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Bullous pemphigoid in a lichen sclerosus lesion

Published:August 06, 2022DOI:https://doi.org/10.1016/j.ajog.2022.07.050
      A 72-year-old woman obtained consultation for a 2-week history of anogenital erosions and bullae resulting in pain and a burning sensation. She had a history of lichen sclerosus. Physical examination revealed a white patch surrounding the anogenital area with erosions and ruptured bullae (Figure 1). Histologic examination depicted a subepidermal mononuclear inflammatory infiltrate and subepidermal blistering (Figure 2). Direct immunofluorescence microscopy of a skin biopsy showed linear deposits of immunoglobulin G and C3 along the dermoepidermal junction (Figure 3). An enzyme-linked immunosorbent assay test demonstrated positive serum autoantibodies against BP180. Polymerase chain reactions for varicella-zoster and herpes simplex viruses were negative. These findings were consistent with bullous pemphigoid associated with preexisting lichen sclerosus. Bullous pemphigoid is an uncommon autoimmune pruritic skin disease that may involve the formation of blisters in the space between the epidermal and dermal skin layers. Topical treatment with clobetasol propionate ointment 0.05% once daily was successful. The desired outcomes may not always be achieved with topical treatment, and systemic immunosuppressive treatment could be required. We advise taking a skin biopsy for direct immunofluorescence in case of an atypical clinical presentation of vulvar skin/mucosal disease.
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      Figure 1Erosions, ruptured bullae, and a white patch surrounding the anogenital area
      Boeijink. Bullous pemphigoid in a lichen sclerosus lesion. Am J Obstet Gynecol 2022.
      Figure thumbnail gr2
      Figure 2Hematoxylin and eosin-stained tissue section
      A, Subepidermal mononuclear inflammatory infiltrate. B, Subepidermal blistering. C, Horizontally oriented collagen bundles. D, The absence of rete ridges.
      Boeijink. Bullous pemphigoid in a lichen sclerosus lesion. Am J Obstet Gynecol 2022.
      Figure thumbnail gr3
      Figure 3Direct immunofluorescence microscopy of lesional skin
      Evidence of linear deposition of immunoglobulin G (A) and C3 (B).
      Boeijink. Bullous pemphigoid in a lichen sclerosus lesion. Am J Obstet Gynecol 2022.
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