Pemphigus Vulgaris vs Bullous Pemphigoid
Pemphigus Vulgaris and Bullous Pemphigoid are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.
Pemphigus Vulgaris vs Bullous Pemphigoid at a glance
- Pemphigus Vulgaris: Autoimmune intraepidermal blistering disease with flaccid bullae and painful mucosal erosions.
- Bullous Pemphigoid: Most common autoimmune subepidermal blistering disease of the elderly; tense bullae on an urticarial base.
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Side-by-side comparison
| Feature | Pemphigus Vulgaris | Bullous Pemphigoid |
|---|---|---|
| At a glance | Autoimmune intraepidermal blistering disease with flaccid bullae and painful mucosal erosions. | Most common autoimmune subepidermal blistering disease of the elderly; tense bullae on an urticarial base. |
| Classic presentation | Painful oral erosions preceding flaccid cutaneous bullae in a middle-aged adult; positive Nikolsky.; Painful, persistent oral erosions (often the presenting symptom, precede skin disease by months); Burning, painful skin lesions rather than itch; Dysphagia, odynophagia, weight loss from oropharyngeal involvement; Hoarseness if laryngeal… | Severe pruritus and tense bullae on an urticarial base in an elderly patient.; Severe generalized pruritus, often weeks to months before blisters appear (prodromal or non-bullous phase); Tense fluid-filled blisters arising on urticarial or normal-appearing skin; Predilection for flexural areas: lower abdomen, inner thighs, axillae,… |
| Workup / key labs | Diagnosis requires clinical findings plus histology and immunofluorescence. Lesional biopsy: suprabasal acantholysis with 'tombstone' row of basal cells. Perilesional direct immunofluorescence (DIF): intercellular 'chicken-wire' IgG and C3 deposition. Serum anti-desmoglein antibodies confirm and track activity.; Serum indirect… | Diagnosis requires clinical features plus histopathology and immunofluorescence. Lesional biopsy: subepidermal blister with eosinophil-rich dermal infiltrate. Perilesional DIF: linear deposition of IgG and C3 along the basement membrane zone. Salt-split skin DIF: antibodies bind the epidermal (roof) side, distinguishing BP from EBA.;… |
| Imaging | No routine imaging required; Esophagogastroduodenoscopy if dysphagia or odynophagia suggests esophageal involvement; Chest imaging and age-appropriate cancer screening to exclude paraneoplastic pemphigus in atypical cases | No routine imaging; tailor to comorbid evaluation; Consider age-appropriate malignancy screening if atypical presentation, but routine paraneoplastic workup is not indicated |
| First-line treatment | Systemic corticosteroid: prednisone 1 mg/kg/day, methylprednisolone IV for severe disease; taper slowly over months; Rituximab (anti-CD20) — now first-line with steroids per 2020 international consensus and Joly et al. 2017 RITUX 3 trial; 1 g IV days 0 and 14 (rheumatoid arthritis dosing) or 375 mg/m² weekly × 4 (lymphoma dosing); Wound… | Localized or mild disease: superpotent topical corticosteroid — clobetasol propionate 0.05% applied to the entire body 30-40 g/day (per Joly NEJM 2002 trial showing equivalent efficacy to oral steroids with fewer adverse events); Moderate-to-severe disease: prednisone 0.5 mg/kg/day with taper as disease controls; goal taper to <10… |
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