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A Systematic Review of Treatments for Bullous Pemphigoid
Nonhlanhla P. Khumalo, MD;
Dedeé F. Murrell, MD;
Fenella Wojnarowska, MD;
Gudula Kirtschig, MD
Arch Dermatol. 2002;138:385-389.
Objective To assess the effectiveness of treatments for bullous pemphigoid.
Methods The Cochrane Library search strategy was used to identify randomized
controlled trials from MEDLINE and EMBASE, from their inception to September
30, 2001. All randomized controlled trials on interventions for bullous pemphigoid,
confirmed by immunofluorescence studies, were included.
Results We found 6 randomized controlled trials with a total of 293 patients.
Two trials, one comparing prednisolone, 0.75 mg/kg per day, with prednisolone,
1.25 mg/kg per day, and the other comparing methylprednisolone with prednisolone,
did not find any significant difference in effectiveness. The higher dose
of prednisolone, however, was associated with more severe adverse effects.
Combination treatments of prednisone with azathioprine in one trial and of
prednisolone with plasma exchange in another were useful in halving the corticosteroid
dose required (mean ± SD, 0.52 ± 0.28 mg/kg in the plasma exchange–treated
group vs 0.97 ± 0.33 mg/kg in the prednisolone only–treated group).
However, a fifth trial, including all 3 treatment groups (prednisolone alone,
prednisolone and azathioprine, and prednisolone and plasma exchange), failed
to confirm the benefit of combination treatment over prednisolone alone. A
trial of 20 patients, comparing prednisone with tetracycline and niacinamide,
found no statistically significant difference in response between the 2 groups,
but the prednisone-treated group had more serious adverse effects.
Conclusions There is inadequate evidence for a recommendation of a specific treatment
for bullous pemphigoid, and there is a need for larger randomized controlled
trials with adequate power. Starting doses of prednisolone greater than 0.75
mg/kg per day do not seem to give additional benefit, and it seems that lower
doses may be adequate for disease control. The effectiveness of the addition
of plasma exchange or azathioprine to corticosteroids has not been established.
Combination treatment with tetracycline and niacinamide seems useful, although
this needs further validation.
From the Departments of Dermatology, The Churchill Hospital, Oxford,
England (Drs Khumalo, Wojnarowska, and Kirtschig); Groote Schuur Hospital,
Capetown, South Africa (Dr Khumalo); St George Hospital, The University of
New South Wales, Sydney, Australia (Dr Murrell); and Vrije Universiteit Medical
Centre, Amsterdam, the Netherlands (Dr Kirtschig).
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