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Pruritus and bullous pemphigoid in older adults
Itch is the most common skin complaint in old age and usually comes from dry skin treated with moisturisers; but persistent itch requires a search for a systemic cause, a drug or scabies — and in an older adult with itch and tense blisters, think of bullous pemphigoid, an autoimmune disease of older age treated mainly with a potent topical steroid.
Why it matters in the exam
The exam presents an 80-year-old with itch for many weeks followed by large, tense blisters on a red base on the limbs and in the folds, without mouth sores, and asks for the diagnosis: bullous pemphigoid — a subepidermal blister, antibodies against BP180 and BP230, and direct immunofluorescence with linear IgG and C3 along the basement membrane. The difference from pemphigus vulgaris: there the blisters are flaccid, the Nikolsky sign is positive and the oral mucosa is involved.
Recurring points: pemphigoid is linked to neurological diseases (dementia, Parkinson disease, stroke) and to drugs — mainly DPP-4 inhibitors (gliptins), which are stopped; first treatment is topical clobetasol over the whole body, and in extensive disease oral prednisone (about 0.5 mg/kg), with doxycycline as an alternative; and in itch without a rash check the blood count, iron, liver, kidney and thyroid tests, and review drugs.
Chronic itch harms sleep and quality of life, and scratching causes wounds and skin infections. In a care-home resident with widespread itch think also of scabies, including highly contagious crusted scabies. Prolonged itch without a cause may be the first sign of lymphoma.
Key points
- Dry skin — the common cause of itch in old age; moisturisers.
- Persistent itch — look for a systemic cause, a drug or scabies.
- Pemphigoid: tense blisters, BP180/BP230, linear IgG and C3.
- Treatment: topical clobetasol; prednisone in extensive disease; stop the gliptin.
- Pemphigus: flaccid blisters, mouth, positive Nikolsky.
Summary table
| Condition | Clues | Treatment |
|---|---|---|
| Dry skin (xerosis) | Dry, flaking skin, worse in winter and with hot showers | Moisturisers twice a day, short lukewarm showers |
| Itch from a systemic cause | Kidneys, liver (cholestasis), iron, thyroid, lymphoma | Treat the cause; blood tests |
| Scabies | Night itch, burrows, other residents itching | Permethrin; treat all contacts |
| Bullous pemphigoid | Tense blisters, itch, no mouth involvement, negative Nikolsky | Topical clobetasol; prednisone in extensive disease; stop the gliptin |
| Pemphigus vulgaris | Flaccid blisters, mouth sores, positive Nikolsky | Systemic steroids and rituximab — refer |
Free exam questions
בן 88 שוחרר ממחלקת עור לאחר אשפוז עם אבחנה של Bullous pemphigoid. אילו אברים נוספים פרט לעור יכולים להיפגע מהמחלה? (the question as examined, in Hebrew)
- א. פגיעה במערכת ההולכה של הלב עם סיכון ל- AV BLOCK
- ב. פגיעה בריריות של הפה והעיניים
- ג. פגיעה בעצמות דמויית מחלת פאג'ט
- ד. פגיעה כלייתית טובולרית הגורמת להיפוקלמיה והיפומגנזמיה
איזה מהווריאנטים הקליניים הבאים לא תואר ב-BULLOUS PEMPHIGOID? (the question as examined, in Hebrew)
- א. DYSHIDROSIFORM
- ב. ERYTHRODERMIC
- ג. LUPUS PEMPHIGOIDES
- ד. PEMPHIGOID VEGETANS
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Sources
- European guidelines (EADV) for the management of bullous pemphigoid, 2022 — Diagnosis and treatment
- Rook's Textbook of Dermatology, 10th edition (2024) — Pemphigoid group; Pruritus
- Geriatrics Review Syllabus (American Geriatrics Society), 11th edition (2022) — Dermatologic diseases and disorders
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.