N Engl J Med, Vol. 346, No.

January 31, 2002

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321

COMPARI SON OF ORAL AND TOPI CAL CORTI COSTEROI DS I N PATI ENTS WI TH BULLOUS PEMPHI GOI D

A COMPARISON OF ORAL AND TOPICAL CORTICOSTEROIDS IN PATIENTS
WITH BULLOUS PEMPHIGOID

P

ASCAL

J

OLY

, M.D., P

H

.D., J

EAN

-C

LAUDE

R

OUJEAU

, M.D., J

ACQUES

B

ENICHOU

, M.D., P

H

.D., C

ATHERINE

P

ICARD

, M.D.,
B

RIGITTE

D

RENO

, M.D., P

H

.D., E

MMANUEL

D

ELAPORTE

, M.D., P

H

.D., L

OC

V

AILLANT

, M.D., P

H

.D.,
M

ICHEL

DI

NCAN

, M.D., P

H

.D., P

ATRICE

P

LANTIN

, M.D., C

HRISTOPHE

B

EDANE

, M.D., P

H

.D., P

AUL

Y

OUNG

, M.D.,

AND

P

HILIPPE

B

ERNARD

, M.D., P

H

.D.,

FOR



THE

B

ULLOUS

D

ISEASES

F

RENCH

S

TUDY

G

ROUP

*

A

BSTRACT

Background

Bullous pemphigoid is the most
common autoimmune blistering skin disease of the
elderly. Because elderly people have low tolerance
for standard regimens of oral corticosteroids, we
studied whether highly potent topical corticosteroids
could decrease mortality while controlling disease.

Methods

A total of 341 patients with bullous pem-
phigoid were enrolled in a randomized, multicenter
trial and stratified according to the severity of their
disease (moderate or extensive). Patients were ran-
domly assigned to receive either topical clobetasol
propionate cream (40 g per day) or oral prednisone
(0.5 mg per kilogram of body weight per day for those
with moderate disease and 1 mg per kilogram per
day for those with extensive disease). The primary end
point was overall survival.

Results

Among the 188 patients with extensive
bullous pemphigoid, topical corticosteroids were su-
perior to oral prednisone (P=0.02). The one-year sur-
vival rate was 76 percent in the topical-corticosteroid
group and 58 percent in the oral-prednisone group.
Disease was controlled at three weeks in 92 of the 93
patients in the topical-corticosteroid group (99 per-
cent) and 86 of the 95 patients in the oral-prednisone
group (91 percent, P=0.02). Severe complications oc-
curred in 27 of the 93 patients in the topical-cortico-
steroid group (29 percent) and in 51 of the 95 patients
in the oral-prednisone group (54 percent, P=0.006).
Among the 153 patients with moderate bullous
pemphigoid, there were no significant differences
between the topical-corticosteroid group and the
oral-prednisone group in terms of overall survival,
the rate of control at three weeks, or the incidence of
severe complications.

Conclusions

Topical corticosteroid therapy is effec-
tive for both moderate and severe bullous pemphigoid
and is superior to oral corticosteroid therapy for ex-
tensive disease. (N Engl J Med 2002;346:321-7.)

Copyright 2002 Massachusetts Medical Society.

From the Departments of Dermatology and Biostatistics, INSERM
Unite 519, University of Rouen, Rouen (P.J., J.B., P.Y.); and the Depart-
ments of Dermatology at the University of Paris XII, Creteil (J.-C.R.);
Bichat University, Paris (C.P.); the University of Nantes, Nantes (B.D.); the
University of Lille, Lille (E.D.); the University of Tours, Tours (L.V.); the
University of Clermont-Ferrand, Clermont-Ferrand (M.D.); the General
Hospital of Quimper, Quimper (P.P.); the University of Limoges, Limoges
(C.B.); and the University of Reims, Reims (P.B.) all in France. Address
reprint requests to Dr. Joly at the Clinique Dermatologique, Hpital
Charles Nicolle, 1, rue de Germont, 76031 Rouen CEDEX, France, or at
[email protected].
*Other participants in the Bullous Diseases French Study Group are list-
ed in the Appendix.

ULLOUS pemphigoid is the most com-
mon blistering autoimmune disease of the
skin

1,2

; it is manifested by cutaneous blisters
without mucosal involvement.

3

Histologic
features include subepidermal blisters.

