Doxycycline or Prednisolone? Which Is Better to Treat Bullous Pemphigoid

Bullous pemphigoid (BP) is a relatively rare blistering skin disorder that causes intense itching, erythema, blisters and risk for secondary infection, mostly affecting patients older than 70. A recent clinical trial, The Bullous Pemphigoid Steroids and Tetracyclines (BLISTER), compared strategies of starting treatment with doxycycline or with oral prednisolone. The goals were to determine whether an acceptable level of short-term blister control could be achieved when treatment starts with doxycycline. Doxycycline has more desirable safety profile for long-term use. The trial also compared the cost effectiveness of both treatments.

The trial recruited about 250 patients with BP and evaluated efficacy outcome at 6 weeks and a long-term safety outcome at 52 weeks. The results showed that although doxycycline was a significantly safer treatment than prednisolone, it was less effective for blister control at the 6 week mark. The authors conclude that the BLISTER trial provides the most robust cost-effectiveness evidence to date comparing the two treatments. For patients with mild-to-moderate BP the cost-effectiveness and safety profiles of the two treatments were similar. However, for patients with severe blistering (> 30 blisters) at presentation, starting with prednisolone resulted in lower cost and higher quality of life.