Pemphigus foliaceus and bullous pemphigoid are 2 distinct forms of autoimmune blistering disorders with unique clinical, histologic, and immunologic features. We describe a patient with pemphigus foliaceus that converted into bullous pemphigoid, providing evidence of clinical intermolecular epitope spreading.
Contrasting features of 2001 and 2006 patient presentations. In 2001, the clinical findings were superficial erosions without intact blisters; histopathologically, an intraepidermal acantholytic blister; and under direct immunofluorescence, IgG deposits at epithelial cell surfaces. In 2006, the clinical findings were tense blisters and erosions; histopathologically, subepidermal blister with infiltrating eosinophils; under direct immunofluorescence, linear deposits of IgG at the skin basement membrane zone; and under indirect immunofluorescence, binding of IgG antibodies to the epidermal side of 1.0M sodium chloride–split skin (LL indicates the lamina lucida space). Original magnification ×40 for all histopathologic photographs. Photographs not available for the clinical presentation and direct immunofluorescence in 2001; indirect immunofluorescence and enzyme-linked immunosorbent assay (ELISA) were not done in 2001.
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