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Post-Surgical Anti-BP230 Bullous Pemphigoid: A Rare Cause of Non-Healing Wound

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Case Presentation

A woman in her 80s presented with a 10-month history of a nonhealing figurate erosive lesion that traces almost precisely the outline of the surgical abdominal scar following bowel resection performed one year earlier ( Figure 1A ). The wound had not improved despite advanced wound care and topical and systemic antibiotics. While the histological examination was unspecific, direct immunofluorescence revealed the presence of linear IgG and C3 deposits at the basement membrane zone. Moreover, an enzyme-linked immunosorbent assay was positive for IgG against BP230 (30 UI/mL: reference value < 9 UI/ml), with no evidence of anti-BP180 antibodies. Clinical and laboratory findings were compatible with the post-traumatic anti-BP230 bullous pemphigoid diagnosis. The patient was treated with a tapering course of oral prednisone at a starting dose of 0.5/mg/kg/die, with rapid improvement of the condition ( Figure 1B ).

Teaching Point

Bullous pemphigoid is the most frequent autoimmune bullous disease. In most cases, it presents with itch and tense blisters over erythematous and edematous skin [ 1 ] . Although BP180 is the major autoantigen of bullous pemphigoid, some cases of patients having only anti-BP230 autoantibodies have been reported yet. Interestingly, patients having bullous pemphigoid with only anti-BP230 autoantibodies usually show a more localized clinical involvement as well as atypical clinical features; moreover, some of these cases are secondary to trauma [ 2 ] . In conclusion, bullous pemphigoid should be considered as a differential diagnosis in patients with post-surgical wounds that do not heal with conventional wound care; in these patients, steroids usually lead to a prompt remission.

References

  1. Pemphigoid diseases Schmidt E, Zillikens D. Lancet.2013;381(9863):320-332. CrossRef PubMed
  2. Bullous pemphigoid (BP) patients with selective IgG autoreactivity against BP230: Review of a rare but valuable cohort with impact on the comprehension of the pathogenesis of BP Ramcke T, Vicari E, Bolduan V, Enk A, Hadaschik E. J Dermatol Sci.2022;105(2):72-79. CrossRef PubMed

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