Rituximab, Omalizumab, and Dupilumab Treatment Outcomes in Bullous Pemphigoid: A Systematic Review

Front Immunol. 2022 Jun 13:13:928621. doi: 10.3389/fimmu.2022.928621. eCollection 2022.


Background: Bullous pemphigoid (BP) is the most common autoimmune subepidermal bullous disease of the skin. First-line treatment of systemic corticosteroids may cause serious adverse events. Rituximab, omalizumab, and dupilumab should be explored as alternative treatment options to improve outcomes.

Objective: To systematically review the rituximab, omalizumab, and dupilumab treatment outcomes in bullous pemphigoid.

Methods: A PubMed, Embase, Web of Science, and Cochrane library search were conducted on March 10, 2022. A total of 75 studies were included using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Results: Use of rituximab (n=122), omalizumab (n=53) and dupilumab (n=36) were reported in 211 patients with BP. Rituximab led to complete remission in 70.5% (n=86/122) and partial remission in 23.8% (n=29/122) of patients within 5.7 months, with a recurrence rate of 20.5% (n=25/122). 9.0% (n=11/122) of patients died and infection (6.6%, n=8/122) was the most common adverse event. Omalizumab led to complete remission in 67.9% (n=36/53) and partial remission in 20.8% (n=11/53) of patients within 6.6 months, with a recurrence rate of 5.7% (n=3/53). 1.9% (n=1/53) of patients died and thrombocytopenia (1.9%, n=1/53) was observed as the most common adverse event. Dupilumab led to complete remission in 66.7% (n=24/36) and partial remission in 19.4% (n=7/36) of patients within 4.5 months of treatment without any reported adverse events, with a recurrence rate of 5.6% (n=2/36).

Conclusions: Rituximab, omalizumab, and dupilumab have similar clinical benefits for BP patients. However, rituximab resulted in higher recurrence rates, adverse events, and mortality rates.

Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022316454.

Keywords: biologics; bullous pemphigoid; dupilumab; omalizumab; rituximab.

Publication types

  • Systematic Review

MeSH terms

  • Antibodies, Monoclonal, Humanized
  • Humans
  • Omalizumab* / adverse effects
  • Pemphigoid, Bullous*
  • Rituximab / therapeutic use
  • Treatment Outcome


  • Antibodies, Monoclonal, Humanized
  • Omalizumab
  • dupilumab
  • Rituximab