Johnsen Nicole, Goldgar Sarah
Department of Dermatology, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, USA.
Department of Medicine, Division of General Internal Medicine, University of California Los Angeles, Los Angeles, USA.
Cureus. 2025 Jan 3;17(1):e76856. doi: 10.7759/cureus.76856. eCollection 2025 Jan.
Bullous pemphigoid (BP) is an autoimmune blistering disorder characterized by tense bullae and severe generalized pruritus. However, atypical presentations in elderly patients may involve localized pruritus prior to the development of bullae, which can obscure the diagnosis and delay appropriate treatment. We present a case of BP induced by furosemide in an 83-year-old male patient with congestive heart failure. The patient initially experienced persistent pruritus on the bilateral arms and back, which emerged approximately three months after initiating furosemide therapy. This pruritus was initially attributed to xerosis. Subsequently, erythematous papules developed in these areas, raising suspicion for atypical scabies, although they did not respond to permethrin treatment. A shave biopsy revealed subepidermal bullous disease with numerous eosinophils, and direct immunofluorescence confirmed the diagnosis of BP, showing linear IgG and granular C3 deposition at the basement membrane zone. The papules then evolved into tense bullae, and serologic testing supported the diagnosis with elevated IgG titers and positive BP180 antibodies. Furosemide was discontinued as the likely trigger. Initial treatment with prednisone led to improvement; however, bullae reappeared upon tapering the medication. Further management with doxycycline and topical triamcinolone resulted in enhanced improvement. Ultimately, biweekly dupilumab injections effectively controlled the symptoms. This case underscores the diagnostic challenges of BP, particularly in the elderly, where isolated pruritus may precede the appearance of visible bullous lesions. Clinicians should maintain a high index of suspicion for BP in elderly patients with unexplained pruritus, especially when standard treatments are ineffective. Additionally, this case highlights the importance of considering drug-induced BP, with furosemide recognized as a potential trigger.
大疱性类天疱疮（BP）是一种自身免疫性水疱性疾病，其特征为紧张性水疱和严重的全身性瘙痒。然而，老年患者的非典型表现可能在水疱出现之前就有局部瘙痒，这可能会掩盖诊断并延误适当治疗。我们报告一例83岁充血性心力衰竭男性患者因使用呋塞米诱发BP的病例。患者最初在双侧手臂和背部出现持续瘙痒，这在开始使用呋塞米治疗约三个月后出现。这种瘙痒最初归因于皮肤干燥。随后，这些部位出现红斑丘疹，尽管对氯菊酯治疗无反应，但引起了对非典型疥疮的怀疑。刮除活检显示表皮下水疱性疾病，有大量嗜酸性粒细胞，直接免疫荧光证实了BP的诊断，显示基底膜带线性IgG和颗粒状C3沉积。丘疹随后发展为紧张性水疱，血清学检测支持诊断，IgG滴度升高且BP180抗体阳性。停用呋塞米作为可能的触发因素。最初使用泼尼松治疗后病情有所改善；然而，在逐渐减少用药时水疱再次出现。使用强力霉素和外用曲安奈德进一步治疗后病情有更大改善。最终，每两周注射一次度普利尤单抗有效控制了症状。该病例强调了BP的诊断挑战，尤其是在老年人中，孤立性瘙痒可能先于可见水疱性病变出现。临床医生对不明原因瘙痒的老年患者应高度怀疑BP，尤其是在标准治疗无效时。此外，该病例突出了考虑药物性BP的重要性，呋塞米被认为是一个潜在触发因素。
