Non-bullous lesions as the first manifestation of bullous pemphigoid: A retrospective analysis of 181 cases.

The aim of the present study was to explore the clinical and histopathological characteristics and treatment of patients with bullous pemphigoid (BP) that initially manifested as non-bullous lesions and provide information for early diagnosis and improved treatment. Medical records of 491 cases of BP were collected. The clinical and histopathological characteristics, treatment and outcomes of patients who initially presented with non-bullous lesions (prodromal BP, PBP) were analyzed and compared with those from patients who initially presented with bullous lesions (classical BP, cBP). Of the BP patients studied, 36.8% had PBP and presented with diversified initial lesions before the appearance of typical bullae, with erythema as the most frequent (31.67%), followed by concurrent erythema and papules (30.4%). The mean duration before bullae appearance was 15.91 ± 0.65 months. The degree of itch in PBP patients was higher than that in cBP patients. There was no difference in the hospital stay and time to disease control between the PBP and cBP patients. However, the mean glucocorticoid dose for control of the lesions in PBP patients was significantly higher than that in cBP patients. In addition, the PBP patients experienced side-effects more frequently than did the cBP patients (87.85% vs 17.41%). In conclusion, intensive treatment is required for PBP patients due to delayed diagnosis and advanced development of the disease. Itching, concurrent erythema and papules occurring in the elderly may be clues for the early diagnosis of PBP.