DEAR DR. ROACH: I am a 73-year-old woman who is in otherwise good health, but I was diagnosed with bullous pemphigoid, a rare autoimmune disease, in January 2022. I have been treated by three different dermatologists with doxycycline, prednisone and Dupixent. The only effective treatment has turned out to be prednisone.
I have been taking a dosage of 5-10 mg depending on the severity of the disease flare-up for the past three years. I really dislike the side effects of weight gain and bruising easily with prednisone. The skin blisters and intense itching cause me to take it for relief. My doctor has suggested looking into a treatment like Imuran, but the side effects seem daunting.
I would appreciate any thoughts you might have. — D.B.
ANSWER: You’re exactly right that bullous pemphigoid is a rare autoimmune blistering skin disease, which usually occurs in older adults. Your dermatologists have used the standard of care with doxycycline and prednisone. They even put you on one of our most powerful steroid-sparing medications, dupilumab (Dupixent), which is effective for 92% of people who take it, so you were quite unlucky that it didn’t help at all.
Other options to replace or reduce the dose of prednisone (besides Imuran) include dapsone, methotrexate, and mycophenolate, which are all medicines that have been used for many years and are relatively safe when used cautiously by experts.
It’s important to consider the long-term effects of prednisone on your immune system, blood sugar, blood pressure, and risk of osteoporosis when considering alternative treatments. I would really consider a steroid-sparing medication.
DEAR DR. ROACH: I am a woman aged 58, and I have very high blood pressure from a fall that dissected my aorta. I somehow survived and am thriving. Well, the last time I checked my blood pressure about a week ago, it was 193/119 mmHg, which is low for me. It’s usually around 220/130 mmHg, give or take.
I won’t take meds because I have only one kidney that has 75% function and don’t want two problems; they also make me feel sick and depressed and make me gain weight. From my CT scan, it shows a lot of narrow areas on my aorta. I keep hearing from doctors and nurses that I’m going to die. I’ve been alive for 12 years (longer than my surgeon thought), so am I really in any danger? I know this sounds a bit daft.
Also, my pulse is 55-60 bpm. I’m very athletic, and my heart is strong. — M.W.
ANSWER: An aortic dissection is a separation of the layers of the aorta, which is the largest blood vessel in the body. It is a life-threatening event. In most cases, aortic dissection is due to uncontrolled hypertension. If the dissection extends to one or both renal arteries (the blood supply to the kidneys), the kidney may not get enough blood flow. Kidneys respond to this by secreting a substance (renin), which ultimately causes a person’s blood pressure to go up.
Having blood pressure at the level you do is very dangerous to your remaining kidney, the blood vessels all over your body, and most especially to your heart and brain. Your risk of a heart attack and stroke is much higher than a person with normal blood pressure. Obviously, nobody can predict when something bad might happen, but there is no doubt that you are in real danger.
With time and patience, it is very likely that your doctors could find a blood pressure treatment for you that protects your heart, kidneys and brain while minimizing side effects. Depression and weight gain would be very unusual side effects in this case.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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