Milia En Plaque After Bullous Pemphigoid: An Unusual Sequela

We present the case of a 36-year-old paraplegic woman with a history of spinal cord injury who developed a generalized blistering rash, later diagnosed as bullous pemphigoid (BP). During her hospitalization, she was treated with prednisone and rituximab infusions, transitioning to maintenance therapy with topical steroids, doxycycline, and nicotinamide. A year later, she presented with concerns about a BP flare on her feet. Examination revealed 1-2 mm white, dome-shaped papules coalescing into erythematous plaques on the plantar surfaces, leading to a diagnosis of milia en plaque (MEP). Treatment with tretinoin 0.05% cream resulted in near-complete resolution within six months. MEP is a rare but benign condition characterized by keratinous cysts on erythematous plaques, often linked to immunobullous disorders such as epidermolysis bullosa acquisita or mucous membrane pemphigoid, and only rarely associated with BP. Distinguishing MEP from active BP is critical, as the latter requires immunosuppressive therapy, while MEP can be managed conservatively. This case underscores MEP as a sequela of BP, highlighting the importance of accurate diagnosis and appropriate management.