From the Guidelines
Bullous pemphigoid treatment should involve topical corticosteroids, such as clobetasol propionate 0.05% cream or ointment, applied to affected areas twice daily until lesions resolve, with oral prednisone as an adjunct for moderate to severe disease, starting at 0.5-1 mg/kg/day, and tapering to the lowest effective maintenance dose once disease control is achieved, as recommended by the European Dermatology Forum consensus in collaboration with the European Academy of Dermatology and Venereology 1.
Treatment Approach
The treatment approach for bullous pemphigoid involves a combination of topical and oral corticosteroids. Topical treatment with high-potency steroids like clobetasol propionate 0.05% cream or ointment is applied to affected areas twice daily until lesions resolve. For oral therapy, prednisone is the mainstay, usually starting at 0.5-1 mg/kg/day (typically 40-60 mg daily) for moderate to severe disease.
Dosing and Tapering
The dose of topical corticosteroids should be adjusted based on the severity of the disease, with a recommended initial dose of 30-40 g per day of clobetasol propionate 0.05% cream or ointment, applied in two applications over the entire body, including both normal skin and blisters and erosions, but sparing the face 1. The dose of oral prednisone should be gradually tapered over several months to the lowest effective maintenance dose, often 5-10 mg daily, once disease control is achieved, which is usually within 1-2 weeks.
Adjunctive Treatments
Adjunctive treatments like dapsone, methotrexate, or mycophenolate mofetil are often added as steroid-sparing agents to reduce long-term steroid exposure. These treatments can help minimize the side effects associated with prolonged steroid use, such as glucose intolerance, hypertension, and osteoporosis.
Monitoring and Side Effects
Patients should be monitored for steroid side effects, including glucose intolerance, hypertension, and osteoporosis. Topical steroids cause fewer systemic side effects but can lead to skin atrophy with prolonged use. Regular follow-up appointments are necessary to adjust the treatment plan as needed and to monitor for any potential side effects.
Disease Control and Remission
The definition of disease control is the time point at which new lesions or pruritic symptoms cease to form and established lesions begin to heal 1. The treatment goal is to achieve complete remission, which is defined as the absence of new or established lesions or pruritus while the patient is receiving minimal therapy for at least 2 months. A tapering schedule with dose adaptation is recommended, with treatment every 2 days in the second month, twice per week in the third month, and once per week starting in the fourth month 1.
From the FDA Drug Label
CLINICAL PHARMACOLOGY The corticosteroids are a class of compounds comprising steroid hormones secreted by the adrenal cortex and their synthetic analogs. In pharmacologic doses, corticosteroids are used primarily for their anti-inflammatory and/or immunosuppressive effects Topical corticosteroids such as clobetasol propionate are effective in the treatment of corticosteroid-responsive dermatoses primarily because of their anti-inflammatory, antipruritic, and vasoconstrictive actions.
The FDA drug label does not answer the question about pemphigoid bullosa oral and topical steroid treatment.
From the Research
Treatment of Pemphigoid Bullosa with Oral and Topical Steroids
- The use of oral and topical steroids in the treatment of pemphigoid bullosa has been studied in several research papers 2, 3, 4, 5, 6.
- Topical corticosteroids, such as clobetasol propionate, have been shown to be effective in treating pemphigoid bullosa with fewer adverse effects compared to systemic steroids 2, 3, 4.
- A study published in 1989 found that clobetasol propionate cream applied twice daily to affected skin resulted in complete epithelialization in all 10 patients within 4 to 17 days of treatment 2.
- Another study published in 2014 found that whole body application of clobetasol propionate cream was effective in treating mild and severe pemphigoid bullosa, with disease control achieved in 90% of patients with mild disease and 73.5% of patients with severe disease 3.
- A review of treatments for pemphigoid bullosa published in 2011 found that ultrapotent topical corticosteroids, such as clobetasol propionate, were effective treatments for pemphigoid bullosa with fewer systemic side effects than oral high-dose corticosteroids 4.
- A Cochrane review published in 2023 found that clobetasol propionate cream applied over the whole body was probably similarly effective as, and may cause less mortality than, oral prednisone for treating pemphigoid bullosa 5.
- The use of oral steroids, such as prednisone, has also been studied, but has been found to have more adverse effects, particularly in elderly patients with multiple comorbidities 6.
Adverse Effects of Oral and Topical Steroids
- The adverse effects of oral and topical steroids in the treatment of pemphigoid bullosa have been reported in several studies 3, 4, 5, 6.
- Local adverse effects of topical corticosteroids, such as skin atrophy and purpura, have been reported in some studies 3.
- Systemic adverse effects of topical corticosteroids, such as deep vein thrombosis, hypertrichosis, and adrenocortical insufficiency, have been reported in some studies 3.
- The adverse effects of oral steroids, such as hypertension, hyperglycemia, and decreased survival, have been reported in several studies 4, 6.
Comparison of Oral and Topical Steroids
- Several studies have compared the effectiveness and adverse effects of oral and topical steroids in the treatment of pemphigoid bullosa 2, 3, 4, 5.
- A study published in 2014 found that whole body application of clobetasol propionate cream was effective in treating mild and severe pemphigoid bullosa, with fewer adverse effects compared to oral prednisone 3.
- A Cochrane review published in 2023 found that clobetasol propionate cream applied over the whole body was probably similarly effective as, and may cause less mortality than, oral prednisone for treating pemphigoid bullosa 5.