4

Autoantibod-
ies directed against two proteins of the basement-
membrane zone, bullous pemphigoid antigens 1 and
2, are detectable by both direct and indirect immu-
B

nofluorescence.

5-10

Bullous pemphigoid is most com-
mon in elderly persons.

11-14

Systemic corticosteroids
are considered the standard treatment for bullous
pemphigoid.

3,15

A dose of prednisone of 1 mg per
kilogram of body weight per day is usually recom-
mended for the treatment of patients with severe
disease; a lower dose may be used for patients with
moderate disease.

15

Systemic corticosteroids are poor-
ly tolerated by elderly patients, however, and have
been suspected of contributing to the high rates of
death observed in some series.

11,12,16-18

Many efforts have been devoted to finding corti-
costeroid-sparing agents for the treatment of bullous
pemphigoid. Uncontrolled studies have suggested
the usefulness of immunosuppressive drugs.

19-26

Un-
fortunately, the single controlled study published to
date failed to demonstrate a benefit from the addition
of azathioprine to corticosteroid therapy.

27

Topical
corticosteroids have been proposed as possible treat-
ments for mild forms of bullous pemphigoid.

28-30

Be-
cause complications attributable to oral corticoster-
oids may contribute to the poor prognosis of patients
with bullous pemphigoid, we conducted a random-
ized trial comparing topical corticosteroid treatment
with oral corticosteroid treatment in patients with
bullous pemphigoid. The aim of the present study was
to assess whether topical corticosteroids could sub-
stantially increase the rate of survival among patients
with bullous pemphigoid and whether they could ef-
fectively control the disease.

METHODS

Study Patients

Twenty dermatologic centers in France participated in this pro-
spective, randomized study. The study was approved by the ethics
committee of Seine Maritime, and written informed consent was
obtained from each patient.
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322

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The New Engl and Jour nal of Medi ci ne

Consecutive patients with newly diagnosed bullous pemphi-
goid were eligible for entry if the following criteria were met: clin-
ical features suggestive of bullous pemphigoid

14

; subepidermal blis-
ter on skin biopsy; and linear deposits of IgG and C3 along the
basement-membrane zone. Exclusion criteria were predominant or
exclusive mucosal involvement and treatment with oral or topical
corticosteroids, dapsone, or immunosuppressive drugs during the
previous six months.

Study Design

This randomized, nonblinded study compared two parallel
groups of patients treated with topical or oral corticosteroids.
Since overall survival was the primary outcome, blinding was not
deemed necessary. Randomization was stratified according to the
clinical center and the severity of disease, which was determined
on the basis of the mean number of new bullae that had appeared
daily during the three previous days (moderate disease was defined
by 10 new bullae daily and extensive disease by >10). Random-
ization was performed centrally with the use of random numbers
in permuted blocks of four within each stratum. Patients were ran-
domly assigned to receive either topical applications of 0.05 per-
cent clobetasol propionate cream (Dermoval cream, Glaxo Smith-
Kline, Philadelphia), or oral prednisone (Cortancyl, Roussel, Paris).
Prednisone was administered once daily at a dose of 0.5 mg per
kilogram of body weight per day in patients with moderate dis-
ease and a dose of 1 mg per kilogram per day in those with ex-
tensive disease. The initial dose was maintained for 15 days after
control of the disease had been attained; thereafter, the dose was
reduced by 15 percent every 3 weeks. Treatment was stopped af-
ter 12 months.
Irrespective of the severity of their disease, patients who were
assigned to receive topical corticosteroids received a daily dose of
40 g of clobetasol propionate that was applied twice daily on the
entire surface of the body until 15 days after control of the disease
had been attained. The doses were then gradually reduced to
20 g daily for one month, 10 g daily for two months, 10 g every
other day for four months, and finally 10 g twice a week for four
months. When possible, topical corticosteroids were applied by
the patients themselves or by members of their households. A
nurse performed this task for patients who were in poor condi-
tion generally.
Relapse was defined as the occurrence of at least three new bul-
lae daily for three consecutive days during treatment. In patients
who had a relapse during the period when the dose was being re-
duced, the dose was increased to the previous level that had per-
mitted control of the disease. Other therapy that might affect the
activity of bullous pemphigoid was avoided throughout the study
period. Investigators stopped treatment if a life-threatening side
effect occurred, irrespective of the patients treatment group.

