Track

Abstract

A 79- year-old male with past medial history significant for bullous pemphigoid and recent right composite submental resection for buccal invasive, moderately differentiated squamous cell carcinoma presented with bulla and ulcerations confined to the recipient mandibular and autograft donor anterolateral thigh sites. His bullous pemphigoid was previously well controlled with dupilumab for over one year. The rest of his exam was without lesions. He denied associated pain or pruritus. These lesions were non-responsive to topical corticosteroids, oral and topical antibiotics. The differential diagnosis for these lesions included pyoderma gangrenosum. A 4mm punch biopsy was performed at the ulcer edge for histopathologic evaluation and an additional biopsy performed for direct immunofluorescence. The histopathology was significant for suppurative epidermal ulceration with adjacent lacunae formation with dermal eosinophils. Direct immunofluorescence demonstrated antibody localization in a linear pattern along the basement membrane zone for immunoglobulin IgG and complement C3. Considering the clinic presentation of bulla, histopathologic findings of subepidermal lacunae formation and a positive linear direct immunofluorescence for IgG and C3 at the basement membrane zone, the diagnosis of bullous pemphigoid was favored. While the patient had a prior history of bullous pemphigoid, he was in remission with dupilumab which was continued during his peri-operative course. There are rare reports of trauma induced bullous pemphigoid but this has not been reported in previously well controlled patients on therapy. Patients should be monitored closely in the post-operative course for disease progression regardless of their disease control. Bullous pemphigoid should be considered with post-operative bulla formation.