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The article emphasizes a pre-bullous phase where patients may present insidiously with persistent urticaria and intense pruritus lasting weeks to months, risking delayed diagnosis. A 79-year-old man with refractory, persistent itchy “hives” for 3 weeks on a 4-month background later developed blisters on an urticated base. Indirect immunofluorescence showed anti–basement membrane zone IgG antibodies, leading to steroid and doxycycline therapy with good recovery.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/persistent-urticaria-heralding-the-onset-of-bullous-pemphigoid-case-report-and-learning-points/420575/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/persistent-urticaria-heralding-the-onset-of-bullous-pemphigoid-case-report-and-learning-points/420575.png","ImageObject",300,407,{"name":92,"@type":93},"pixelkiddo","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-28",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",11,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"Why can bullous pemphigoid be missed when it starts with urticaria?","Question",{"text":113,"@type":114},"It may present in a lesser-known pre-bullous phase with insidiously persistent urticaria and intense pruritus, which can be refractory to standard antihistamines and topical therapies. This can delay consideration of autoimmune blistering disease.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"How was the diagnosis confirmed in the case?",{"text":118,"@type":114},"Serum indirect immunofluorescence demonstrated anti–basement membrane zone IgG antibodies on primate oesophagus and salt-split skin, showing an epidermal pattern on salt-split skin. This supported bullous pemphigoid despite initial ELISA negativity.",{"name":120,"@type":111,"acceptedAnswer":121},"What treatment was used and what was the result?",{"text":122,"@type":114},"The patient received immunomodulatory therapy with oral prednisolone and high-dose antihistamines, plus high-potency topical corticosteroids. Doxycycline was added, and azathioprine followed due to persistent blisters, leading to complete resolution of blisters and skin erosions.","https://schema.org",{"og:url":83,"og:type":125,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":127,"canonical":83},"index,follow",{"doc_id":129,"site_id":62},420575,1790783906,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":92,"user_avatar":134,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":105,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":19,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":52,"preview_page_count":4},962090883892,"https://ap-avatar.wpscdn.com/avatar/e00115db34f3e0f11b?x-image-process=image/resize,m_fixed,w_180,h_180&k=1790152879550218658","Images in Hospital Medicine  \nPersistent Urticaria Heralding the Onset of Bullous Pemphigoid  \nIsaac Ng, MBBS, MRCP1, Charisse Loh, MBBS, MRCP2, An Jian Leung, MBBS, MRCP3  \n1 Division of Rheumatology and Allergy, National University Hospital,  \n2 Division of Infectious Diseases, National University Hospital,  \n3 Department of Advanced Internal Medicine, National University Hospital  \nJournal of Brown Hospital Medicine Vol. 5, Issue 1, 2025  \nArticle Information  \nKeywords: Urticaria, Bullous Pemphigoid, Dermatology  \n[https://doi.org/10.56305/001c.147410](https://doi.org/10.56305/001c.147410)  \nSubmitted: August 24, 2025 EST  \nAccepted: November 10, 2025 EST  \nPublished: January 01, 2026 EST  \nAbstract  \nBullous pemphigoid is a common autoimmune blistering disorder that predominantly affects older adults aged 65 and older. While most cases present with a tense blistering eruption, characteristic of the disease, there is a lesser-known pre-bullous phase of the condition that can present insidiously with urticaria and intense pruritus, which can last for several weeks or months. Failure to consider this entity in patients with treatment-refractory, persistent urticaria or itch may lead to delayed diagnosis and poor quality of life. We describe a case of a 79-year-old gentleman who presented with a 3-week history of generalized urticaria on a background of intense pruritus for 4 months. His diagnosis was eventually clinched when he developed blistering lesions on an urticated base, with serum indirect immunofluorescence demonstrating anti-basement membrane zone IgG antibodies. He was commenced on immunomodulatory treatment with moderate doses of oral corticosteroids and doxycycline, with good clinical recovery thereafter. This case vignette highlights several learning points pertaining to the recognition and management of patients with urticarial manifestations in the pre-bullous phase of this common autoimmune blistering disease.  \nA 79-year-old gentleman, with no significant medical history or family history of skin or autoimmune conditions, presented to the hospital with a 3-week history of persistent, itchy “hives” over his trunk and limbs, on a background of generalized pruritus for 4 months. He also described intermittent episodes ofangioedema of his eyes that self-resolve. His general practitioner treated him with low-moderate potency topical corticosteroids, antihistamines, and short courses of low-dose prednisolone 10 mg/day with minimal improvement. Over the week before admission, he noticed several blisters and bullae forming on his feet. On examination, there were generalised urticated plaques observed over the trunk, abdomen, and upper limbs, with two tiny blisters noted over the anterior abdominal wall. However, several large blisters and tense bullae were evident over the bilateral feet, some of which had spontaneously burst (Figure 1) . There was no oral or genital mucosal involvement. Nikolsky’s sign was negative.  \nInitial laboratory tests revealed peripheral eosinophilia (AEC 2.33 x 109/L; reference range 0.05-0.5 x 109/L) with normal renal and liver function. Serum bullouspemphigoid (BP) 180/230 IgG antibodies were negative (reference range \u003C 20 RU/ml) on ELISA testing, but serum indirect immunofluorescence (IIF) anti-basement membrane zone (BMZ) IgG antibodies were detected on both primate oesophagus and salt-split skin substrate,  \ndemonstrating an epidermal pattern on salt-split skin. Asthe patient was not keen to proceed with a skin biopsy, he was treated for BP, based on the clinical findings and serum IIF results, with oral prednisolone 40 mg OM (between 0.5-0.75 mg/kg range), high-dose antihistamines (telfast 360 mg BD), and high-potency topical corticosteroids (clobetasol dipropionate 0.05% cream BD) . Subsequently, doxycycline 100 mg BD and eventually azathioprine 50 mg OM were added due to persistent blisters. Thereafter, the patient had a good clinical response, with complete resolution of blisters","cbCailOEXMonqNyt","https://ap.wps.com/l/cbCailOEXMonqNyt","pdf",227630,"English","# Case presentation\n## Clinical course and diagnostic workup\n## Treatment and outcome\n# Urticaria differential and learning points","[{\"question\":\"Why can bullous pemphigoid be missed when it starts with urticaria?\",\"answer\":\"It may present in a lesser-known pre-bullous phase with insidiously persistent urticaria and intense pruritus, which can be refractory to standard antihistamines and topical therapies. This can delay consideration of autoimmune blistering disease.\"},{\"question\":\"How was the diagnosis confirmed in the case?\",\"answer\":\"Serum indirect immunofluorescence demonstrated anti–basement membrane zone IgG antibodies on primate oesophagus and salt-split skin, showing an epidermal pattern on salt-split skin. This supported bullous pemphigoid despite initial ELISA negativity.\"},{\"question\":\"What treatment was used and what was the result?\",\"answer\":\"The patient received immunomodulatory therapy with oral prednisolone and high-dose antihistamines, plus high-potency topical corticosteroids. Doxycycline was added, and azathioprine followed due to persistent blisters, leading to complete resolution of blisters and skin erosions.\"}]","Persistent Urticaria Heralding the Onset of Bullous Pemphigoid - Case report and learning points | PDF",1790621527]