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Nicotinamide and Tetracycline Effective for Bullous Pemphigoid

Bullous pemphigoid, typically a disease of the elderly, is usually treated with systemic corticosteroids and cytotoxic drugs, which have a considerable risk of morbidity in this population. There have been anecdotal reports of effective treatment with other agents such as dapsone, erythromycin, cyclosporine, tetracyclines, and nicotinamide. Twenty patients with bullous pemphigoid were enrolled in this randomized, open-label, two-center study comparing oral prednisone with combined tetracycline and nicotinamide.

Fourteen patients received nicotinamide (500 mg three times per day) plus tetracycline (500 mg four times per day) and 6 received prednisone (40 to 80 mg per day). In the first 8 weeks of the trial, 5 patients in the nicotinamide/tetracycline group had complete responses, 5 had partial responses, 1 had no change, and 1 had progression of the disease. Two patients were lost to follow-up. In the prednisone-treated group, 1 patient had a complete response and 5 had partial responses. Eight patients were available for long-term follow-up: 2 of the 3 available prednisone-treated patients and only 1 of the 5 available nicotinamide/tetracycline-treated patients experienced flares of the disease while the medications were being tapered.

Although responses were good in both groups, side effects were considerably different. Five of the 6 patients treated with prednisone developed major complications including hypertension, osteomyelitis, decubitus ulcers, deep venous thrombosis, and erosive gastritis. One patient died because of sepsis. In the other group, one patient with a prior history of renal insufficiency developed acute tubular necrosis after 4 weeks of treatment. Two others had significant gastrointestinal distress necessitating a switch from tetracycline to minocycline.

Comment: Although this is a small open trial, the results are impressive. The combination of tetracycline and nicotinamide may be more effective and is certainly safer than systemic corticosteroids in patients with bullous pemphigoid. Because of a concern of nephrotoxicity, tetracycline should not be used in patients with underlying renal insufficiency.

Blisters in bullous pemphigoid are rich in neutrophils, eosinophils, and histamine. Both tetracycline and nicotinamide inhibit neutrophil and eosinophil chemotaxis, and nicotinamide has antihistamine effects at the receptor and inhibits histamine release. These mechanisms are likely involved in the therapeutic effect seen with these drugs.

— K Wiss

Published in Journal Watch Dermatology August 1, 1994

Citation(s):

Fivenson DP et al. Nicotinamide and tetracycline therapy of bullous pemphigoid. Arch Dermatol 1994 130 753-758.

• Medline abstract (Free)

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