Pemphigus Vulgaris

Authored by Dr Oliver Starr, Reviewed by Dr Adrian Bonsall on | Certified by The Information Standard

Pemphigus vulgaris is a very serious skin disease that causes blisters. It is rare. Pemphigus vulgaris is more serious than most other blistering skin conditions. Before treatment became available, most people with the condition used to die soon after the disease started. These days most cases can be controlled with treatment. Treatment is usually with steroid medicines and other medicines to suppress the immune system. A skin specialist should supervise treatment.

Pemphigus vulgaris is a rare skin condition that causes blisters. It is a serious disease that needs treatment. If it is not treated, it is often fatal. The following image shows very bad pemphigus on someone's back, along with the ulcers that are found in the mouth:

Pemphigus vulgaris

Pemphigus vulgaris

Image source: Waschke's The desmosome and pemphigus - see Further reading reference below

Note: several skin conditions can cause blisters and it is important to know exactly which disease you have. There are other types of pemphigus called: pemphigus foliaceous, pemphigus erythematosus, paraneoplastic pemphigus and benign familial pemphigus.

There are also conditions with similar sounding names that cause blisters - for example, pemphigoid. See the separate leaflet called Bullous Pemphigoid. These different conditions vary greatly in their seriousness, outlook (prognosis) and treatment. Pemphigus vulgaris is the most common form of pemphigus and one of the most serious blistering skin conditions.

This leaflet is only about pemphigus vulgaris

Pemphigus vulgaris is rare - between one and five people in a million develop pemphigus vulgaris each year in the UK. Most cases develop in people aged over 50. It is very rare in children. Men and women are equally affected. It is more common in certain groups of people - those from the Mediterranean, from the Indian subcontinent or of Jewish origin. Pemphigus vulgaris is not infectious and you cannot catch it from an affected person.

Pemphigus vulgaris is an autoimmune disease. The immune system normally makes antibodies to attack bacteria, viruses and other germs. In people with autoimmune diseases, the immune system also makes antibodies against a part of the body. In people with pemphigus vulgaris, antibodies are made against a protein that binds the skin cells together. As a result, the binding between many skin cells is broken and this causes the cells to separate from each other. Fluid builds up between the separated cells and forms blisters.

It is not known why pemphigus vulgaris and other autoimmune diseases occur. It is thought that something triggers the immune system to attack the body's own tissues. Possible triggers include viruses, infection, or other environmental factors. There may be an inherited factor which makes some people more prone to develop autoimmune diseases.

  • Skin blisters. Many blisters may develop on any part of the skin. The most common areas affected are the face, scalp, armpits, groins, and pressure points (buttocks, etc). The blisters can be several centimetres across and are not normally itchy. The blisters are loose (flaccid) and fragile so they easily burst. This leaves raw, red areas of skin which can be very sore and painful. The raw areas of skin heal without scarring, but the affected skin may become darker (more pigmented).
  • Mouth blisters are common. The blisters burst soon after forming, to leave raw painful areas like severe mouth ulcers (mouth erosions). Some people with pemphigus vulgaris only get mouth blisters, without any skin blisters. Other people may get mouth blisters as the first symptom of pemphigus vulgaris.
  • Other inner skin areas (mucous membranes) such as the throat, back passage (anus), genitals, vagina and front of eye are sometimes affected in a similar way to the mouth. If blisters occur in the voice box (larynx), you may get hoarseness. Sometimes blisters can occur in the throat, which can make swallowing painful.

Often it is the mouth blisters which develop first. These soon burst and form painful mouth erosions, which are like ulcers. The skin blisters may follow some weeks or months later.

If pemphigus vulgaris is left untreated, the blisters tend to persist and the number of blisters tends to increase. It can become distressing if there are many blisters, as they can burst to leave areas of raw, painful skin. These raw areas are at risk of infection which can be serious.

When pemphigus vulgaris is active in the mouth or throat it can become difficult to eat or drink. If this occurs you may need nutritional advice or supplements from your GP.

If pemphigus vulgaris is severe you may need treatment in hospital until it improves.

The diagnosis may not be clear at first. There are other causes of mouth ulcers and skin blisters. Therefore, if your doctor suspects that you have pemphigus vulgaris, he or she will refer you to a skin specialist. Tests are usually done to confirm the diagnosis. These include:

  • A small sample (biopsy) of skin may be taken. This is looked at under the microscope and tested to confirm that the blisters are due to pemphigus vulgaris.
  • A blood test for antibodies. This uses methods called immunofluorescence or ELISA to measure the level of the antibody that causes pemphigus vulgaris in your bloodstream. As well as helping to confirm the diagnosis, the level of auto-antibody in your blood gives a good indication of how active the disease is. It may also be measured from time to time to monitor how well treatment is working. When the antibody level goes down, the disease is less active.

