In this video blog, Brittany Schultz, MD, discusses highlights from her lecture, Immunofluorescence/Immunobullous Work-up Tips & Tricks, on July 25, 2024, during the inaugural Elevate-Derm Alliance Summer Conference at the Westin Copley Place in Boston, Massachusetts.

In this video

Dr. Schultz frames the diagnostic work-up as "easy as ABC": immunofluorescence, ELISA, and H&E — all three needed to diagnose an autoimmune blistering disease. The H&E and direct immunofluorescence come from tissue biopsy, while indirect immunofluorescence and ELISA come from serologies in the blood. She stresses biopsy location: take the H&E from the active lesion (blister, vesicle, or urticarial patch), but keep the DIF perilesional, about five millimeters away, since antibodies get "chewed up" too close to the action.

She also explains mucous membrane pemphigoid (MMP), a subepidermal blistering disease that matters because scarring and fibrosis at mucosal sites — eyes, esophagus, vaginal or urethral tissue — carry real morbidity and potential loss of function. Cutaneous involvement occurs roughly 30 to 50% of the time, and disease can be monosite or multisite. For the oral biopsies many clinicians find intimidating, she shares two techniques (a suture-and-snip approach and scoring with a punch tool before snipping with curved iris) and which sites to favor and avoid.

  • Diagnosing autoimmune blistering disease requires all three: immunofluorescence, ELISA, and H&E.
  • Biopsy the active lesion for H&E, but take the DIF perilesional (~5 mm away) so antibodies aren't degraded.
  • Mucous membrane pemphigoid is a subepidermal blistering disease notable for scarring and fibrosis at mucosal sites, with cutaneous involvement about 30–50% of the time.
  • For oral biopsies, favor the lips and anterior buccal mucosa; avoid the posterior buccal mucosa, palate, attached gingiva, and floor of the mouth (nerves and salivary glands).
  • Two useful oral biopsy techniques: throw a suture and snip below it, or score the mucosa with a punch tool and snip underneath with curved iris for more depth control.