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. 2011 Oct 25;3(3):e43. doi: 10.4081/dr.2011.e43

Table 1. Distinguishing features between bullous lupus erythematosus, bullous lichen planus, bullous pemphigoid, lichen planus, lichen planus pemphigoides, and psoriasis.

Bullous lupus erythematosus Bullous lichen planus Bullous pemphigoid Lichen planus Lichen planus pemphigoides Psoriasis
Clinical features

  1. Systemic lupus erythematosus (fulfil American Rheumatism Association criteria for SLE)

  2. Symmetrical vesiculobullous eruption on trunk, proximal upper extremities, neck and face

  1. Blistering on lichen planus affected skin of life

  2. Tense bullae on skin surface with predilectioin on flexural areas

  1. Affects elderly in fifth to seventh decades papules and plaques over the extremities and trunk

  2. Wickham's striae

  3. Mucosal involvement

  1. Shiny, flat-topped violaceous to erythmatous

  2. Subepidermal blisters affecting lichen planus and non-affected skin

  1. Violaceous, planar papules and plaques plaques with overlying silvery scales affecting the buttocks, elbows, lower back, scalp and knees

  1. Symmetrically distributed, well demarcated erythematous

  2. Nail dystrophy

  3. Arthropathy
Histology

  1. Subepidermal blister withpredominant neutrophilic dermal infiltrate DIF – IgG (+/− IgA and IgM at BMZ)

  1. Intense, and exaggerated basal vacuolar alteration resulting in a subepidermal cleft

  2. Other features of LP DIF – Shaggy fibrinogen along the basement membrane and IgM ovoid bodies. Negative for IgG and C3 along the BMZ.

  1. Subepidermal blisters with predominant eosinophil infiltration. DIF – linear deposition of IgG and C3 at BMZ IIF - IgG autoantibodies that bind to the epidermal(roof) of salt-split skin substrate

  1. Epidermal acanthosis with hypergranulosis

  2. Saw-toothed appearance of rete ridges

  3. Band-like infiltrate of lymphocytes in the upper dermis

  4. Colloid bodies and apoptotic keratinocytes DIF – Shaggy fibrinogen along the BMZ and IgM ovoid bodies

  1. Subepidermal blister

  2. May occur with or without features of lichen planus DIF – IgG and C3 along the BMZ IIF – IgG autoantibodies that bind to the epidermal (roof) side of salt-split skin substrate

  1. Parakeratosis

  2. Psoriasiform hyperplasia

  3. Neutrophilic and lymphocytic exocytosis

  4. +/− Munro's microabscesses
Antibodies Type VII collagen, bullous pemphigoid antigen 1, laminin-5 and laminin -611 Associated with HLA- B7, DR1, DR10 IgG autoantibodies to bullous pemphigoid antigens Associated with HLA- B7, DR1, DR10 BP230 and BP180 Anticollagen XVII (directed against BP180), BP antigens against 200kDa, and 230-kDa Elevated levels of TNF-α HLA-Cw6
Treatment

  1. Corticosteroids

  2. Dapsone

  3. Azathioprine, methotrexate, mycophenolate mofetil

  1. Corticosteroids (topical and systemic)

  2. NBUVB, Psoralen with UV-A

  3. Acitretin, sulfasalazine

  1. Corticosteroids (topical and systemic)

  2. Tetracycline, nicontinamide, and erythromycin

  3. Azathioprine, methotrexate, mycophenolate mofetil, cyclophosphamide

  4. Rituximab

  1. Corticosteroids (topical and systemic)

  2. NBUVB, Psoralen with UV-A

  3. Acitretin, sulfasalazine

  1. Corticosteroids (topical and systemic)

  2. Tetracycline and nicontinamide

  3. Isotretinoin, dapsone, azathioprine, methotrexate, mycophenolate mofetil

  1. Topical corticosteroids

  2. Vitamin D analogues, topical retinoids

  3. Phototherapy

  4. Methotrexate, acitretin, ciclosporin, hydroxyurea

  5. Biologics

BMZ, basement membrane zone; DIF, direct immunofluorescence; HLA, human leukocyte antigen; IIF, indirect immunofluorescence; TNF, tumour necrosis factor.