Careful consideration should be given in treating bullous pemphigoid with oral steroids

Steroid alternatives should be considered for patients with bullous pemphigoid, who are most likely to be treated with oral prednisolone, according to a study.

“Bullous pemphigoid is an autoimmune disease, characterized by the formation of intensely itchy blisters, that largely affects older people,” Monica S. M. Persson, PhD, from the Centre of Evidence Based Dermatology at the University of Nottingham School of Medicine, and colleagues wrote. “Oral prednisolone has traditionally been the first-line systemic treatment for bullous pemphigoid for decades. In recent years, the benefit of safer alternatives has been demonstrated including super potent topical corticosteroids and anti-inflammatory antibiotics (eg, doxycycline), but systemic steroids are still widely used.

A prospective cohort study of patients in U.K. general practices, using data from the Clinical Practice Research Datalink, aimed to evaluate the proportion of patients with incident bullous pemphigoid prescribed oral prednisolone.

The study included 3,322 people (median age 79.7 years; 55.9% women) who met the criteria for inclusion. Of these, 2,312 (69.6%) were prescribed oral prednisolone after diagnosis. Median duration of exposure was 10.6 months, with 71.5% of prednisolone users exposed continuously for longer than 3 months, 39.8% for longer than 1 year, 14.7% for longer than 3 years, 5% for longer than 5 years and 1.7% for longer than 10 years.

Prednisolone exposure can increase the risk for osteoporosis and diabetes, as well as other comorbidities, especially in older populations who are generally more likely to have bullous pemphigoid, according to the study.

Therefore, clinicians are urged to monitor usage of large doses of prednisolone in their older patients and consider bone protection therapies and other prophylactic treatments. In addition, other treatments such as doxycycline should be considered.

“We urge clinicians to be mindful that this population, who may already be frail due to age and significant comorbidities, may be on large doses of prednisolone for substantial periods of time,” the authors wrote.