SLR - January 2023 - Carmen Johnson, DPM
Title: Lower Extremity Salvage in the Setting of Bullous Pemphigoid Exacerbation: A Case ReportReference: Pollock S, Rice S, Ferree S, Friedstat J, Eberlin K, Kourosh A. Lower Extremity Salvage in the Setting of Bullous Pemphigoid Exacerbation: A Case Report. Plastic and Reconstructive Surgery - Global Open. 2021; 9 (8): e3722. doi: 10.1097/GOX.0000000000003722.
Level of Evidence: Level 4
Reviewed By: Carmen Johnson, DPM
Residency Program: Corewell Health Farmington Hills – Farmington Hills, MI
Podiatric Relevance: Bullous pemphigoid is an autoimmune disease affecting the skin, often in the lower extremities. Patients with a past medical history of bullous pemphigoid are at risk of reactivation after a period of quiescence with surgery or debridement of wounds. It is important to take this into consideration with surgical planning. Timely diagnosis and treatment are necessary to prevent morbidity, limb loss and death. As podiatric practitioners, it is important to recognize this dermatologic presentation in the lower extremities in order to adequately formulate a patient treatment plan.
Methods: Case report of 71-year-old female with past medical history of epidermal growth factor positive, metastatic lung adenocarcinoma on erlotinib chemotherapeutic drug presented with chronic nonhealing ulceration of the left distal leg. Biopsy revealed basal cell carcinoma. She then presented one month later with bullae on bilateral lower extremities which were biopsied and found contain pathologic features consistent with bullous pemphigoid. Erlotinib was then discontinued due to concern for precipitating bullous pemphigoid recurrence. Intravenous immunoglobulin (IVIG) and methotrexate were initiated with subsequent resolution of the bullous pemphigoid. The patient then received radiation therapy for basal cell carcinoma therapy with re-initiation of erlotinib chemotherapy for the lung adenocarcinoma, after which the bullous pemphigoid then recurred. At this time, topical steroids, oral steroid taper, IVIG, and methotrexate were initiated and the recurrent radiation induced bullous pemphigoid subsequently resolved again. At this time, local wound care including debridement, free rectus abdominus muscle flap, and split thickness skin graft were performed to treat the remaining lower extremity ulceration.
Results: The lower extremity ulceration that presented secondary to chemotherapy induced bullous pemphigoid eruption eventually went on to heal with treatment of IVIG, methotrexate, steroids, debridement, free rectus abdominus muscle flap, and split thickness skin graft. This was complicated by recurrent eruption of bullous pemphigoid with re-initiation of chemotherapeutic agents.
Conclusions: In this article, the authors concluded that patients with history of bullous pemphigoid while undergoing certain chemotherapeutic agents are at risk of bullous pemphigoid reactivation with the trauma of surgery, trauma, or radiation therapy. In cases of traumatically, surgically, or radiation induced reactivation of bullous pemphigoid, skin grafts and muscle flaps in combination with IVIG, methotrexate, and oral steroids may be required to heal lower extremity ulceration defects.