When should I refer a patient with bullous pemphigoid to a dermatologist for further management?

Refer a patient with bullous pemphigoid to a dermatologist for further management when the diagnosis is uncertain, the disease is severe, refractory to initial treatment, or when systemic corticosteroids or other specialist therapies are likely to be required. Dermatology referral is essential to confirm the diagnosis, especially as bullous pemphigoid may only become clear when the bullous stage appears, and to initiate appropriate systemic treatment if necessary NICE CKS.

In primary care, mild cases may be managed initially with topical corticosteroids, but referral should be made urgently if the patient has extensive blistering, significant symptoms, or if the condition is not responding to topical treatment NICE CKS. The dermatologist can provide specialist assessment, confirm diagnosis with immunofluorescence or biopsy if needed, and manage systemic immunosuppressive therapies NICE CKS.

European guidelines Rashid et al. 2021Schmidt et al. 2021 support this approach, emphasizing early specialist involvement for diagnosis confirmation and management of moderate to severe disease, including mucous membrane involvement or treatment-resistant cases. They recommend multidisciplinary care and specialist monitoring due to the potential side effects of systemic therapies and the chronic relapsing nature of bullous pemphigoid Rashid et al. 2021Schmidt et al. 2021.

Therefore, in general practice, refer patients with suspected or confirmed bullous pemphigoid promptly to dermatology if the diagnosis is unclear, if the disease is moderate to severe, or if systemic treatment is indicated or required NICE CKS Rashid et al. 2021Schmidt et al. 2021.