Bullous pemphigoid
Bullous pemphigoid is an autoimmune condition causing sub-epidermal blistering of
the skin. This is secondary to the development of antibodies against
hemidesmosomal proteins BP180 and BP230.
Bullous pemphigoid is more common in elderly patients. Features include
● itchy, tense blisters typically around flexures
● the blisters usually heal without scarring
● there is stereotypically no mucosal involvement (i.e. the mouth is spared)
○ in reality around 10-50% of patients have a degree of mucosal
involvement. It would, however, be unusual for an exam question to
mention mucosal involvement as it is seen as a classic differentiating
feature between pemphigoid and pemphigus.
Rosacea
Rosacea (sometimes referred to as acne rosacea) is a chronic skin disease of unknown
aetiology.
Features
,● typically affects nose, cheeks and forehead
● flushing is often first symptom
● telangiectasia are common
● later develops into persistent erythema with papules and pustules
● rhinophyma
● ocular involvement: blepharitis
● sunlight may exacerbate symptoms
,
, Management
● simple measures
○ recommend daily application of a high-factor sunscreen
○ camouflage creams may help conceal redness
● predominant erythema/flushing
○ topical brimonidine gel may be considered for patients with
predominant flushing but limited telangiectasia
○ brimonidine is a topical alpha-adrenergic agonist
○ this can be used on an 'as required basis' to temporarily reduce redness
○ it typically reduces redness within 30 minutes, reaching peak action at
3-6 hours, after which the redness returns to the baseline
● mild-to-moderate papules and/or pustules
○ topical ivermectin is first-line
○ alternatives include: topical metronidazole or topical azelaic acid
● moderate-to-severe papules and/or pustules
○ combination of topical ivermectin + oral doxycycline
Referral should be considered if
● symptoms have not improved with optimal management in primary care
○ laser therapy may be appropriate for patients with prominent
telangiectasia
● patients with a rhinophyma
Bullous pemphigoid is an autoimmune condition causing sub-epidermal blistering of
the skin. This is secondary to the development of antibodies against
hemidesmosomal proteins BP180 and BP230.
Bullous pemphigoid is more common in elderly patients. Features include
● itchy, tense blisters typically around flexures
● the blisters usually heal without scarring
● there is stereotypically no mucosal involvement (i.e. the mouth is spared)
○ in reality around 10-50% of patients have a degree of mucosal
involvement. It would, however, be unusual for an exam question to
mention mucosal involvement as it is seen as a classic differentiating
feature between pemphigoid and pemphigus.
Rosacea
Rosacea (sometimes referred to as acne rosacea) is a chronic skin disease of unknown
aetiology.
Features
,● typically affects nose, cheeks and forehead
● flushing is often first symptom
● telangiectasia are common
● later develops into persistent erythema with papules and pustules
● rhinophyma
● ocular involvement: blepharitis
● sunlight may exacerbate symptoms
,
, Management
● simple measures
○ recommend daily application of a high-factor sunscreen
○ camouflage creams may help conceal redness
● predominant erythema/flushing
○ topical brimonidine gel may be considered for patients with
predominant flushing but limited telangiectasia
○ brimonidine is a topical alpha-adrenergic agonist
○ this can be used on an 'as required basis' to temporarily reduce redness
○ it typically reduces redness within 30 minutes, reaching peak action at
3-6 hours, after which the redness returns to the baseline
● mild-to-moderate papules and/or pustules
○ topical ivermectin is first-line
○ alternatives include: topical metronidazole or topical azelaic acid
● moderate-to-severe papules and/or pustules
○ combination of topical ivermectin + oral doxycycline
Referral should be considered if
● symptoms have not improved with optimal management in primary care
○ laser therapy may be appropriate for patients with prominent
telangiectasia
● patients with a rhinophyma
