A 72-year-old woman with extensive bullous pemphigoid has contraindications to high-dose systemic corticosteroids because of uncontrolled diabetes. According to the BLISTER randomized trial, which alternative showed non-inferior efficacy with fewer serious adverse effects?

• A Colchicine 1 mg per day
• B Methotrexate 15 mg weekly
• C Azathioprine 2 mg/kg/day
• D Doxycycline 200 mg per day ✓

Explanation

The BLISTER trial demonstrated that doxycycline 200 mg daily was non-inferior to prednisolone for maintaining disease control in bullous pemphigoid at six weeks, with fewer life-threatening adverse events. Its anti-inflammatory action suppresses matrix metalloproteinases and eosinophil function. Methotrexate, azathioprine and colchicine are used as steroid-sparing agents but were not the comparator showing non-inferiority in this trial.

Reference: Rook's Textbook of Dermatology, 9th ed.

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