Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2024;14(1):e2024031 1 Post-Surgical Anti-BP230 Bullous Pemphigoid: A Rare Cause of Non-Healing Wound Carlo Pipitò1, Maria E Baffa1, Roberto Maglie1, Stefano Senatore1, Emiliano Antiga1 1 Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy Citation: Pipitò C, Baffa ME, Maglie R, Senatore S, Antiga E. Post-Surgical Anti-BP230 Bullous Pemphigoid: A Rare Cause of Non-Healing Wound. Dermatol Pract Concept. 2024;14(1):e2024031. DOI: https://doi.org/10.5826/dpc.1401a31 Accepted: May 31, 2023; Published: January 2024 Copyright: ©2024 Pipitò et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Carlo Pipitò, Department of Health Sciences, Section of Dermatology, University of Florence, Hospital Piero Palagi, Viale Michelangiolo 41, 50125, Florence, Italy. E-mail: carlo.pipito@unifi.it Case Presentation A woman in her 80s presented with a 10-month history of a nonhealing figurate erosive lesion that traces almost pre- cisely the outline of the surgical abdominal scar following bowel resection performed one year earlier (Figure 1A). The wound had not improved despite advanced wound care and topical and systemic antibiotics. While the histological exam- ination was unspecific, direct immunofluorescence revealed the presence of linear IgG and C3 deposits at the basement membrane zone. Moreover, an enzyme-linked immunosor- bent assay was positive for IgG against BP230 (30 UI/mL: reference value < 9 UI/ml), with no evidence of anti-BP180 antibodies. Clinical and laboratory findings were compati- ble with the post-traumatic anti-BP230 bullous pemphigoid diagnosis. The patient was treated with a tapering course of oral prednisone at a starting dose of 0.5/mg/kg/die, with rapid improvement of the condition (Figure 1B). Teaching Point Bullous pemphigoid is the most frequent autoimmune bul- lous disease. In most cases, it presents with itch and tense blisters over erythematous and edematous skin [1]. Although BP180 is the major autoantigen of bullous pemphigoid, some cases of patients having only anti-BP230 autoanti- bodies have been reported yet. Interestingly, patients having bullous pemphigoid with only anti-BP230 autoantibodies usually show a more localized clinical involvement as well as atypical clinical features; moreover, some of these cases are secondary to trauma [2]. In conclusion, bullous pemphigoid should be considered as a differential diagnosis in patients with post-surgical wounds that do not heal with conven- tional wound care; in these patients, steroids usually lead to a prompt remission. 2 Image Letter | Dermatol Pract Concept. 2024;14(1):e2024031 References 1. Schmidt E, Zillikens D. Pemphigoid diseases. Lancet. 2013; 381(9863):320-332. DOI: 10.1016/S0140-6736(12)61140-4. PMID: 23237497. 2. Ramcke T, Vicari E, Bolduan V, Enk A, Hadaschik E. Bullous pemphigoid (BP) patients with selective IgG autoreactivity against BP230: Review of a rare but valuable cohort with im- pact on the comprehension of the pathogenesis of BP. J Dermatol Sci. 2022;105(2):72-79. DOI: 10.1016/j.jdermsci.2021.11.011. PMID: 34930674. Figure 1. (A) Non-healing figurate erosive lesion that traces almost precisely the outline of the surgical abdominal scar following bowel resection. (B) Improvement of the lesion after one week.