Twice-triggered localized bullous pemphigoid following orthopedic surgery: A rare presentation

Localized bullous pemphigoid (BP) is a rare variant of an autoimmune blistering disease commonly affecting elderly individuals. While BP is typically associated with systemic triggers, its localized form can result from physical trauma or surgical procedures. We present a case of a 60-year-old man who developed localized BP following two orthopedic surgeries on the same limb. Two weeks after femur fracture fixation with retrograde intramedullary nailing, he developed tense, pruritic bullae around the knee and lower leg. Histopathological analysis and direct immunofluorescence confirmed the diagnosis of BP. Lesions resolved after treatment with oral corticosteroids. However, the patient experienced a recurrence of similar lesions after a second procedure for bone grafting due to fracture non-union. The lesions extended above the knee but responded to the same corticosteroid regimen, resolving completely. This case highlights the potential role of surgical trauma and postoperative tissue changes as triggers for localized BP, emphasizing the importance of early recognition and management.