Base-Line and Follow-up Measurements

At base line, each patient underwent physical examination. The
Karnofsky score was assessed. The score is a measure of the patients
general condition and degree of autonomy on a scale ranging from
0 to 100, with higher scores indicating better condition and greater
autonomy.

31

The number of new bullae that appeared daily was
noted by a nurse who was not otherwise involved in the study.
Because of the high mortality reported in recent studies during
the first year after the diagnosis of bullous pemphigoid, we planned
12 months of follow-up. At each follow-up visit (on days 7, 14,
21, 30, 90, 180, and 360), the patients underwent physical exam-
ination, and the number of new bullae that appeared daily was
noted, as was the number of units of clobetasol propionate cream
that had been used. The date of any relapse was recorded, as were
the date and cause of death in any patient who had died. Any side
effects of treatment were assessed, and their severity was graded
1 for mild effects, 2 for moderate effects, 3 for severe effects, or
4 for life-threatening effects, according to standard criteria of the
World Health Organization.

32

Statistical Analysis

The primary end point was overall survival during the first year
after the onset of bullous pemphigoid. Secondary end points were
control of the disease at day 21, defined as the absence of new
bullae for three consecutive days; occurrence of severe (grade 3 or
4) side effects (adverse events requiring hospitalization or prolon-
gation of hospitalization or life-threatening events) during the first
year; and cumulative hospital days (including the initial hospital-
ization plus all rehospitalizations).
The study was designed to have 80 percent power to detect a 50
percent reduction in the one-year mortality rate for both moderate
and extensive bullous pemphigoid, from 40 to 20 percent, with
the two-sided log-rank test and a type I error of 5 percent. To
achieve this power, 75 patients were needed in each treatment
group. Separate intention-to-treat analyses were performed for
patients with moderate and severe bullous pemphigoid. No inter-
im efficacy analysis was either scheduled or performed.
Distributions of overall survival according to treatment group
were estimated by the KaplanMeier method and compared with
the use of the log-rank test. A Cox model was used to adjust the
comparisons between treatment groups for base-line characteris-
tics that were suspected a priori to have prognostic significance
namely, older age (80 years vs. <80 years) and poor general
condition as measured by the Karnofsky score (40 vs. >40).

11

Fishers exact test was used to compare the treatment groups in
terms of the proportions of patients with controlled bullous pem-
phigoid at day 21, as well as the frequency of severe side effects.
Exact binomial probabilities were used to estimate 95 percent
confidence intervals for the rates of control of disease. Students
t-test was used to compare the mean durations of hospitalization.
For all tests, two-sided P values of less than 0.05 were considered
to indicate statistical significance. Continuous variables are ex-
pressed as means SD.

RESULTS

Patients

Between January 1996 and December 1998, 364
patients were assessed for eligibility. Eight declined
to provide informed consent. Previous use of medi-
cation effective against bullous pemphigoid (in eight
patients), diagnosis of another autoimmune blister-
ing-skin disease (in four patients), spontaneous heal-
ing of skin lesions (in two patients), and immediate
withdrawal of consent (in one patient) were other
reasons for exclusion. Of the 341 remaining patients,
153 had 10 or fewer new bullae daily (moderate dis-
ease) and 188 had more than 10 new bullae daily (ex-
tensive disease). A total of 77 patients with moderate
disease were randomly assigned to receive clobetasol
propionate cream and 76 to receive oral prednisone
at a dose of 0.5 mg per kilogram per day. A total of
93 patients with extensive disease were randomly as-
signed to receive clobetasol propionate cream and
95 to receive oral prednisone at a dose of 1 mg per
kilogram per day. The base-line characteristics of the
patients are shown in Table 1. Among both patients
with moderate bullous pemphigoid and patients with
extensive bullous pemphigoid, the treatment groups
were well balanced in terms of the base-line charac-
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COMPARI SON OF ORAL AND TOPI CAL CORTI COSTEROI DS I N PATI ENTS WI TH BULLOUS PEMPHI GOI D

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323

teristics. The mean duration of follow-up among sur-
viving patients with severe bullous pemphigoid was
360 days in the oral-prednisone group and 359 days
in the topical-corticosteroid group. The correspond-
ing figures among surviving patients with moderate
bullous pemphigoid were 361 and 360 days, respec-
tively. One patient with moderate bullous pemphi-
goid who was randomly assigned to the topical-cor-
ticosteroid group decided to stop treatment during
the third month of the study.

