In this video blog, Brittany Schultz, MD, discusses highlights from her lecture, Updates in Immunobullous Disorders, on July 26, 2024, during the inaugural Elevate-Derm Alliance Summer Conference at the Westin Copley Place in Boston, Massachusetts.

In this video

Dr. Schultz likens treating bullous pemphigoid to "parkour" rather than climbing a traditional therapeutic ladder — with complex, multi-morbid patients you're "jumping around to either side of the ladder," deciding where to start based on each patient's comorbidities. She often begins with topical steroids plus doxycycline and niacinamide, then escalates to mycophenolate or dupilumab, favoring dupilumab when she can get it covered (about 50% of the time) because it isn't immunosuppressive. More severe patients may need azathioprine, methotrexate, rituximab, or IVIG.

On rituximab, she stresses doing your "due diligence" — screening for hepatitis B, C, HIV, and tuberculosis and vaccinating ahead of time, since patients can't mount as strong a response for up to a year afterward. For mucous membrane pemphigoid, one of the most challenging conditions she treats, she notes that DIF, IIF, and ELISA testing are less sensitive and that hard-to-biopsy sites make a multidisciplinary approach essential.

  • Treat bullous pemphigoid like "parkour" — individualize where you start on the ladder based on comorbidities; begin with topical steroids, doxycycline, and niacinamide, then escalate to mycophenolate or dupilumab.
  • Dupilumab uses standard atopic dermatitis dosing (600 mg loading, then 300 mg every two weeks) and is preferred when covered because it isn't immunosuppressive; mycophenolate is typically titrated to 1500 mg twice daily, with enteric-coated mycophenolic acid for GI upset.
  • Before starting rituximab, screen for hepatitis B, C, HIV, and TB, and vaccinate two to four weeks ahead — flu, COVID, pneumonia, and shingles — since immune response to vaccines is blunted for up to a year afterward.
  • Mucous membrane pemphigoid is hard to diagnose: patients have lower circulating autoantibody levels, serologic tests are less sensitive, and involved sites like the eye and esophagus are difficult to biopsy.
  • Managing mucous membrane pemphigoid requires a multidisciplinary team to both diagnose and manage complications such as esophageal strictures.