Treatment and Diagnosis Strategies for Bullous Pemphigoid, With Donna Culton, MD, PhD

Donna Culton, MD, PhD, spoke in an interview with HCPLive at the 2025 Fall Clinical Dermatology Conference in Las Vegas, highlighting notable takeaways from her portion of the session, ‘Bullous Pemphigoid: The Time to Treat is Now.’1

Cutlon’s discussion with HCPLive focused on takeaways from this talk on bullous pemphigoid. This talk, co-presented by Culton and Prince Adotma, MD, highlighted the emergence of non-bullous presentations, such as urticaria and eczematous eruptions, in over half of patients.

“One of the newer concepts that we're realizing is, is this concept of non-bullous pemphigoid,” Culton said. “A lot of patients, we know, will start with a prodromal urticarial phase. But what we're realizing is, oftentimes, it's not just a prodrome, and sometimes it's more than just urticaria. So, for non-bullous pemphigoid, in over half of patients, the first presentation of their pemphigoid is not blisters. It can be urticaria. It can be an eczematous eruption. It can be prurigo nodularis-like lesions. Even itch in an elderly patient should really be tipping us off.”

About 20% of patients never go on to develop blisters, Culton noted, highlighting a study in which investigators’ follow-up interactions over 18 months demonstrated a lack of blisters in patients with the condition.

“We really need to be thinking about this condition in patients over 60, and certainly over 70, any new onset, pruritic eruption, and be thinking about pemphigoid,” Culton said. “So, you might ask, ‘Well, how do we make the diagnosis of pemphigoid, whether it be bullous or non-bullous?’ We all know that you do a biopsy for routine light microscopy, or for H and E, and that typically will show a subepidermal split with the eosinophils when the patient has blisters. But if they don't have blisters, it may not show that. In fact, it might just show eosinophilic spongiosis or examination eruption.”

In light of this, Culton noted the real way to confirm the diagnosis would be a biopsy with direct immunofluorescence.

“You remember that has to be perilesional, so not on the blister, and it should show IgG and C3 at the basement membrane zone,” Culton explained. “And that really is the key to making the diagnosis, because that would be positive whether the pemphigoid is presenting with blisters or without blisters.”

To find out more information about this topic and other points made in this interview, view Culton’s full video above.

The quotes included in this summary article were edited for clarity.

Culton previously reported the following disclosures: Argenx, Advisory board; iCell, Consultant; Sanofi Genzyme, Advisory board; Sitala, Consultant; Regeneron, Consultant and Investigator; Cabaletta, Investigator; Incyte, Investigator and Stockholder; and Lilly, Investigator.

References

1. Adotama P, Culton D. Seminar-in-Depth: Bullous Pemphigoid: The Time to Treat is Now. Session presentation at the 2025 Fall Clinical Dermatology Conference, Las Vegas, Nevada, Oct 23-26, 2025.