Addressing Cutaneous Blisters and Chronic Bullous Disorders With Megan Noe, MD, MPH, MSCE

Megan Noe, MD, MPH, MSCE, is an assistant professor of dermatology at Brigham and Women's Hospital and Harvard Medical School. At the 2023 Society of Dermatology Physician Assistants (SDPA) Annual Summer Dermatology Conference, Noe presented a session titled, "Diagnosis and Management of Blistering Disorders."

Noe told Dermatology Times® about the highlights of her session, as well as considerations for cutaneous blister causes and treatment, as well as best practices for managing chronic bullous disorders.

Dermatology Times: What are key highlights and takeaways from your session, "Diagnosis and Management of Blistering Disorders?"

Megan Noe, MD, MPH, MSCE: I have 4 big take home points for my talk. The first one is just highlighting that the differential diagnosis for cutaneous blisters is really broad and includes things like injury and trauma, infections, drug reactions, autoimmune diseases, and genetic disorders.

The second key point is that the distribution of these blisters is really key. The distribution of patient factors are really key to making the diagnosis. There are certain specific tests, so skin biopsies, direct immunofluorescence, and indirect immunofluorescence, that can aid in the diagnosis of immunobullous disorders, and I talk about that in a little bit more detail so that people understand how to order the correct test and interpret it once the results are available.

And then finally, sort of treatment of anyone with cutaneous blisters really revolves around wound care and preventing secondary infection. But then for a lot of these diseases, patients need ongoing treatment, anti inflammatory immunosuppressive medication to prevent blisters, to prevent the blistering eruption from continuing.

Dermatology Times: What are your recommended best practices for managing chronic bullous disorders?

Noe: So it really varies. Sometimes, we'll just use topical steroids, but for a lot of the autoimmune blistering diseases, we use medications like methotrexate, we use standard immunosuppressive therapies like CellCept [mycophenolate mofetil]. And then now, we're using rituximab more for pemphigus and other autoimmune blistering diseases. So it's really a spectrum depending on the patient, and disease severity, and the actual diagnosis.

Dermatology Times: How does being aware of the cause of a cutaneous blister help clinicians determine appropriate treatment and management?

Noe: I think in general, when a physician gets a new consult, an outpatient setting, but also in dermatologists who take care of patients in the hospital, blisters can be scary, because you're worried about the more severe things that can happen, like a severe drug reaction that results in blisters, or a severe variant of an autoimmune or genetic disease. And so I think that's the top thing on everyone's mind dermatology, and also the consulting teams, too.

And so it's really important to think about the rare things. I think it can be really comforting to the to a primary team, if you think about in a hospital setting, they're worried about a severe drug reaction. But after evaluating the patient, you realize it's probably just an edema blister, and so we don't need to worry, we don't need to do any extra treatment, we don't need to put patients on immunosuppressive medication that they don't need. So in that case, a lot of times, we can be reassuring about the more common causes of blisters.

And then the same thing is true on the other end of the spectrum. So you need to be aware and knowledgeable about the more serious things that can happen with blisters, like the severe drug reactions, like the severe variants of autoimmune diseases, because we want to make sure those things are identified as quickly as possible so that patients can be started on appropriate therapy.

[Transcript edited for clarity]