In this video blog, Margaret Bobonich, FNP-C summarizes her lecture, Difficult Cases Learned in Blistering Disorders on November 8, 2024, at the 5th Annual Elevate-Derm West Conference at the Westin Kierland Resort in Scottsdale, AZ.

In this video

Interviewed by Veronica Richardson, Bobonich explains why these disorders matter for APPs: high incidence for some, high mortality for others. She starts with bullous pemphigoid, the immune-mediated skin disease you're most likely to see in practice, typically in adults 50 or older. The catch is that "blistering diseases don't always have blisters" — about 30% of patients have a pruritic prodrome and a subset present only with urticarial plaques, so unremitting pruritus in the right age group belongs on the differential. Diagnosis requires two biopsies: a perilesional H&E at the blister edge and a DIF taken about one centimeter away on healthy-looking skin, sent in Michel's solution.

She contrasts that with pemphigus vulgaris — less common but higher mortality, with fragile epidermal blisters that rupture (check for a positive Nikolsky sign). Rituximab, the first FDA-approved therapy, has let clinicians withdraw prednisone faster and reduce the opportunistic-infection risk that drove much of the mortality. Bobonich also covers chronic bullous disease of childhood (managed well on dapsone), drug triggers led by gliptins, NSAIDs, and captopril/beta blockers, and dermatitis herpetiformis, where roughly 75% of patients show colonoscopy findings despite only about 20% reporting GI symptoms.

  • Bullous pemphigoid is the most common immune-mediated skin disease APPs will see; put it on the differential for unremitting pruritus in patients 50 and older, even without visible blisters.
  • Diagnose blistering diseases with an immunohistochemical test: perilesional H&E at the blister edge plus a DIF taken ~1 cm away on healthy skin in Michel's solution.
  • Pemphigus vulgaris carries high mortality; look for a positive Nikolsky sign, and use rituximab to taper off prednisone faster and lower opportunistic-infection risk.
  • Chronic bullous disease of childhood (pediatric linear IgA) responds well to dapsone and recovers faster than in adults.
  • Screen for drug triggers — gliptins, NSAIDs, captopril and beta blockers — and in dermatitis herpetiformis refer to GI and screen for hypothyroidism, since GI disease is often present despite absent symptoms.