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PubMed This is a summary of 17 peer-reviewed journal articles Updated
Dermatology

Managing Your Care and Blisters

At a Glance

Managing bullous pemphigoid requires a combination of gentle daily skin care and medical therapy to calm the immune system. Core treatments include corticosteroids, steroid-sparing agents like doxycycline, and advanced biologics. Never pop blisters, as they protect the skin from infection.

Managing Bullous Pemphigoid (BP) requires a careful balance between clearing the skin and protecting your overall health. Because BP most commonly affects older adults, doctors prioritize treatments that minimize the risk of serious side effects while effectively cooling down the overactive immune system [1][2].

Daily Skin and Blister Care

While medication treats the internal cause, proper daily wound care is critical for healing and preventing infections [3]:

  • Do Not Pop the Blisters: The roof of the blister acts as a sterile, natural biological dressing. Puncturing it increases the risk of infection [4].
  • Gentle Cleansing: Wash the affected areas gently with mild soap and water. Do not scrub [5].
  • Protecting Broken Blisters: If a blister breaks naturally, cover the raw skin with a non-stick pad (such as a silicone dressing) or soft gauze [5].
  • Clothing: Wear loose, soft cotton clothing to prevent friction and rubbing [4].

The Foundation of Treatment: Corticosteroids

Corticosteroids (often just called “steroids”) rapidly reduce the inflammation that causes skin layers to separate [6].

Treatment Type Pros Cons
Topical Creams (e.g., clobetasol) Highly effective; avoids many internal side effects; protects blood sugar and bones [5][6]. Can be very difficult and time-consuming for patients or caregivers to apply to the whole body daily [5].
Oral Pills (e.g., prednisone) Easy to take; clears widespread blisters quickly [7]. High risk of serious side effects like weakened bones, elevated blood sugar, and infections over time [1][8].

Steroid-Sparing Strategies

To avoid the risks of long-term oral steroids, doctors introduce “steroid-sparing” agents. This allows them to lower your steroid dose while keeping the disease under control [9].

  • Doxycycline and Niacinamide: This combination of an antibiotic (doxycycline) and a B-vitamin (niacinamide, also called nicotinamide) works together to reduce inflammation without the severe risks of steroids. It is highly effective for mild to moderate BP and much safer for long-term use [10][7].
  • Immunosuppressants: Medications like methotrexate, azathioprine, or mycophenolate mofetil may be added to help quiet the immune system [9].

Advanced and Biologic Therapies

If standard treatments are not enough, targeted “biologic” medications may be used [11][12].

  • Dupilumab: Originally for eczema, this has shown great promise in treating BP with a very high safety profile [13][14].
  • Omalizumab: Often used if blood tests show high levels of IgE [15][16].
  • Rituximab: A powerful therapy that clears out the B-cells responsible for making the autoantibodies [17].

For details on the side effects to watch for during treatment, read Monitoring and Long-Term Outlook.

Common questions in this guide

Should I pop my bullous pemphigoid blisters?
No, you should never pop the blisters. The roof of the blister acts as a natural, sterile dressing that protects the raw skin underneath and helps prevent infection.
What is the best way to clean the skin during a BP flare-up?
Wash the affected areas gently using mild soap and water without scrubbing. If a blister breaks naturally, cover the raw skin with a non-stick silicone dressing or soft gauze.
Why are topical steroid creams preferred over oral pills for BP?
Topical steroid creams treat the skin directly while avoiding many internal side effects. This helps protect your blood sugar levels and bone health, which can be negatively affected by long-term oral steroids like prednisone.
What is a steroid-sparing treatment for bullous pemphigoid?
Steroid-sparing treatments are medications that control the disease so your doctor can safely lower your steroid dose. A common combination is doxycycline and niacinamide, which reduces inflammation without the severe risks of long-term steroids.
Are there targeted biologic therapies for severe bullous pemphigoid?
Yes, if standard treatments aren't enough, doctors may prescribe biologic medications like dupilumab, omalizumab, or rituximab. These targeted therapies work by calming specific parts of the overactive immune system responsible for the blisters.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Based on the number of blisters I have, is my condition considered mild, moderate, or severe?
  2. 2.Am I a candidate for topical steroid creams instead of oral pills to protect my blood sugar and bone health?
  3. 3.Would starting a combination of doxycycline and niacinamide be a safe 'steroid-sparing' approach for me?
  4. 4.If I cannot taper off steroids safely, which immunosuppressant agent is safest for me?
  5. 5.At what point should we consider advanced biologic therapies like dupilumab or omalizumab?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (17)
  1. 1

    An open, multicentre, randomized clinical study in patients with bullous pemphigoid comparing methylprednisolone and azathioprine with methylprednisolone and dapsone.

    Sticherling M, Franke A, Aberer E, et al.

    The British journal of dermatology 2017; (177(5)):1299-1305 doi:10.1111/bjd.15649.

    PMID: 28494097
  2. 2

    Prognostic factors for mortality in bullous pemphigoid: A systematic review and meta-analysis.

    Chen X, Zhang Y, Luo Z, et al.