Overall Survival

A total of 107 patients died during the one-year
follow-up; 46 of these had moderate bullous pem-
phigoid, and 61 had extensive bullous pemphigoid.
The causes of death were determined in 71 cases; the
main causes were sepsis (in 27 patients, including 20
with pneumonia), cardiovascular disease (in 13 pa-
tients), and stroke (in 9 patients).
Among the patients with moderate bullous pem-
phigoid, 23 patients in the topical-corticosteroid
group died (30 percent), and 23 in the oral-predni-
sone group died (30 percent). The log-rank test did
not indicate any difference in overall survival between
the two treatment groups (P=0.95). The one-year
KaplanMeier survival rate was 69 percent in both
groups (Fig. 1A). Similarly, no difference was evi-
dent in the Cox regression model that included age
and Karnofsky score (P=0.69).
Among the patients with extensive bullous pem-
phigoid, 22 patients in the topical-corticosteroid
group died (24 percent), and 39 patients in the oral-
prednisone group died (41 percent). Overall survival
was significantly longer with topical corticosteroids
than with oral prednisone (P=0.02). One-year Kap-
lanMeier survival rates were 76 percent and 58 per-
cent, respectively (Fig. 1B). With the use of the Cox
regression model, this beneficial effect of clobetasol
propionate was confirmed after adjustment for age
and Karnofsky score (P=0.009).

Disease Control and Relapse

In all 77 patients with moderate bullous pemphi-
goid who were assigned to the topical-corticosteroid
group (100 percent; 95 percent confidence interval,
95 to 100 percent) and 72 of the 76 patients with
moderate bullous pemphigoid who were assigned to
the oral-prednisone group (95 percent; 95 percent
confidence interval, 87 to 99 percent), control of
bullous pemphigoid was achieved by day 21 (P=
0.06). Control was achieved by day 21 in 92 of the
93 patients with extensive bullous pemphigoid in the
topical-corticosteroid group (99 percent; 95 percent
confidence interval, 94 to 100 percent) and in 86 of

*Plusminus values are means SD. Among both patients with moderate bullous pemphigoid and
patients with extensive bullous pemphigoid, no significant differences were observed between patients
assigned to receive topical applications of clobetasol propionate cream and those assigned to receive
oral prednisone.

T

ABLE

1.

B

ASE

-L

INE

C

HARACTERISTICS



OF



THE

P

ATIENTS

.*

C

HARACTERISTIC

M

ODERATE

D

ISEASE


(10

NEW



BULLAE

/

DAY

)
E

XTENSIVE

D

ISEASE


(>10

NEW



BULLAE

/

DAY

)

TOPICAL



CLOBETASOL



PROPIONATE


(

N

=77)

ORAL



PREDNISONE


(

N

=76)

TOPICAL



CLOBETASOL



PROPIONATE


(

N

=93)

ORAL



PREDNISONE


(

N

=95)
Age yr 828 8110 8011 819
Sex no.
Male
Female
29
48
28
48
40
53
32
63
Days since onset of disease 106205 7979 66160 79213
Karnofsky score 6325 6624 6523 6324
No. of new bullae daily 33 43 6554 6575
Coexisting conditions no. (%)
Cardiovascular disease
Neurologic disorder
Dementia
Diabetes mellitus
Chronic lung condition
46 (60)
26 (34)
11 (14)
3 (4)
3 (4)
55 (72)
22 (29)
10 (13)
8 (11)
3 (4)
67 (72)
25 (27)
17 (18)
7 (8)
7 (8)
61 (64)
32 (34)
18 (19)
11 (12)
6 (6)
Eosinophil count per mm

3

10541005 10211474 18511664 19401737
Presence of circulating antibodies
against basement-membrane
zone antigens no. (%)
50 (65) 51 (67) 61 (66) 66 (69)
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324

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The New Engl and Jour nal of Medi ci ne

the 95 patients with extensive bullous pemphigoid in
the oral-prednisone group (91 percent; 95 percent
confidence interval, 83 to 96 percent; P=0.02).
A total of 30 of the 76 patients with moderate dis-
ease in the oral-prednisone group (39 percent; 95
percent confidence interval, 28 to 50 percent) and
27 of the 77 patients in the topical-corticosteroid
group (35 percent; 95 percent confidence interval,
24 to 46 percent) had relapses during follow-up af-
ter a mean interval of 149109 days and 178118
days, respectively. The corresponding figures among
the patients with extensive disease were 44 of the 95
patients in the oral-prednisone group (46 percent;
95 percent confidence interval, 36 to 56 percent) af-
ter a mean interval of 210133 days and 34 of the
93 patients in the topical-corticosteroid group (37
percent; 95 percent confidence interval, 27 to 46
percent) after a mean interval of 187118 days.

