Corticosteroid-Sparing Control of Bullous Pemphigoid with Dupilumab and Tripterygium Glycosides: A Real-World Cohort with Longitudinal Transcriptomics

Background: Bullous pemphigoid (BP) often requires long-term corticosteroids with substantial adverse effects. Effective corticosteroid-sparing treatments could improve safety and quality of life for patients with BP. Objective: To evaluate the clinical efficacy, safety, and transcriptomic correlates of dupilumab combined with tripterygium glycoside (TG) in moderate-to-severe BP. Materials and Methods: We conducted a clinical cohort study at Peking Union Medical College Hospital. Twelve consecutive BP patients (bullous pemphigoid disease area index [BPDAI] ≥20) who had received dupilumab combined with oral TG were retrospectively identified. Systemic corticosteroids were avoided whenever feasible; rescue initiation or dose escalation was permitted for relapse or inadequate control. Outcomes included BPDAI, pruritus Numeric Rating Scale (NRS), serum anti-BP180 antibody levels, and eosinophil percentage from baseline to week 12. Safety was monitored throughout follow-up. Longitudinal peripheral blood samples were collected before and after treatment for transcriptomic profiling. Results: < 0.001). One patient reported transient cognitive symptom worsening. Transcriptomic analysis showed downregulation of C-X-C motif chemokine receptor 4 (CXCR4) and matrix metallopeptidase 9 (MMP-9), and reduced interleukin-8- and type I interferon-related inflammation. Conclusion: Dupilumab combined with TG is a promising corticosteroid-sparing treatment strategy for moderate-to-severe BP. Dupilumab likely contributed substantially to disease control, while TG may have provided adjunctive immunomodulatory effects. Transcriptomic findings point to CXCR4 and MMP-9 as candidate markers distinguishing pre- versus post-treatment samples, warranting external validation.