Lower Extremity Salvage With Free Tissue Transfer in the Setting of Bullous Pemphigoid

Bullous pemphigoid (BP) is a rare but devastating autoimmune dermatologic condition and can be triggered by infection, trauma, radiation, or surgery, all conditions routinely encountered by reconstructive surgeons. Chronic wounds secondary to BP are difficult to manage with local wound care and can necessitate soft tissue coverage, yet there remains a paucity of literature surrounding the evaluation and management of autoimmune skin conditions as they relate to the reconstructive surgeon. A 57-year-old man presented with a chronic left heel wound secondary to BP, and despite medical therapies, continued to have worsening ulcerations. He underwent debridement of the wound followed by free anterolateral thigh flap reconstruction. On postoperative day 3, he developed erythema and blistering of the distal edge skin flap. The dangle protocol was halted, and dermatology was consulted, who recommended 0.05% clobetasol cream applied to the areas of erythema. By the day of discharge on postoperative day 16, the flap remained stable in appearance, and erythema had significantly improved. Literature surrounding the management of chronic wounds in patients with pemphigoid diseases remains scarce. This case report added to the literature on the evaluation and management of wounds in these patients. The ideal treatment of chronic wounds secondary to BP necessitates the involvement of a multidisciplinary team, stabilization of the dermatologic disease preoperatively, aggressive resection of diseased tissue, and adequate wound bed preparation. Following this, the preferred method of reconstruction should take into consideration the pathophysiologic mechanism of the disease, followed by close postoperative monitoring and early intervention for postoperative skin changes.