Compliance with Treatment and Adverse Effects

In accordance with the study protocol, the inves-
tigators switched three patients with moderate
bullous pemphigoid and four with extensive bullous
pemphigoid from the oral-prednisone group to the
topical-corticosteroid group because of side effects
of treatment. The life-threatening side effects in these
patients were septicemia (in two patients), severe
pneumonia with respiratory distress (in two patients),
postoperative sepsis after hip fracture (in one pa-
tient), necrotizing cellulitis of the leg (in one pa-
tient), and myocardial infarction with acute cardiac
failure (in one patient). Two of these seven patients
died during the study period. There were no life-
threatening side effects in patients assigned to the
topical-corticosteroid group. One patient with severe
bullous pemphigoid who was initially assigned to the
topical-corticosteroid group was later treated with
oral prednisone, at a dose of 1 mg per kilogram per
day, by a physician who was not aware of the proto-
col; this patient died of pneumonia 15 days after the
treatment was changed.
Overall, 172 severe (grade 3) or life-threatening
(grade 4) side effects were reported in 132 patients
(Table 2). Severe side effects were reported in 29 of
the 76 patients with moderate disease in the oral-
prednisone group (38 percent), as compared with 25
of the 77 patients with moderate disease in the top-
ical-corticosteroid group (32 percent, P=0.46). Se-
vere side effects were observed in 51 of the 95 pa-
tients with extensive disease in the oral-prednisone
group (54 percent), as compared with 27 of the 93
patients with extensive disease in the topical cortico-
steroid group (29 percent, P=0.006). Among the
10 patients with extensive bullous pemphigoid in
whom disease was not controlled by day 21, severe
adverse events occurred in 5 of the 9 patients in the

Figure 1.

KaplanMeier Estimates of the Overall Survival of Pa-
tients with Moderate Bullous Pemphigoid (Panel A) or Exten-
sive Bullous Pemphigoid (Panel B), According to Treatment-
Group Assignment.
P values were determined by the log-rank test.
0.0
1.0
0 400
0.8
0.6
0.4
0.2
50 100 150 200 250 300 350
Days since Randomization
P=0.02
NO. AT RISK
Clobetasol
propionate
Prednisone
93

95
88

81
80

70
77

69
73

65
71

63
70

62
64

52
Prednisone (1 mg/kg/day)
Clobetasol propionate cream
Extensive Bullous Pemphigoid B
P
r
o
p
o
r
t
i
o
n

S
u
r
v
i
v
i
n
g
0.0
1.0
0 400
0.8
0.6
0.4
0.2
50 100 150 200 250 300 350
Days since Randomization
P=0.95
NO. AT RISK
Clobetasol
propionate
Prednisone
77

76
71

72
63

63
57

62
57

57
55

56
55

56
49

50
Prednisone (0.5 mg/kg/day)
Clobetasol propionate cream
Moderate Bullous Pemphigoid A
P
r
o
p
o
r
t
i
o
n

S
u
r
v
i
v
i
n
g
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325

oral-prednisone group, and 3 of the 9 patients in
that group died, whereas neither a severe adverse
event nor death occurred in the 1 patient in the top-
ical-corticosteroid group.

Duration of Hospitalization

Most patients were initially hospitalized during
the acute phase of their disease. Some patients were
rehospitalized during the follow-up period because
of relapse or side effects. The length of hospital stay
according to treatment group is shown in Table 3.
The mean cumulative duration of hospitalization was
shorter in the topical-corticosteroid group than in the
oral-prednisone group: 1111 days and 1714 days,
respectively, among patients with moderate bullous
pemphigoid (P=0.02) and 1714 days and 2520
days, respectively, among those with extensive bullous
pemphigoid (P=0.002).

DISCUSSION

Systemic corticosteroids have been considered the
mainstay of treatment for bullous pemphigoid for 40
years.