    PloS one 2022; (17(4)):e0264705 doi:10.1371/journal.pone.0264705.

    PMID: 35427358
  3. 3

    Assessment of the Characteristics and Associated Factors of Infectious Complications in Bullous Pemphigoid.

    Chen J, Mao X, Zhao W, et al.

    Frontiers in immunology 2020; (11()):1607 doi:10.3389/fimmu.2020.01607.

    PMID: 32793235
  4. 4

    Unilateral, localized bullous pemphigoid in a patient with chronic venous stasis.

    Shi CR, Charrow A, Granter SR, et al.

    JAAD case reports 2018; (4(2)):162-164 doi:10.1016/j.jdcr.2017.09.032.

    PMID: 29387773
  5. 5

    Autoreactive Peripheral Blood T Helper Cell Responses in Bullous Pemphigoid and Elderly Patients With Pruritic Disorders.

    Didona D, Scarsella L, Fehresti M, et al.

    Frontiers in immunology 2021; (12()):569287 doi:10.3389/fimmu.2021.569287.

    PMID: 33841390
  6. 6

    Adjuvant treatment of severe/refractory bullous pemphigoid with protein A immunoadsorption.

    Hübner F, Kasperkiewicz M, Knuth-Rehr D, et al.

    Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG 2018; (16(9)):1109-1118 doi:10.1111/ddg.13642.

    PMID: 30179319
  7. 7

    Prospective study in bullous pemphigoid: association of high serum anti-BP180 IgG levels with increased mortality and reduced Karnofsky score.

    Holtsche MM, Goletz S, van Beek N, et al.

    The British journal of dermatology 2018; (179(4)):918-924 doi:10.1111/bjd.16553.

    PMID: 29607480
  8. 8

    Multimorbidity in bullous pemphigoid: a case-control analysis of bullous pemphigoid patients with age- and gender-matched controls.

    Sim B, Fook-Chong S, Phoon YW, et al.

    Journal of the European Academy of Dermatology and Venereology : JEADV 2017; (31(10)):1709-1714 doi:10.1111/jdv.14312.

    PMID: 28485892
  9. 9

    Association of bullous pemphigoid and comorbid health conditions: a case-control study.

    Lee S, Rastogi S, Hsu DY, et al.

    Archives of dermatological research 2021; (313(5)):327-332 doi:10.1007/s00403-020-02100-2.

    PMID: 32647978
  10. 10

    Doxycycline versus prednisolone as an initial treatment strategy for bullous pemphigoid: a pragmatic, non-inferiority, randomised controlled trial.

    Williams HC, Wojnarowska F, Kirtschig G, et al.

    Lancet (London, England) 2017; (389(10079)):1630-1638 doi:10.1016/S0140-6736(17)30560-3.

    PMID: 28279484
  11. 11

    Emerging treatments for bullous pemphigoid.

    Garrido PM, QueiróS CS, Travassos AR, et al.

    The Journal of dermatological treatment 2022; (33(2)):649-661 doi:10.1080/09546634.2020.1782325.

    PMID: 32536232
  12. 12

    Emerging Biomarkers and Therapeutic Strategies for Refractory Bullous Pemphigoid.

    Zhou T, Peng B, Geng S

    Frontiers in immunology 2021; (12()):718073 doi:10.3389/fimmu.2021.718073.

    PMID: 34504496
  13. 13

    Real-world evaluation of the effectiveness and safety of dupilumab in bullous pemphigoid: an ambispective multicentre case series.

    Planella-Fontanillas N, Bosch-Amate X, Jiménez Antón A, et al.

    The British journal of dermatology 2025; (192(3)):501-509 doi:10.1093/bjd/ljae403.

    PMID: 39418120
  14. 14

    Use of dupilumab for recalcitrant bullous pemphigoid: A case report.

    Lamb J, Purdy K, Sutherland A

    SAGE open medical case reports 2024; (12()):2050313X241274855 doi:10.1177/2050313X241274855.

    PMID: 39185064
  15. 15

    Bullous pemphigoid successfully treated with omalizumab.

    Gönül MZ, Keseroglu HO, Ergin C, et al.

    Indian journal of dermatology, venereology and leprology 2016; (82(5)):577-9 doi:10.4103/0378-6323.183628.

    PMID: 27297272
  16. 16

    Detection of IgE autoantibodies to BP180 and BP230 and their relationship to clinical features in bullous pemphigoid.

    Hashimoto T, Ohzono A, Teye K, et al.

    The British journal of dermatology 2017; (177(1)):141-151 doi:10.1111/bjd.15114.

    PMID: 27716903
  17. 17

    Treatment of recalcitrant bullous pemphigoid (BP) with a novel protocol: A retrospective study with a 6-year follow-up.

    Ahmed AR, Shetty S, Kaveri S, Spigelman ZS

    Journal of the American Academy of Dermatology 2016; (74(4)):700-8.e3.

    PMID: 26851830

This page provides general information on bullous pemphigoid treatments and daily blister care. It is not a substitute for professional medical advice from your dermatologist or healthcare team.

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