How do you manage patients with bullous pemphigoid who have IgE autoantibodies to BP180?

40% of patients with BP can have IgE class autoantibodies directed against BP. Treatment does not have to differ from patients without IgE class autoantibodies: for mild or localized disease or in patients who cannot tolerate immunosuppression, doxycycline and high potency topical steroids can be used. Otherwise, prednisone (0.5 - 1 mg/kg/day) and a steroid-sparing agent (MMF, MTX, or AZA) can be used; rituximab is a good option for refractory disease.

Omalizumab can be used, and in the short term, omalizumab can be as effective as rituximab. But long term remission is unlikely with omalizumab, and there is a high relapse rate. In contrast, rituximab is associated with a much lower rate of relapse. However, for patients with comorbidities o...