Bullous pemphigoid: Diagnosis and treatment

Bullous pemphigoid is a disease that can cause widespread blisters, itching, and rashes on your skin. These sometimes develop inside your mouth and other areas.

Research breakthroughs (many made by dermatologists) are giving patients more options for treating bullous pemphigoid. These options, which include FDA-approved medication, may help patients gain better control of their condition long term.

How do dermatologists diagnose bullous pemphigoid?

If you are worried that you have bullous pemphigoid, seeing a board-certified dermatologist can help you get an accurate diagnosis and treatment. Different types of diseases can cause blisters, and specialized testing may be necessary to find out what type of blistering disease you have. Dermatologists usually perform this specialized testing.

Have you had cancer, surgery, or radiation therapy?

Be sure to tell your dermatologist, as some medications and other treatments can trigger bullous pemphigoid.

To find out if you have bullous pemphigoid, your dermatologist will:

• Ask questions

• Examine your blisters and rashes

• Perform one or more skin biopsies (can be done during an office visit)

• Order blood tests, as needed

During your first appointment, your dermatologist will look for signs of infection as well as examine any blisters and rashes.

If you have a skin infection or several blisters that have ruptured and caused open skin, your dermatologist may admit you to a hospital. Having open skin over much of your body can lead to a type of infection called sepsis. This is a life-threatening condition.

If you have blisters that are leaking fluid and opening up, get immediate (within 24 hours) medical care

Treatment can prevent a serious — and sometimes life-threatening — infection.

If the medical tests confirm that you have bullous pemphigoid, your dermatologist will create a personalized treatment plan.

Will bullous pemphigoid go away without treatment?

This disease tends to come and go. You will likely have times when you continue to get new blisters and weeks when you have few — if any — blisters.

Occasionally, this disease goes away without treatment and the person never develops blisters again. This is more likely to happen when medication has caused bullous pemphigoid and the patient is able to stop taking that medication.

Patients also can experience a remission, which differs from a cure. There are two types of remission.

A partial remission means the disease lessens. For example, you may have noticeably fewer blisters on your skin.

A complete remission means everything goes away . . . the blisters, itching, and rash. While you’re in complete remission, keep in mind that the disease can come back. If the disease comes back, it’s called a relapse.

If you have bullous pemphigoid, treatment can reduce the amount of time that it takes for bullous pemphigoid to go into remission.

For most patients, remission occurs within 9 weeks of starting treatment. About 50% of patients go into complete remission about 2 years after treatment starts.

To stay in remission, you may need to continue treating bullous pemphigoid. Some patients continue treatment for months to years to keep the disease under control.

How do dermatologists treat bullous pemphigoid?

Your dermatologist will tailor your treatment plan to your needs. The goals of treatment are to:

• Stop (or reduce) new blisters

• Heal existing blisters and sores

• Treat an infection if it has developed

• Relieve any itch and pain

A personalized treatment plan usually includes medication and wound care.

Treatment can help heal your skin so that bullous pemphigoid goes into remission

Treatment can also help relieve the itch and pain.

One or more of the following may be part of your treatment plan:

Corticosteroids

Your dermatologist may prescribe creams and ointments called corticosteroids. This medication is often the first treatment prescribed to treat bullous pemphigoid. It can quickly reduce blisters and other lesions on the skin and stop the itch.

To get bullous pemphigus under control, dermatologists often prescribe a very potent corticosteroid, which you apply to your skin. You may apply this medication once or twice a day.

If bullous pemphigus covers a large area of your skin, your dermatologist may prescribe a corticosteroid pill, such as prednisone.

Like other medications, corticosteroids can have side effects. When used long-term, possible serious side effects include thinning skin, stomach ulcers or bleeding, bone loss that can lead to weak and fragile bones, eye problems, high blood pressure, weight gain, and diabetes.

To reduce your risk of developing side effects, your dermatologist may prescribe a corticosteroid and a second medication to calm down your immune system. For example, many treatment plans start with the corticosteroid. Once you start to feel some relief, you may start another medication while you continue with the corticosteroid. Some patients start both medications at the same time. These tactics can help reduce the risk of developing side effects from the corticosteroid.

As you continue treatment, your dermatologist can start to decrease how much corticosteroid you apply (or take), with the goal of stopping it entirely.

Antibiotics

This medication is often prescribed when you have mild disease. An antibiotic can reduce blisters and other lesions on your skin. Your dermatologist may prescribe doxycycline or another antibiotic, such as tetracycline, minocycline, or dapsone. All can reduce inflammation.

The most common side effect of doxycycline and tetracycline is that your skin becomes more sensitive to the sun. You’ll need to protect your skin from the sun and not use indoor tanning while taking either medication.

Other possible side effects include nausea (feel sick to your stomach), vomiting, diarrhea, and an increased risk of developing a yeast infection.

Biologics

For some patients, a biologic can bring relief. This treatment works by changing the way your immune system reacts. By doing so, biologics can:

• Reduce blisters and itching.

• Heal blisters and other lesions caused by bullous pemphigoid.

• Prevent new lesions from forming.