Treatment aims to stop, or greatly reduce, the number of blisters that form. The aim is to stop the flare-up (active) phase and produce a quiet phase (a remission). There are various types of medicines used in pemphigus vulgaris. Unfortunately, there is not enough evidence yet to say definitely which treatment works best. A specialist will advise on the most up-to-date thinking on the best treatment. Treatment options include the following: 

Steroids

The usual treatment is to take steroid tablets such as prednisolone. Steroids reduce redness and soreness and suppress the immune system. A high dose is usually needed at first and this may be given by injection. Steroid treatment can work fairly quickly. Symptoms may start to improve within a few days. New blisters may stop in 2-3 weeks and old blisters may heal in 6-8 weeks.

The dose of steroid is reduced once new blisters have stopped forming. A lower daily dose is usually then needed to stop the blisters coming back. The aim is to find the lowest dose needed to control symptoms. The dose needed varies from person to person. Some people are able to stop steroid tablets from time to time when the blister activity is low. The tablets can be restarted if symptoms flare up again.

Are there side-effects of steroids?

All steroids, whether tablets or creams, can have side-effects. Side-effects from steroids can sometimes be serious, especially if you take high-dose steroids for a long time. For example, you are more prone to certain infections if you take regular high-dose steroids. Another side-effect is 'thinning' of the bones (osteoporosis). If you take steroid treatment for more than a month, you will probably be advised to take vitamin D and calcium tablets to help prevent osteoporosis. You should be aware that long-term steroid treatment should not be stopped suddenly. See the separate leaflet called Oral Steroids which explains their possible side-effects in more detail.

Immunosuppressant medicines

An immunosuppressant medicine may be advised. These medicines work by suppressing the immune system. They can be used in addition to steroid tablets. The two together tend to work better than either alone. Also, the dose of steroid needed may be less if you take an immunosuppressant. This means that any side-effects from steroids may be less severe. Sometimes an immunosuppressant is used alone instead of steroids. The aim is to find the lowest dose of treatment (or combination of treatments) which controls the blisters.

Examples of immunosuppressant medicines which may be used for pemphigus vulgaris are cyclophosphamide, azathioprine, ciclosporin, methotrexate or mycophenolate mofetil. Immunosuppressants usually take longer to work than steroids (about 4-6 weeks).

Skin and mouth treatments (topical treatments)

  • A steroid cream is sometimes used on the skin blisters in addition to other treatments. This may keep the dose of steroid tablets lower than would otherwise be needed. Steroid mouthwashes or sprays may be used to help treat mouth blisters and erosions.
  • Mouthwashes containing antiseptic or local anaesthetic can also help.
  • Wound care treatments such as dressings help raw areas to heal.
  • Compresses or soaks using sterile salt water (saline) or certain antiseptics, may be advised if there are large areas of raw skin. This is to reduce the chance of infection and to stop raw skin from becoming too dry.
  • If your pemphigus vulgaris is going through a flare-up, you may be advised to protect the skin and mouth from roughness as much as possible. For example, avoid contact sports, eat soft bland food and use cream or ointment to protect skin from friction.
  • Antifungal medication (usually drops or pastilles) helps if thrush infects the mouth or throat.

Other treatments

Various other medicines and treatments have been used with some success. Plasmapheresis, intravenous immunoglobulin and rituximab (a monoclonal antibody) may be tried if your pemphigus vulgaris does not respond to high doses of steroids. Sometimes they may also be tried in combination with steroid tablets. Research continues to find better treatments or the best combination of treatments to treat pemphigus vulgaris.

If left untreated

Before treatment with steroids became available, up to 8 in 10 people with pemphigus vulgaris died within a year or so of the disease starting. The cause of death was often serious infection combined with lack of fluid in the body (dehydration). Dehydration can easily occur if you have widespread raw areas of skin. Having untreated pemphigus vulgaris is a bit like having widespread skin burns, with the consequent risk of infection and dehydration.

With treatment

With treatment blisters usually heal and stop forming, and the risk of death is greatly reduced. Many patients with pemphigus vulgaris are able to have long periods of inactive disease (remission). However, treatment does not always work well and side-effects from treatment can sometimes be serious. About 1 in 10 people with pemphigus vulgaris die of their condition or as a consequence of severe side-effects from treatment. Older people are more likely to have side-effects or die as a result of pemphigus vulgaris.

Further reading and references

  • Daniel BS, Murrell DF; Management of pemphigus. F1000Prime Rep. 2014 May 66:32. doi: 10.12703/P6-32. eCollection 2014.

  • Lowe S; Pemphigus vulgaris. BMJ. 2007 Dec 1335(7630):1152-4.

  • Waschke J; The desmosome and pemphigus. Histochem Cell Biol. 2008 Jul130(1):21-54. doi: 10.1007/s00418-008-0420-0. Epub 2008 Apr 3.

  • Bystryn JC, Rudolph JL; Pemphigus. Lancet. 2005 Jul 2-8366(9479):61-73.

  • Martin LK, Werth V, Villanueva E, et al; Interventions for pemphigus vulgaris and pemphigus foliaceus. Cochrane Database Syst Rev. 2009 Jan 21(1):CD006263.

  • Langan SM, Smeeth L, Hubbard R, et al; Bullous pemphigoid and pemphigus vulgaris - incidence and mortality in the UK: population based cohort study. BMJ. 2008 Jul 9337:a180. doi: 10.1136/bmj.a180.

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