Dermatology 2026

Background: Pemphigus foliaceus (PF) is an autoimmune blistering disorder typically characterised by superficial erosions and crusted lesions. A prominent pustular presentation is uncommon and may mimic other neutrophilic dermatoses, posing a diagnostic challenge.

Case Presentation: We report a 47-year-old woman presented with a flare characterised by widespread erythema, scaling, superficial erosions, and fine pustules involving multiple body sites. The oral mucosa was spared. Histopathological examination demonstrated superficial acantholsis and a superficial intraepidermal blister containing neutrophils, eosinophils, and acantholytic cells, with additional neutrophilic and eosinophilic exocytosis. These findings supported the diagnosis of PF despite the prominent pustular morphology. Treatment with corticosteroids yielded an inadequate response. Rituximab infusion was attempted but discontinued because of hypotension, preventing assessment of its therapeutic efficacy. Subsequent treatment with dapsone was associated with clinical improvement.

Conclusion: This case challenges the conventional clinical picture of pemphigus foliaceus and highlights the importance of recognising neutrophilic inflammation in an atypical pustular presentation. It also underscores the value of clinicopathological correlation in avoiding diagnostic pitfalls. The favourable response to dapsone raises an important therapeutic consideration in selected cases, particularly when conventional treatment is inadequate or poorly tolerated.

Dermatology doctor with focused experience in medical dermatology and aesthetic procedures. Co-founder of Derma Organization, leading dermatology outreach programs and coordinating multidisciplinary medical teams in high-impact community campaigns. Actively involved in humanitarian and volunteer work, delivering dermatological care to underserved populations and contributing to service development, patient education, and preventive skin health initiatives.