Selective immunosuppression for chronic pemphigoid ulceration in the setting of multiple comorbidities.

An 82-year-old male with a history of poorly controlled type 2 diabetes mellitus (T2DM) was admitted for a chronic, non-healing ulceration of his left lower extremity. A 4mm punch biopsy of the ulceration sent for direct fluorescent antibody testing showed positive immunofluorescence consistent with a diagnosis of bullous pemphigoid (BP).

The patient also had significant medical comorbidities, including a below the knee amputation of his right lower extremity and amputation of his 10 left lower extremity digits, resulting in impaired mobility and consequently the development of a non-healing sacral ulcer. Initially, topical steroids were used without improvement of his ulceration. Brief trials of prednisone were attempted but stopped due to increases in his blood glucose levels.

Subsequently, the patient’s case was further complicated by the development of osteomyelitis secondary to his sacral ulcer, limiting the ability to treat his BP with other conventional systemic immunosuppressive therapies. Thus, the decision was made to start dupilumab, a novel therapeutic option for BP. Dupilumab is a humanized recombinant monoclonal antibody that targets interleukin-4α receptors, inhibiting both interleukin-4 and interleukin-13 to reduce inflammation. A previous single-center retrospective study showed efficacy of dupilumab in the management of moderate-to-severe BP in the absence of significant comorbidities.1 Furthermore, dupilumab is generally well-tolerated by patients and side effects are typically mild in nature. Within 12 weeks of initiating dupilumab, the patient’s leg ulceration begun to show significant improvement characterized by re-epithelization of the ulcer without impairing the resolution of his osteomyelitis or elevating his blood glucose levels.

In conclusion, older adults with multiple comorbidities who present with chronic ulcerations are a common but challenging demographic. This case discusses the unique considerations of treating autoimmune-induced skin ulcerations in the setting of other significant medical comorbidities. As demonstrated in this case, selective immunologic blockage with medications like dupilumab may serve an important role in the management of immunologic-induced ulcerations in the setting of multiple medical comorbidities.