3
However, this treatment is responsible for nu-
merous side effects in elderly people and has been
suspected of being associated with a mortality rate
of up to 40 percent per year among elderly persons
with bullous pemphigoid.
11,12,16-18,33,34
The present
study confirms the poor prognosis of patients with
bullous pemphigoid who are treated with 1 mg of
prednisone per kilogram per day, among whom the
one-year mortality rate was 41 percent. Among the
patients who received topical treatment, there was no
difference in overall survival between patients with
moderate bullous pemphigoid and those with exten-
sive bullous pemphigoid, suggesting that survival of
patients with bullous pemphigoid is more likely to
be related to the type of treatment than to the se-
verity of disease.
11,27
The present study was designed to test the hy-
pothesis that topical corticosteroids could be an ef-
fective alternative treatment for patients with bullous
pemphigoid and would result in a decrease in the in-
cidence of severe adverse events. Our results clearly
demonstrate the efficacy of clobetasol propionate
cream. In all patients with moderate bullous pemphi-
goid and 99 percent of those with extensive bullous
pemphigoid, the disease was controlled by day 21
an improvement over oral-corticosteroid treatment
that was significant among those with extensive dis-
ease. Moreover, the rates of control of disease in
both subgroups of the oral-prednisone group were
higher than those usually reported with oral cortico-
steroids.
27,35
This finding may be related to the high
bioavailability of prednisone and seems consistent
*All P values were calculated with the use of Fishers exact test.
Diabetes was diagnosed according to the standard criteria of the American Diabetes Association, but only cases of
diabetes requiring insulin were included in the analysis of severe (grade 3) or life-threatening (grade 4) adverse events.
Data include both clinically apparent fractures and vertebral fractures visible on radiography.
TABLE 2. INCIDENCE OF GRADE 3 OR 4 ADVERSE EVENTS AFTER THE INITIATION OF TREATMENT.*
ADVERSE EVENT MODERATE DISEASE (10 NEW BULLAE/DAY) EXTENSIVE DISEASE (>10 NEW BULLAE/DAY)
TOPICAL
CLOBETASOL
PROPIONATE
(N=77)
ORAL
PREDNISONE
(N=76) P VALUE
TOPICAL
CLOBETASOL
PROPIONATE
(N=93)
ORAL
PREDNISONE
(N=95) P VALUE
no. of events (% of all events) no. of events (% of all events)
Pneumonia 8 (10) 11 (14) 0.47 6 (6) 11 (12) 0.31
Other severe infection (septi-
cemia, arthritis, cellulitis,
or peritonitis)
3 (4) 5 (7) 0.49 2 (2) 11 (12) 0.02
Diabetes mellitus requiring
insulin
2 (3) 7 (9) 0.10 4 (4) 13 (14) 0.04
Myocardial infarction or cardiac
failure
7 (9) 6 (8) 1.00 4 (4) 11 (12) 0.10
Psychiatric symptoms (psycho-
sis or delirium)
0 4 (5) 0.06 0 6 (6) 0.03
Stroke 4 (5) 4 (5) 1.00 7 (8) 5 (5) 0.57
Deep venous thrombosis or
pulmonary embolism
4 (5) 6 (8) 0.53 5 (5) 4 (4) 0.75
Bone fracture 3 (4) 3 (4) 1.00 2 (2) 4 (4) 0.68
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326 N Engl J Med, Vol. 346, No. 5 January 31, 2002 www.nejm.org
The New Engl and Jour nal of Medi ci ne
with the greater effectiveness reported for predni-
sone than for prednisolone in controlling bullous
pemphigoid.
35
The main finding of this study is the significant
and substantial improvement in outcome among pa-
tients with extensive bullous pemphigoid who were
treated with clobetasol propionate cream, as com-
pared with those treated with 1 mg per kilogram per
day of oral prednisone. This difference was observed
consistently for all the outcomes we studied: overall
survival, control of disease, occurrence of severe side
effects, and duration of hospitalization.
It is important to consider whether the nonblind-
ed nature of the study may have biased our results.
We think such bias is unlikely, for several reasons.
First, it is unlikely that overall survival, our primary
end point, could be subject to such bias. Moreover,
bias concerning secondary end points is unlikely as
well, because most were graded semiquantitatively and
