The correct answer is A. Taper corticosteroids and begin doxycycline and nicotinamide.

Elderly patients with bullous pemphigoid are at high risk for systemic corticosteroid complications, including steroid-induced hyperglycemia and increased white blood cell count. Doxycycline plus nicotinamide has been shown to be non-inferior to steroids in mild-to-moderate disease and is safer in elderly populations.

Mycophenolate and azathioprine both have slower onsets and are not suitable for rapid control in this acute setting. IVIG is appropriate for severe, refractory, or rapidly progressing disease, but this case is a drug side effect. Rituximab is a second-line or for refractory disease, not first-line treatment.

References:

Bullous pemphigoid: A practical approach to diagnosis and management in the modern era. Powers, Camille M. et al. Journal of the American Academy of Dermatology, Volume 92, Issue 6, 1337 – 1350.

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