Bullous Pemphigoid: A Multifactorial Review of a Dermatologic Mystery

Bullous pemphigoid is the most common autoimmune bullous skin disease and primarily affects patients older than 60 years. This chronic disease can lead to significant morbidity characterized by spontaneous remissions and exacerbations. Although the etiopathogenesis is uncertain, it is proposed that certain drugs (especially polypharmacy), vaccinations, infections, and exposures precede the dermatological presentation. Bullous pemphigoid patients initially present with moderate-to-severe pruritis with or without eczematous or urticarial lesions, followed by the development of cutaneous bullae weeks to months later testing with a notable false-positive Nikolsky sign. As frontline providers, emergency department nurse practitioners should be aware of these skin diseases in the elderly. Prompt recognition of bullous pemphigoid leads to an earlier diagnosis and management of this common autoimmune bullous skin disease and requires clinicians to have critical observation skills.