Bullous Pemphigoid (BP) is a chronic, autoimmune disease with blisters in the sub-epidermal part of the skin as its predominant manifestation. This condition may persist for months or years, with a tendency to spontaneous remissions and exacerbations.
Since it may be confused with another similar sounding disease, Pemphigus vulgaris (PV), which also targets the skin, the distinguishing characteristics of each are highlighted here. PV is comparatively more common, is limited to the upper epidermis, almost always involves the mucous membrane, features blisters which rupture easily, and has a higher fatality rate. On the other hand, BP is located between the dermis and epidermis, the tense blisters do not break easily, mucous membrane involvement is much lesser, and it is more amenable to treatment, though it too can be fatal in the elderly or debilitated people. Both diseases can be diagnosed using skin biopsy for Direct Immunoflourescence test (DIF) and Indirect Immunoflourescence test (IDIF) using serum. While autoantibodies desmoglein 1 and 3 denote PV disease, the presence of anti-BPA 1 and 2 confirm a diagnosis of BP.
The standard treatment of BP aims to reduce and heal blisters and erosions and prevent recurrence with continued use of the minimum possible dosage of medicines. Treatment includes anti-inflammatory drugs like corticosteroids, tetracycline and dapsone; and immune suppressant drugs like azathioprine, methotrexate, mycophenolate mofetil and cyclophosphamide. Doxycycline can be used as a steroid sparing drug, since it has been found to be more effective and with lesser adverse effects as compared to prednisone. Treatment of about 6-60 months is required to bring about long term remission in most patients.
The long term use of drugs for treatment is a major contributor to the morbidity associated with this disease. Steroids can cause and also aggravate hypertension, heart disease, diabetes, peptic ulcer, and bone thinning; these comorbidities are already present in most elderly people, and it is this population which is most susceptible to BP. In order to avoid the side effects of oral steroid therapy, potent topical corticosteroid ointments along with anti-inflammatory medicines can be used, especially when there is limited and localized skin involvement. Biological treatment with Rituximab may benefit patients who do not respond satisfactorily to standard treatment.
Since modern treatment may contribute to morbidity from BP, Ayurvedic herbal treatment can be used as an alternative since it is safe for long term use, and can effectively provide prolonged or permanent remission from the disease. It is pertinent to note here that Ayurvedic treatment guidelines and protocol for both BP and PV are similar, since there is no different treatment approach based upon the different layers of affected skin.
Herbal medicines which have a direct action on skin, subcutaneous tissue, capillaries, blood, and blood vessels are quite useful in BP treatment. Since this is an autoimmune disorder, the common principles of treatment for all autoimmune disorders apply here too; these include managing inflammation, allergy, chronic infection, detoxification, strengthening and rejuvenation of faulty or dysfunctional tissue, and gradual modulation of immunity. For the remission phase, treatment involves generalized rejuvenation of the full body, also known as Rasayan therapy; for this purpose, herbomineral formulations are used which not only activate healthy body metabolism, but also simultaneously provide control for inflammation, allergy, and help gradually build up true body immunity.
Patients who are refractory to standard Ayurvedic herbal treatment are subjected to systematic detoxification plans known in Ayurveda as Panchkarma, which may be given singly or in combination. These procedures include induced emesis, induced purgation, blood-letting, nasal medication, and medicated enemas. Since BP is mainly found in the elderly population, caution needs to be exercised while doing such detoxification procedures. For recurrent, localized skin involvement, simple blood-letting from a vein near the affected parts, or leech application in several sittings may provide dramatic results at almost no risk.
Simplified treatment which may provide benefit to most patients affected with BP includes the local application of herbal ointments along with a few oral herbs. Ayurvedic herbal treatment for about 6-8 months is usually sufficient in providing long term remission to most patients with mild to moderate symptoms. However, severe autoimmune involvement may require aggressive treatment for nearly 18- 24 months. The presence of comorbidities in the elderly population may additionally prolong treatment. In spite of this, most people affected with BP usually get significant relief and lasting remission with Ayurvedic herbal treatment.