Blister Breakthroughs: Emerging Targeted Therapies for Bullous Pemphigoid

Prince Adotama, MD and Mark Lebwohl, MD provided a comprehensive update on bullous pemphigoid (BP), a rare autoimmune blistering disease that predominantly affects older adults. They reviewed the underlying pathophysiology, in which autoantibodies against BP180 and BP230 disrupt dermal–epidermal adhesion and trigger a robust inflammatory cascade involving eosinophils, neutrophils, and Th2 cytokines such as IL-4 and IL-13. Disease severity closely correlates with elevated IgE levels and eosinophilia, helping explain the intense pruritus and blister formation seen in affected patients. The presenters emphasized that BP often presents atypically, with more than half of patients initially developing nonbullous eczematous or urticarial lesions, underscoring the need for heightened diagnostic suspicion.

The session also highlighted growing awareness of drug-induced BP, with more than 50 medications implicated. Notably, DPP4 inhibitors used in type 2 diabetes are associated with a threefold increased risk, and immune checkpoint inhibitors have also been linked to disease onset. While traditional management still includes high-potency topical steroids and short-term systemic corticosteroids with immunomodulators, the treatment landscape is rapidly changing. Dupilumab, approved in June 2025 for adult BP, has demonstrated rapid disease control in the majority of patients, with a favorable safety profile and significant steroid-sparing benefits. Additional targeted options, including omalizumab and rituximab, have shown strong efficacy in selected patients, particularly those with high IgE levels or refractory disease.

Overall, the presenters emphasized that targeted biologic therapies are transforming BP care by improving disease control while minimizing the long-term risks of systemic corticosteroids. This shift marks a new era in BP management, prioritizing precision therapy, safety, and durable remission in a vulnerable patient population.