Clinically Probable Generalized Bullous Pemphigoid in an 81-Year-Old Woman: A Case Report

Abstract

Bullous pemphigoid is the most common autoimmune subepidermal blistering disorder in older adults, but definitive diagnosis generally requires immunopathologic confirmation. This report describes an 81-year-old Indonesian woman with a one-week history of generalized, symmetric, tense bullae measuring approximately 0.5-3 cm on erythematous skin, accompanied by erosions, crusting, and several purulent-appearing lesions. Oral and genital mucosae were unaffected. Histopathology, direct and indirect immunofluorescence, BP180/BP230 serology, and bacterial culture were unavailable. Based on advanced age, generalized tense bullae, absent mucosal involvement, and lack of scarring, clinically probable generalized bullous pemphigoid with suspected secondary bacterial infection was diagnosed. Treatment included systemic methylprednisolone, topical clobetasol, wound care, antihistamine therapy, and empiric antibiotics. During six days of hospitalization, new blister formation appeared to decrease and many lesions became dry and crusted, although long-term follow-up was unavailable. The case emphasizes that diagnostic certainty must match the available evidence. In resource-limited settings, referral for immunopathologic confirmation, toxicity-conscious corticosteroid use, microbiologically guided antibiotic therapy, and close monitoring of older patients remain essential.