Bullous Disorders Decoded: Clinical Clarity Meets Therapeutic Breakthroughs

At Dermatology Week APP Day 2025, Christopher Bunick, MD, PhD, delivered a deeply practical and visually rich session titled “Clinical Insights Into Common Bullous Diseases.” From bacterial infections to autoimmune conditions, Dr Bunick offered a structured diagnostic approach and highlighted a major therapeutic leap for bullous pemphigoid (BP).

“We want to understand not just how these diseases present, but how to recognize and manage them effectively in clinic,” he said, opening a talk that walked attendees through real-world cases, histopathology, and key treatment updates.

He began with bullous impetigo—an often-overlooked entity in the discussion of bullous diseases. It “tends to have a flaccid type of appearance as opposed to tense bulla,” Dr Bunick noted, and can often be confused with other infections or inflammatory disorders. Key pathogens include Staphylococcus aureus, which releases exfoliative toxins targeting desmoglein-1. Diagnosis often requires culture, and treatment typically includes topical or systemic antibiotics.

Next came bullous mastocytosis, a condition that can prompt emergency visits in infants due to sudden blistering. “Sixty percent of all pediatric cutaneous mastocytosis cases present at birth,” Dr Bunick explained, emphasizing the importance of CD117 staining in confirming diagnosis.

But the session’s central focus was autoimmune bullous disease, specifically BP. From classic presentations on the dorsal hands to tricky variants mimicking dyshidrotic eczema or prurigo nodularis, Dr Bunick underscored the need for biopsy, immunofluorescence, and diagnostic suspicion. “If something isn’t responding the way you expect, consider a biopsy,” he advised.

The session crescendoed with a breakthrough update: the US Food and Drug Administration approval of dupilumab for BP. In the ADEPT trial, 18.3% of patients achieved sustained remission on dupilumab compared to 6% with placebo. Nearly 40% reported ≥4-point itch reduction, quadrupling the placebo response. “It gives us a medicine we know that we trust, and it can deliver really good efficacy for bullous pemphigoid,” Dr Bunick said.

He closed with a practical reminder about tetracyclines. In mucous membrane pemphigoid, he shared the case of a patient unable to tolerate doxycycline who responded well to narrow-spectrum sarecycline. “It preserved her gut microbiome and controlled her symptoms,” he noted.

In an era of expanding biologics, Dr Bunick emphasized balancing innovation with empathy. “It’s important to communicate expectations. Dupilumab controls disease, but it’s not an instant cure.”

For more meeting coverage, visit the Dermatology Week APP Day newsroom.

Maximize your experience by adding up to 90 days of on-demand access. Find the package that works for you. Upgrade here.

Reference
Bunick C. Clinical insights into common bullous diseases. Presented at: Dermatology Week; October 22–25, 2025; Virtual.