Treatment patterns for bullous pemphigoid in older adults: A population-based study.

Background: Bullous pemphigoid (BP) is a chronic autoimmune blistering disease that disproportionately affects older adults and is associated with substantial morbidity, mortality, and treatment-related risks. Despite an expanding therapeutic landscape, real-world prescribing patterns in this population remain poorly characterized. Objective: To evaluate medication prescribing patterns among older adults with BP and assess the feasibility of using national claims data to characterize treatment exposures relevant to drug safety and risk stratification. Methods: We conducted a retrospective cohort study using Medicare fee-for-service claims data (2016-2020). Adults aged 65 years or older with BP were identified using ICD-10 codes. Prescription drug event data were linked to outpatient claims to capture medication use. Treatments were categorized into topical corticosteroids (by potency), oral immunomodulators and antibiotics, and biologic therapies. Descriptive analyses were performed to evaluate prescribing distributions. Results: Among 10,959 patients with BP and 78,468 outpatient claims, we identified 19,663 prescriptions. Oral immunomodulators and antibiotics comprised 67.5% of prescriptions, followed by topical corticosteroids (32.5%) and biologics (0.04%). Prednisone accounted for 62.9% of oral prescriptions, followed by doxycycline (20.2%) and mycophenolate (6.0%). Among topical steroids, medium-potency agents were most common (40.6%), followed by super high-potency (38.2%). Biologic use was rare, with dupilumab accounting for most prescriptions. Conclusion: Systemic corticosteroids remain the predominant therapy for BP in older adults, with substantial variability in topical steroid use and minimal uptake of biologics. These findings highlight gaps in treatment optimization and support the need for risk-informed, steroid-sparing strategies in this high-risk population.