Sequential Immunomodulatory Therapy For Mucous Membrane Pemphigoid

Mucous membrane pemphigoid (MMP) is a chronic autoimmune blistering disorder predominantly affecting oral mucosa. Diagnosis relies on clinical, histopathological, and immunopathological findings. Treatment challenges arise in elderly patients with comorbidities, necessitating tailored therapeutic strategies to minimize systemic side effects. A 71-year-old female presented with recurrent palatal blisters for 11 months. Clinical examination revealed erosions (0.2–0.3 cm) and intact vesicles on the soft palate. Histopathology showed subepithelial blistering, and direct immunofluorescence (DIF) demonstrated linear C3 deposition at the basement membrane zone. BP180 antibody was negative (6.5 U/mL). The patient, with hypertension and elevated glucose (6.25 mmol/L), avoided systemic corticosteroids. Sequential therapy included: (1) dexamethasone mouthwash, thalidomide (50 mg/day), and total glucosides of peony (0.6 g twice/day) for 1 month; (2) minocycline (100 mg twice/day) and continued peony glucosides for 3 months. Complete remission was achieved at 9-month follow-up. This case underscores the importance of integrating DIF and histopathology for MMP diagnosis despite negative BP180. The sequential immunomodulatory regimen prioritized safety in an elderly, comorbid patient. Topical corticosteroids and tetracyclines (e.g., minocycline) aligned with European guidelines, balancing efficacy and reduced systemic risks. Avoidance of long-term steroids mitigated oral dysbiosis and glycemic exacerbation. For mild MMP in elderly patients, sequential immunomodulatory therapy offers a viable alternative to systemic corticosteroids. Comprehensive diagnostic criteria (clinical, DIF, histopathology) and individualized treatment strategies are critical, particularly for patients with comorbidities. This approach minimizes adverse effects while achieving sustained remission.