From the Guidelines
Bullous pemphigoid affecting the hands and feet should be treated with superpotent topical corticosteroids as the first-line treatment, with oral corticosteroids such as prednisone considered for more severe cases. The treatment approach for bullous pemphigoid is guided by the severity and extent of the disease. According to the European Dermatology Forum consensus in collaboration with the European Academy of Dermatology and Venereology 1, for localized or limited disease with mild activity, superpotent topical corticosteroids are recommended as the first choice, with the option to apply them either to the whole body except the face or to lesions only.
For generalized disease, superpotent topical corticosteroids on the whole body sparing the face, or oral corticosteroids, are considered first-line treatments 1. The use of superpotent topical corticosteroids is validated by randomized prospective single-centre or multicentre studies, providing a strong evidence base for their effectiveness in managing bullous pemphigoid.
Key Considerations for Treatment
- Superpotent topical corticosteroids are the preferred initial treatment for localized or mild disease.
- Oral corticosteroids, such as prednisone, are recommended for more severe cases or generalized disease.
- Steroid-sparing agents, like azathioprine, mycophenolate, or dapsone, may be considered to reduce long-term steroid use.
- Proper wound care is essential to prevent infections and promote healing.
Treatment Duration and Monitoring
Treatment typically continues for 6-12 months, with regular monitoring for medication side effects and disease activity 1. The maintenance treatment should be continued for 8 months after the consolidation phase, with a total treatment duration of 12 months, as recommended by the consensus guidelines 1.
Given the potential morbidity and impact on quality of life associated with bullous pemphigoid, as highlighted in the European consensus 1, it is crucial to manage the disease effectively to improve patient outcomes. The treatment approach should be tailored to the individual patient's needs, taking into account the severity of the disease, potential side effects of medications, and the patient's overall health status.
From the Research
Treatment Options for Bullous Pemphigoid in Hands and Feet
- Topical corticosteroids, such as clobetasol propionate, are effective in treating bullous pemphigoid, with fewer systemic side effects compared to oral corticosteroids 2, 3, 4, 5, 6
- High-dose topical corticosteroids, such as clobetasol propionate, can increase initial disease control and 1-year survival in patients with extensive bullous pemphigoid 2, 3, 6
- Lower-dose topical corticosteroids, such as a mild regimen of clobetasol propionate, may be similarly effective as standard-dose topical corticosteroids and have similar mortality rates 5, 6
- Oral corticosteroids, such as prednisone, are effective in treating bullous pemphigoid, but may have more systemic side effects compared to topical corticosteroids 2, 3, 5, 6
- Doxycycline may be less effective than oral corticosteroids, but may cause less mortality and have a more favorable quality of life 6
- Other treatments, such as azathioprine, mycophenolate mofetil, and nicotinamide plus tetracycline, need further investigation to determine their effectiveness in treating bullous pemphigoid 3, 5, 6
Considerations for Treatment
- The choice of treatment should be based on the severity and extent of the disease, as well as the patient's overall health and comorbidities 2, 3, 5, 6
- Topical corticosteroids may be preferred for patients with localized disease or those who are at risk for systemic side effects from oral corticosteroids 2, 3, 4, 5, 6
- Oral corticosteroids may be preferred for patients with more severe or widespread disease, but should be used with caution due to the risk of systemic side effects 2, 3, 5, 6
- Combination therapy, such as topical corticosteroids plus oral corticosteroids or immunosuppressants, may be considered for patients with refractory or severe disease 3, 5, 6