Blistering diseases are facing the danger of being finished, since our understanding of the pathogenesis and therapeutic approaches are undergoing a major revision. A wide spectrum of skin disorders can manifest as a blistering process. A blister is an event associated with tissue injury and fluid accumulation within a specific layer of skin due to either genetic mutations or autoimmune response. Blisters can also occur secondary to bacterial/viral infections, chemical/physical burns or skin necrosis/dermatitis.1,2 Here, the focus of interest is a bullous dermatoses in the child based on a case of pemphigus vulgaris (PV).

The PV is an autoimmune blistering disease of elderly (3rd-5th decade), which was previously fatal before the advent of steroid therapy, mainly due to dehydration or secondary systemic infection.3,4 The PV is characterized by the presence of circulating autoantibodies immunoglobulin G against desmogleins 35,6 which result in loss of cell to cell adhesion and blister formation that rupture and progress to form painful erosions.4 The PV in children aged less than 12 years is known as childhood PV and in those aged between 12 and 18 years as juvenile PV. Data on incidence and prevalence of childhood PV are scarce because in literature only a few cases are reported. In a study, children aged less than 15 years accounted for 3.7% of cases.7 Several environmental factors, medications, and acantholytic substances superimposed on genetic predisposition may play a role in the onset of this disease in children.8


An 11-year-old girl presented to the department of pediatric dentistry, with a complaint of multiple eruptions and blisters all over the mouth, which increased in size gradually over a period of 2 to 3 months and ruptured to form a crusty erosive surfaces with watery discharge (Fig. 1). Later, similar sores appeared on limbs, trunk, and the genital area which were painful and led to considerable discomfort (Figs 2 and 3).

Entire oral mucosa including the tongue was eroded and erythematous, causing extreme discomfort and pain during eating. There was no history of any drug intake during the past 6 months nor any systemic condition identified. The child presented with such a condition for the first time and there was no such disorder noted in the family. Nikolsky's perilesional sign was positive.

The girl was hospitalized in the medical unit and comprehensively managed with the help of a dermatologist (Tables 1 and 2). Direct immunofluorescence was positive and perilesion biopsy containing intact lesion, revealed Tzanck cells, intraepidermal blister and suprabasilar acantholysis (Fig. 4). The connective tissue stroma showed dense mononuclear infiltration. A significant improvement in the condition was observed after 3 to 4 weeks following the standardized steroid treatment regime (Figs 5 to 7).

Figs 1A and B:

Multiple crushed lesions with superficial erosions on lips

Figs 2A and B:

View of lesions on the limbs

Figs 3A and B:

View of wide spread lesions all over the body



Unusual childhood occurrence, though quick response to treatment, however potentially life-threatening nature with substantial morbidity, justifies its consideration in routine dental practice. These chronic recurrent and painful lesions interfere with the daily activities of life, such as eating, drinking, talking, and personal relationships.9 Pediatric dentists have the unique opportunity since initial lesions occur in the oral cavity and complete remission is possible only with early diagnosis.10

Prompt diagnosis and early initiation of aggressive therapy can combat the malignant course of disease in children. The treatment strategies should be based on the understanding of underlying pathogenic processes and recurrence3,11-14 (Tables 3 and 4). Systemic corticosteroids and immunosuppressive therapy are the mainstay treatments for PV. Apart from steroids, adjuvant therapies include azathioprine, mycophenolate mofetil, dapsone, and rituximab in refractory cases.4,7,8 These modern therapies can effectively reduce the circulating antibodies, allowing patients to lead a normal life. Adverse effects associated with long-term use of steroids, such as weight gain, menstrual irregularities, growth retardation, osteoporosis, and hormonal disturbances in adolescence4,5 have always led to the search for newer steroid sparing and novel avenues for eradication of blisters at the molecular level.1,2 As we probe deeper into molecular aspects of the disease, our understanding of the pathogenesis begins to gain focus, offering new novel, and improved methods of therapy or even an opportunity to achieve a cure, which should mark the end of an era of blistering diseases.

Table 1: Systemic treatment regime

DrugsDose, route, and duration*Action
Dexamethasone0.5 mL Inj IM (50-100 mg) 3 to 4 weeksModification of immune response (immunosuppresion)
Roxithromycin150 mg Tab BID – 2 to 3 weekAntibacterial for secondary infection
Prednisolone10-20 mg Tab tapering to 5 mgAnti-inflammatory and modification of immune response
      BID – 2 to 3 months      
HematopoieticsOral capsule OD – 1 monthNutritional supplement
NaCl salineIV fluidElectrolytic balance

*Minimum duration is 3 to 4 weeks, may be extended depending on response and recurrence; IM: Intramuscular injection; BID: Twice (two times) a day; OD: Once daily; IV: Intravenous

Table 2: Topical treatment regime

DrugsDose, route, and duration*Action
TriamcinoloneLocal application for more than 3 weeksPotent anti-inflammatory and alters immune response
Silver sulfadiazine and chlorhexidineLocal application for more than 2 weeksBroad spectrum antimicrobial
Gentamycin with propyl salicylic acidLocal application for more than 2 weeksPrevents secondary infections
Saline compresses over erosive lesionsLocal application for more than 2 weeksFor soothing effect and control of edema
ChlorhexidineOral gargle for more than 3 weeksOral antimicrobial
Fig. 4:

Acantholysis and suprabasilar separation

Fig. 5:

Posttreatment view

Figs 6A and B:

Lesions disappear following standard treatment regime

Figs 7A to C:

Healing of lesions all over the body


Table 3: Protocols for preventing recurrence3,12-14

Maintaining healthy diet and weight
Avoiding sunlight and friction of body folds
Keeping flexural areas clean and dry
Wearing cool garments with absorbent pads
Regular evaluation of secondary infections
Systemic antibiotics, such as tetracycline and erythromycin
Topical use of antibacterial creams, such as benzyl peroxide
Long-term low-dose steroid maintenance therapy
Controlling side effects of long-term steroids

Table 4: The bullous management portfolio5,11-14

Gold line mainstay of therapy – Steroids (Systemic prednisone 1 mg/kg/day and topical triamcinolone)
Broad-spectrum antibiotics for control of secondary infections
Improving the general health and hygiene of the patient
(Fluid replacement, electrolytic balance, and multiple vitamins/minerals)
Symptomatic relief of pain, discomfort, burning, and itching
(Paracetamol, astringents, and aluminium acetate)
Steroid sparing immunosuppressant and adjuvants
(Mycophenolate mofetil, tracolimus, azathioprine, dapsone, retenoids methotrexate, cyclophosphamide, gold, cyclosporine, and chlorambucil)
Newer vistas - Plasmapheresis, intra venous immunoglobulins, anti-B cell monoclonal antibodies, CO2 laser vaporization, dermabrasion, proteinase inhibitors, chimeric molecules, cholinergic agonists, etc.
Conflicts of interest

Source of support: Nil

Conflict of interest: None