Intravenous immunoglobulin
ii. Rituximab
Among all, topical or systemic corticosteroids are considered as the first line therapy in controlling bullous pemphigoid. Other drugs and immunomodulatory therapies are often used as adjunct to minimize the adverse effect of long term use of corticosteroids and improve the healing of the disease. There are several factors that have to be taken into account when choosing the therapies given to the patient: (a) patients age (b) underlying disease such as hypertension, diabetes mellitus and other cardiovascular disease (c) side effect with the use of drugs (d) patients ability to compliant to the therapy (d) severity and extent of disease (e) cost of drugs. Corticosteroids
High potency topical corticosteroid is preferred as the first line treatment due to its efficacy and fewer systemic adverse effects when compared to systemic corticosteroids. Studies have shown that patients with extensive bullous pemphigoid (defined as >10 new bullae per day) treated with topical corticosteroids (Topical Clobetasol Propionate 0.05% cream) had better clinical outcomes than patients with extensive bullae pemphigoid who were treated with systemic glucocorticoid therapy (Prednisone).Systemic glucocorticoids can be used for patients when there are factors that make the use of topical corticosteroids not feasible, such as elderly patient inability to apply the cream on their own, cost or patients own preference. Topical Corticosteroids
Topical Clobetasol Propionate 0.05% cream is usually used and applied twice daily. A study by Joly et al.
In addition to its supply to muscles, this nerve also supplies the distal radioulnar joint and wrist joint.The median nerve also gives off sensory and other branches in the forearm. The palmar cutaneous branch of the median nerve arises at the distal part of the forearm. It supplies sensory innervation to the thenar eminence of the palm and the central palm. Articular branches are given to the elbow joint and proximal radioulnar joint. Vascular branches supply the radial and ulnar arteries. Meanwhile, a communicating branch is given to the ulnar nerve. Hand
The median nerve enters the hand through the carpal tunnel, deep to the flexor retinaculum along with the tendons of flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus. From there, it is divided into recurrent muscular branch and digital cutaneous branch:
The muscular branch (also known as recurrent branch) supplies the thenar muscles (opponens pollicis, abductor pollicis brevis, and superficial part of flexor pollicis brevis)
Digital cutaneous to the proper palmar digital branch and the common palmar digital branch: The proper palmar digital branch gives out three digital branches to the lateral one and a half digits (two digital branches to the thumb, one digital branch to the lateral side of the index finger). The digital branch to the index finger also supplies the first lumbrical. The common palmar digital branch divides further into two branches. Both the medial and lateral branches supply the second and third interdigital clefts with adjoining index, middle, and lateral half of ring finger.