Bullous Pemphigoid — SCE Dermatology MCQ

Correct answer: B — Gradual dose reduction (typically 5 mg every 1-2 weeks once disease control achieved)

The correct answer is B, gradual dose reduction (typically 5 mg every 1-2 weeks once disease control achieved). Once bullous pemphigoid is controlled (no new blisters, existing lesions healing), UK dermatology guidance advises a stepwise taper rather than an abrupt change, balancing the risk of relapse against the risks of prolonged high-dose steroid exposure (osteoporosis, diabetes, infection, adrenal suppression). A common schedule is reduction in 5 mg steps every 1-2 weeks while above 20 mg, moving to smaller steps as the dose falls, with steroid-sparing agents introduced to allow further tapering. This mirrors PCDS guidance that once control is achieved the dose is reduced over a period of weeks, then more slowly as lower doses are approached. Why the other options are wrong: D. Continue same dose for 6 months: Maintaining 30 mg for 6 months once disease is controlled exposes the patient to unnecessary cumulative steroid toxicity with no added therapeutic benefit, contrary to the principle of using the lowest effective dose. A. Reduce by 1 mg per month: This rate is far too slow at the 30 mg starting point; 1 mg monthly reductions are reserved for very low doses (below 10 mg/day) where relapse risk is highest and adrenal recovery must be protected. E. Stop Prednisolone immediately: Abrupt cessation after 6 weeks on 30 mg daily risks both acute disease flare and adrenal crisis due to hypothalamic-pituitary-adrenal axis suppression from prolonged supraphysiological dosing. C. Switch directly to topical Clobetasol without systemic taper: Topical clobetasol is a useful adjunct to reduce cumulative systemic steroid dose, but abruptly stopping systemic prednisolone without a taper still risks adrenal insufficiency and rebound blistering; it does not substitute for a structured systemic taper. Key point: Once bullous pemphigoid is controlled, prednisolone should be weaned gradually (larger steps at higher doses, smaller steps as the dose falls below 10-20 mg) rather than stopped abruptly or held unnecessarily, to avoid both relapse and steroid withdrawal complications.

Reference: Primary Care Dermatology Society (PCDS), Bullous Pemphigoid clinical guidance, https://www.pcds.org.uk/clinical-guidance/bullous-pemphigoid1