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93/bjd/ljaf465.019. PMID: 41412981.
A case study illustrates how infantile bullous pemphigoid can be repeatedly misdiagnosed as common infection, leading to delayed treatment despite a typically rapid response once correctly identified.
Infantile bullous pemphigoid (IBP) is a rare autoimmune blistering disorder that typically presents in early infancy and responds rapidly to systemic therapy when promptly diagnosed. Despite its distinctive clinical and immunopathological features, delayed recognition remains common outside specialist settings. This case report describes a 4-month-old infant who experienced a prolonged diagnostic journey due to repeated misattribution of her blistering eruption to infectious causes, highlighting a critical gap in early recognition at the primary and secondary care levels.
Related: Bullous Pemphigoid with Dr. Donna Culton
The patient initially presented with widespread tense vesicles and bullae accompanied by erythema, yet underwent multiple general practice assessments and a pediatric inpatient admission with presumed viral and bacterial diagnoses. Dermatology input was limited to remote photographic review, which did not prompt specialist referral. Definitive diagnosis was ultimately established through histology and direct immunofluorescence after escalation to pediatric dermatology, confirming IBP. Once treated with systemic corticosteroids and adjunctive antibiotic therapy, lesions resolved rapidly, and treatment was successfully discontinued without relapse.
A 32-year-old woman presents with 3 weeks of sudden onset, asymptomatic, nonpainful patchy hair loss over her scalp. She denies scalp pruritus, pain, or scaling. No recent illnesses or surgeries, no new medications, no significant physical beyond her usual baseline. On exam: multiple circular, smooth, sharply demarcated areas of alopecia, varying from 2–4 cm diameter, some with “exclamation point” hairs at margins. No scarring, no erythema, no scale, no pustules are identified in the areas of alopecia. Eyebrows and eyelashes are unaffected. Fingernail examination shows few pitting changes. Her thyroid function, ANA, and basic labs are normal.
A dermoscopy (trichoscopy) reveals black dots, exclamation-point hairs, broken hairs, and short vellus regrowth.
History
Physical Exam
There are clusters of confluent erythematous urticated papules and plaques on her neck and the extensor aspects of her arms. The rest of the skin is unaffected.
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