What treatment combination approach would you recommend for mucous membrane pemphigoid?

First, it is important to know the extent and severity of the disease (oral, ocular, esophageal); the type of inflammatory infiltrate on histopathology (neutrophils, eosinophils, or cell-poor); and the results of salt split skin and antibody titers on monkey esophagus and/or target antigens (collagen 7, laminin 332, α6β4 integrin, or BP180/230).

Manage mild disease with topical steroids and/or minocycline or doxycycline 100 mg PO BID and niacinamide 500 mg PO TID.

For refractory mild or moderate disease, add oral steroids (0.5-1 mg/kg/day) and a steroid-sparing agent (dapsone if there is a neutrophilic infiltrate; otherwise, mycophenolate mofetil, azathioprine, or methotrexate).

For refractory moderate and severe disease, add IVIG and incre...

I agree with @Dr. First Last. I have a low threshold for going to rituximab in these patients. There is a huge spectrum of severity of this disease; however, and occasionally, topicals alone are effective for mild disease, but always monitor ocular and other non-oral disease very closely and bring out the "big guns" early when this occurs. I don't tend to use much IVIG in this group, and when I do, it is usually in combination with rituximab (or when I can't safely use other things). In my experience, both MMF and methotrexate can actually be pretty effective in a significant number of patients, and I have used both in combination with rituximab when needed.

I used to participate in a collaborative clinic with oculoplastics, cornea and derm and the collaboration was critical in treating this terrible disease.

MMP is not at all a benign disease. It's ocular scarring is irreversible and disease activity in the eye is hard to monitor since past damage will continue to give irritation which is hard to separate from activity of MMP

I'm not aware of controlled trials for any drug.

If disease is limited to the mouth then doxy + steroid is sometimes effective. I cannot imagine what niacinamide would add.

For more serious disease,Dapsone was used in the past and should be avoided. It barely works and seems to have more AE in this group. Likewise imuran. Cellcept does a little. For bad disease cytoxan ha...