Derm Cases · Dermatology / Geriatric Medicine
OSCE — tense bullae in the elderly: bullous pemphigoid work-up and first-line therapy
An 8-minute OSCE station on recognition of bullous pemphigoid, distinction from pemphigus and other bullous disease, diagnostic biopsy/IF strategy, drug triggers, and modern first-line management including high-potency topical corticosteroids.
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Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on recognition of bullous pemphigoid, distinction from pemphigus and other bullous disease, diagnostic biopsy/IF strategy, drug triggers, and modern first-line management including high-potency topical corticosteroids.
Brief (to candidate)
An 78-year-old man has intense pruritus for 6 weeks followed by tense blisters on urticarial plaques over the thighs, flexures and lower abdomen. Mucosa is spared. He takes a DPP-4 inhibitor for type 2 diabetes and a loop diuretic. You have 8 minutes to diagnose, plan investigations and outline first-line management.
Candidate instructions
- Recognise bullous pemphigoid morphology and demographics.
- Differentiate from pemphigus vulgaris, linear IgA disease, mucous membrane pemphigoid, and bullous scabies.
- Plan histology + direct immunofluorescence correctly (sites).
- Review drug triggers and comorbidities.
- Outline first-line therapy and when systemic/steroid-sparing agents are needed.
- Safety-net infection, mobility and elderly frailty issues.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Elderly patient; tense bullae on urticarial/eczematous base; intense pruritus; mucosa usually spared vs pemphigus[1][2] |
| Differential | Pemphigus: flaccid blisters, Nikolsky +, mucosa common, intraepidermal; BP: subepidermal, tense, elderly; consider drug-induced and pretibial/atypical BP |
| Investigations | Lesional biopsy for H&E (subepidermal split, eosinophils) + perilesional DIF (linear IgG/C3 at BMZ); optional salt-split, ELISA BP180/BP230[3] |
| Triggers | Reviews DPP-4 inhibitors, loop diuretics, PD-1/PD-L1 inhibitors; stop culprit if drug-induced BP likely[4] |
| First-line Rx | Super-potent topical clobetasol whole-body regimen is first-line for many (including extensive disease) when practical; systemic corticosteroids if needed; steroid-sparing (e.g. doxycycline/nicotinamide, MTX, dapsone in selected, biologics in refractory) per specialist care[1][2] |
| Supportive care | Wound care, infection watch, VTE risk, glucose control on steroids, physiotherapy/mobility, caregiver plan |
| Communication | Explains chronic relapsing autoimmune disease; drug list review; dermatology follow-up |
Model key actions
- Diagnose classic bullous pemphigoid in elderly with tense bullae and pruritus.[1]
- Dual biopsy strategy: lesional H&E + perilesional DIF.[3]
- Stop possible drug triggers; start high-potency topical steroid-based first-line pathway and supportive care.[2][4]
Common errors
- Treating as pemphigus with the wrong immunofluorescence expectations.
- Biopsying only the blister roof without perilesional DIF.
- Ignoring DPP-4 inhibitor / diuretic drug history.
- High-dose systemic steroids in frail elderly without considering topical-first evidence-based approach.
- Missing secondary infection / mobility complications.
References4ShowHide
- [1]Akbarialiabad H, Schmidt E, Patsatsi A, et al. Bullous pemphigoid. Nature Reviews Disease Primers, 2025.PMID 39979318
- [2]Bernard P, Antonicelli F. Bullous Pemphigoid: A Review of its Diagnosis, Associations and Treatment. American Journal of Clinical Dermatology, 2017.PMID 28247089
- [3]Miyamoto D, Santi CG, Aoki V, et al. Bullous pemphigoid. Anais Brasileiros de Dermatologia, 2019.PMID 31090818
- [4]Verheyden MJ, Bilgic A, Murrell DF. A Systematic Review of Drug-Induced Pemphigoid. Acta Dermato-Venereologica, 2020.PMID 32176310