Nonbullous pemphigoid: Insights in clinical and diagnostic findings, treatment responses, and prognosis

Aniek Lamberts*, Joost M. Meijer, Hendri H. Pas, Gilles F. H. Diercks, Barbara Horvath, Marcel F. Jonkman

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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Background: Nonbullous pemphigoid is an under-recognized phenotype of the autoimmune bullous disease pemphigoid, characterized by the absence of blisters. Several disease aspects have not been studied previously.

Objective: To describe the characteristics of nonbullous pemphigoid.

Methods: A retrospective review study of medical records. The diagnosis of pemphigoid was based on meeting 2 of the following 3 criteria: (1) pruritus, (2) positive direct immunofluorescence microscopy, or (3) positive indirect immunofluorescence microscopy on salt-split skin.

Results: The review included 69 patients. The mean delay in diagnosis was 29 months. Skin examination most often showed pruritic papules/nodules (37%) or pruritus without primary skin lesions (22%). Histopathologic findings were mainly nonspecific. Results of direct and indirect immunofluorescence microscopy were positive in 60% and 69%, respectively. During follow-up, blisters formed in 17%, which was associated with a positive indirect immunofluorescence microscopy (P = .014) and a positive BP180 immunoblot result (P = .032). The Kaplan-Meier estimates of mortality at 1, 2, and 3 years were 14%, 34%, and 46%, respectively, with an 8.6-fold increased all-cause mortality risk.

Limitations: The retrospective study design.

Conclusions: Nonbullous pemphigoid presented with heterogeneous pruritic skin lesions, resulting in delayed diagnosis. Direct and indirect immunofluorescence microscopy are essential to diagnose nonbullous pemphigoid, in contrast to histopathology, mainly showing nonspecific findings. An increased all-cause mortality risk was observed during follow-up.

Original languageEnglish
Pages (from-to)355-363
Number of pages9
JournalJournal of the American Academy of Dermatology
Issue number2
Publication statusPublished - Aug-2019


  • autoimmune blistering disease
  • autoimmune bullous disease
  • case series
  • clinical characteristics
  • mortality
  • nonbullous pemphigoid
  • pemphigoid
  • prognosis
  • treatment
  • BP230
  • 1ST

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