were not directly dependent on subjective judgment.
Indeed, assessment of the control of disease was based
on the determination of the number of new bullae
that appeared daily by nurses who were not directly
involved in the study, and most grade 3 and grade 4
side effects represented well-known side effects of cor-
ticosteroids that were characterized biologically (di-
abetes mellitus), radiologically (stroke, pneumonia,
and bone fracture), or bacteriologically (septicemia,
arthritis, and peritonitis). Differences in the cumula-
tive duration of hospitalization were due, at least in
part, to rehospitalizations initiated by the patients
general practitioners not by study investigators
because of side effects of the treatments.
Our study demonstrates the superiority of an al-
ternative treatment regimen over oral corticosteroids
in the treatment of extensive bullous pemphigoid, in
terms of both the control of disease and survival. In
patients with extensive bullous pemphigoid, topical
corticosteroids led to a 43 percent reduction (95
percent confidence interval, 19 to 69 percent) in the
one-year mortality rate. This benefit is further sup-
ported by the demonstration of a 50 percent reduc-
tion in the mortality rate (95 percent confidence in-
terval, 15 to 71 percent) after adjustment by Cox
regression for age and Karnofsky score two factors
strongly suspected to be related to the prognosis in
patients with bullous pemphigoid.
11
The chief expla-
nation for the present results is the fact that topical
treatment has lower toxicity than 1 mg of prednisone
per kilogram per day, as demonstrated by the fact that
fewer patients in the topical-corticosteroid group had
severe side effects of treatment. This difference was
particularly marked in the case of side effects, such as
sepsis and diabetes mellitus requiring insulin, that are
classically reported with high-dose systemic cortico-
steroids. Our results suggest that topical corticoster-
oids should be considered the standard treatment for
patients with extensive bullous pemphigoid.
Supported by research grants from Rouen University Hospital and the
French Society of Dermatology.
We are indebted to the patients who participated in the study; to
Veronique Chambaretaud for technical assistance during the study;
and to Annick Horville and Richard Medeiros for their assistance
in the preparation of the manuscript.
APPENDIX
The following persons also participated in the Bullous Diseases French
Study. Investigators: P. Saiag, M.D., Ph.D., Boulogne Billancourt; E. Tan-
crede-Bohin, M.D., Paris; B. Sassolas, M.D., Brest; C. Lok, M.D., Ph.D.,
*Plusminus values are means SD. Students t-test was used to compare the mean durations of hospitalization.
TABLE 3. NUMBER OF HOSPITAL STAYS AND DURATION OF HOSPITALIZATION.*
VARIABLE MODERATE DISEASE (10 NEW BULLAE/DAY) EXTENSIVE DISEASE (>10 NEW BULLAE/DAY)
TOPICAL
CLOBETASOL
PROPIONATE
(N=77)
ORAL
PREDNISONE
(N=76) P VALUE
TOPICAL
CLOBETASOL
PROPIONATE
(N=93)
ORAL
PREDNISONE
(N=95) P VALUE
Cumulative duration of hospital-
ization (days)
1111 1714 0.02 1714 2520 0.002
Duration of initial hospitalization
(days)
910 1210 0.16 138 1710 0.002
Rehospitalization
No. of patients
No. of rehospitalizations for
rehospitalized patients
Cumulative duration for rehos-
pitalized patients (days)
Cumulative duration among all
patients (days)
18
1.20.4
118
26
20
1.50.6
2113
511 0.04
22
1.40.6
1812
410
31
1.50.7
2525
818 0.08
Downloaded from www.nejm.org on June 5, 2009 . Copyright 2002 Massachusetts Medical Society. All rights reserved.
COMPARI SON OF ORAL AND TOPI CAL CORTI COSTEROI DS I N PATI ENTS WI TH BULLOUS PEMPHI GOI D
N Engl J Med, Vol. 346, No. 5 January 31, 2002 www.nejm.org 327
Amiens; B. Labeille, M.D., Valence; J.C. Guillaume, M.D., Colmar; F.
Loche, M.D., Toulouse; M.S. Doutre, M.D., Ph.D., Bordeaux; I. Gorin,
M.D., Paris; O. Chosidow, M.D., Ph.D., Paris; C. Pauwels, M.D., Saint
Germain en Laye. Contributors: C. Neveu, M.D., Lillebonne; M.F. Hellot,
M.Sc., Rouen; I. Noblesse, M.D., Rouen.
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