steroids
Other concomitant systemic therapy
# of patients
Results

Pereyo and Davis [13]
500 mg bid
N/A
N/A
N/A
1
All bullae and inflammatory lesions cleared in 2 weeks

Thornfeldt and Menkes [16]a

250–500 mg bid
N/A
N/A
1 received systemic prednisone
2
Complete resolution in 3 weeks

Thomas et al. [15]
1–2 g daily in divided doses
N/A
Betamethasone valerate 0.1 % cream, betamethasone dipropionate 0.05 % cream and fluocinoide 0.05 % ointment
N/A
5
Re-epithelialization in 1–3 weeks. No blister at 1–3 weeks

Fivenson et al. [4]
500 mg qid
500 mg tid
N/A
N/A
12
During the initial 8 weeks period: 5 had complete response, 5 had partial response, 1 with no response and 1 with worsening of disease. TCN was changed to minocycline 100 mg bid in 2 patients due to side effects

Kolbach et al. [10]
2 g daily in divided doses
2 g daily in divided doses
N/A
3/7 received systemic prednisone
7
Blister formation significantly reduced within 1–2 weeks. Bullae ceased to develop in 6–8 weeks

Goon et al. [5]
1.5–2 g daily in divided doses
1.5–2 g daily in divided doses
Betamethasone valerate 0.05–0.1 % cream
N/A
5
4/5 on TCN had complete response, 1/5 had partial response

Berk and Lorincz [2]
1–2 g daily in divided doses
1.5–2.5 g daily in divided doses
2/4 received 0.1 % triamcinolone acetonide ointment
1 also received dapsone
4
Responded within 1–2 weeks. 1 had occasional outbreak. 1 had recurrence and received erythromycin ethylsuccinate three times daily with good control; unclear why TCN was not reinitiated

Hornschuh et al. [7]
500 mg qid
400 mg bid
0.5 % clobetasol
N/A
16
Within 4 weeks, 13/16 had complete response, 2/16 did not respond


bid twice a day, tid three times a day, qid four times a day

aLocalized BP; N/A not applicable



Table 3.2
Summary of BP treated with other TCN family antibiotics +/− Nicotinamide +/− topical steroids




























Reference
Antibiotics starting dose
Nicotinamide
Topical steroids
Other concomitant systemic therapy
# of patients
Results

Safa and Darrieux [14]a

Doxycycline bid
N/A
N/A
N/A
4
Pruritus resolved and complete clearance of skin lesions seen in 1–4 weeks

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Jul 8, 2017 | Posted by in Dermatology | Comments Off on Bullous Pemphigoid and Tetracycline

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