Bullous pemphigoid (BP) is a life-threatening blistering skin disease. Urticaria and trauma to the skin are common underlying causes of bullae, especially in elderly patients. In certain cases, morbidity and mortality may increase due to infected bullae. We present an 82-year-old woman with severe BP after a fractured left leg. Bullae and toenail deformity occurred on both lower extremities. Biopsy direct immunofluorescence showed subepidermal blistering with numerous eosinophils. The dermal-epidermal junction showed 2+ IgG, C3 and granular IgM.
We started her on a regimen of omalizumab 300 mg subcutaneously every four weeks. Within a week, she reported significantly decreased pain and healing time of lesions. Incidentally, bilateral erythematous, non-blistering dermatitis developed five centimeters distal to the injection sites within a week of her first injection and resolved spontaneously. Nail and skin tissue healed and grew back within a two days of drug administration. In the fourth week of each treatment cycle, she develops new blisters in the legs, in the usual areas. She continues to tolerate the omalizumab injections well after four months of treatment and has not developed the injection site dermatitis since the first administration.