If one biologic fails to bring relief, another may work.

Keep in mind that a biologic is not right for every patient. Before deciding whether to treat you with a biologic, your dermatologist will consider your overall health, medications you take, how bullous pemphigoid is affecting your life, and other considerations.

Dermatologists have expertise in treating patients with biologics

They’ve conducted many of the studies that led to treating bullous pemphigoid and other diseases with a biologic.

For the right patient, one of the following biologics may provide effective treatment for bullous pemphigoid.

Dupilumab: The U.S. Food and Drug Administration (FDA) has approved dupilumab to treat bullous pemphigoid in adults.

Many patients start dupilumab while they are treating bullous pemphigoid with a corticosteroid. A corticosteroid can work to quickly bring relief. As dupilumab takes effect, patients are often able to stop the corticosteroid.

In studies, many patients have seen a noticeable decrease in blistering and itchiness. Some patients treated with dupilumab have seen their skin clear and the itch go away. When the skin clears and itch goes away, some patients stop dupilumab without having a relapse (symptoms return). However, the blisters and itching can return. If this happens, tell your dermatologist.

Dupilumab is injected just beneath the skin. If this medication is right for you, you’ll be taught how to inject it so that you can safely treat yourself at home. The medication comes in a prefilled syringe or injectable pen (autoinjector). Patients inject dupilumab every other week.

In clinical trials, the most common side effects were joint pain, eye irritation, and blurred vision.

• Brand name: Dupixent

Omalizumab: This biologic can be an effective treatment. In studies, many patients have seen a noticeable decrease in itchiness and blisters. Some patients have seen their skin clear completely and the itchiness go away.

Omalizumab is injected just beneath the skin. If this medication is right for you, you’ll be taught how to inject it so that you can safely treat yourself at home. The medication comes in a prefilled syringe or injectable pen (autoinjector). Patients inject omalizumab every 2 to 4 weeks. Your dermatologist will tell you how often to inject.

In studies, the most common side effects were skin reaction where you inject the medication, itchiness, and worsening of blisters and other lesions on the skin.

• Brand name: Xolair

Rituximab: This biologic can reduce symptoms quickly. Your dermatologist may prescribe it if other treatments, including corticosteroids and other biologics, fail to work.

Rituximab is given through an IV (infusion), so you’ll need to go to a medical office or infusion center for treatment. Your treatment plan may call for you to receive 2 infusions. The second infusion is given 2 weeks after the first. Some patients receive a lower dose, receiving an infusion once a week for 4 weeks.

Before taking rituximab, make sure your vaccinations are up to date. This medication can increase your risk of developing certain infections.

In studies, the most common side effect in patients who have bullous pemphigoid is an infection (due to this medication’s effect on the immune system). None of the infections were severe or life-threatening, and patients received treatment for their infections.

Fatigue is another common side effect.

• Brand name: Rituxan

Other medications

Some patients take a medication called an immunosuppressant. This type of medication helps to calm the immune system. When the immune system calms down, itching, blisters, and other signs of bullous pemphigoid often lessen. Sometimes, they go away.

Immunosuppressant medications that dermatologists prescribe to treat bullous pemphigoid include azathioprine, mycophenolate mofetil, and methotrexate. These medications are typically prescribed if:

• Blisters cover much of your skin.

• You develop several new blisters every day.

• Your treatment plan includes a corticosteroid (An immunosuppressant can reduce side effects from the corticosteroid.)

Before taking medication that’s an immunosuppressant, make sure your vaccinations are up to date. Taking this type of medication can increase your risk of developing certain infections.

Each medication has its own possible side effects.

Tell your dermatologist about all medications, vitamins, and supplements that you take — or plan to take

Some can interact with the medication in your treatment plan.

Wound care

Open blisters and raw skin can become infected. Wound care can prevent infection, relieve pain, and speed up healing.

Your dermatologist will create a wound care plan that meets your individual needs. Most wound care involves daily cleaning of the wounds, applying medication, and bandaging. When necessary, your dermatologist may refer you to a wound care specialist.

Treatment can take time

The amount of time you need to treat bullous pemphigoid will depend on how severe the disease is and your response to treatment.

Most patients follow a treatment plan for 6 months to 5 years before the disease goes into long-term remission. Once the disease is in long-term remission, many patients can stop treatment. However, some patients need to continue treatment.

Follow-up medical appointments are essential

Treating bullous pemphigoid can be complicated. Your dermatologist may coordinate with your primary care doctor and other doctors as needed. Keeping all your medical appointments will help:

• Determine whether the treatment works for you or needs to be modified.

• Find side effects early.

• See if an infection, which can be serious, has developed.

• Make sure you know what to do, so you can follow your treatment plan.

Following a self-care plan for bullous pemphigoid can improve the results you get from treatment and how well you feel. You’ll find the self-care that dermatologists recommend at: Bullous pemphigoid: Self-care.

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References
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Written by:
Paula Ludmann, MS

Reviewed by:
Jean Bolognia, MD, FAAD
Bittany Oliver, MD, FAAD

Last updated: 8/19/25