Why We Publish This
Most clinics describe who they can help. Very few describe who they cannot, because the second list costs money.
We publish both, because the alternative — taking on a patient we do not expect to help, in a disease that can be serious, while they spend months and money discovering that — is worse for them and eventually worse for us.
Read the second list first. If you are on it, we would rather you did not start.
Who Tends to Respond
People already under conventional control who keep failing at the taper step
This is, by some distance, the group EPOH is best suited to.
The disease is not running. A dermatologist has it in hand. But every attempt to bring the steroid down produces a flare, so the dose never really falls, and the drug's cost accumulates quietly — in bone, in blood sugar, in sleep, in the shape of a face.
The work EPOH does — lowering inflammatory load, repairing the internal terrain, then clearance — is work on the background against which the taper is attempted. It does not shorten the taper and it does not perform the taper, which remains entirely the dermatologist's decision. What it can do is change the patient on whom the taper is being attempted.
Itch-dominant pemphigoid, particularly early
The prodrome of bullous pemphigoid is often itch, sometimes for months before a single blister appears — which is why so many people are treated for eczema or scabies before anyone reaches a biopsy.
Where itch is the dominant burden, it is also the most responsive signal and the earliest to move.
Limited or localised disease
A person whose disease is confined to a region, who is not systemically unwell, has room to run a phased protocol. Nothing urgent is competing with the sequence.
A clear gut and metabolic picture
Longstanding digestive disturbance, poor appetite, disordered sleep, a history of heavy antibiotic or steroid exposure. Where that terrain is prominent, Phase I has something real to do.
People who will keep the diary
This sounds like a virtue test. It is not.
The protocol produces no visible change for the first four to eight weeks, and the only way to know whether anything is engaging is a daily record of itch, new-lesion count, and healing time. A patient who will not keep it cannot be assessed — and a patient who cannot be assessed cannot be helped. They can only be billed.
Who Does Not
Anyone acutely deteriorating
Rapidly extending blistering, systemic illness, fever, extensive skin loss. This is a hospital problem and a dermatology problem, today. A courier box is not a response to it, and we will not pretend otherwise.
Widespread pemphigus vulgaris with extensive mucosal erosion
Untreated pemphigus can kill. The mouth, the throat, the oesophagus, the eyes, the genitals — extensive erosion of mucosal surfaces carries risks of infection and of simply being unable to eat and drink.
This needs conventional immunosuppression, and it needs it now. There is no version of events in which a phased home protocol is the right first move, and the fact that we would like to help does not change what the disease is.
Any eye involvement
Grittiness, redness, a foreign-body sensation, an inturned lash, conjunctival inflammation.
Mucous membrane pemphigoid scars, and scarring on the conjunctiva threatens sight — permanently, and sometimes quickly. This is an ophthalmology emergency. It is not a thing to try something else for first, and if you spend a fortnight on us instead of an ophthalmologist, some of what you lose does not come back.
Anyone who wants to come off their medication
If your reason for being here is to get off steroids or off rituximab, and you intend to do it with or without your dermatologist's agreement, we are not the right clinic and we do not want the case.
We do not taper anyone. We do not advise dose changes. Sudden steroid withdrawal risks adrenal insufficiency and a rebound flare.
Anyone using this instead of a dermatologist
There is no clinic visit in EPOH at any stage. That means we never examine you. We cannot palpate a lesion, elicit a Nikolsky sign, look at your conjunctiva, or judge whether an erosion has become infected.
That gap has to be filled by somebody. If you are not under a dermatologist, you are not a candidate.
Anyone with inherited epidermolysis bullosa
EB is genetic. It is a structural fault in the proteins that anchor skin, present from birth. It is not an autoimmune disease, it is not driven by inflammatory load, and nothing in this protocol addresses it. Nothing in any protocol undoes it, and any practitioner who tells you otherwise is either ignorant or dishonest.
The single exception is epidermolysis bullosa acquisita, which despite the name is autoimmune, and is an entirely different diagnosis — established by biopsy and immunofluorescence, not by the words written on a referral letter.
Anyone without a confirmed diagnosis
Biopsy and direct immunofluorescence. Not a clinical impression, not a photograph, not a strong feeling at two in the morning. DIF is what establishes an autoimmune blistering disease, and building a six-month protocol on a guess wastes your time and your money.
Anyone who needs an answer quickly
The first four to eight weeks produce nothing visible. Surface change, where it happens, is a months-two-to-four phenomenon. Sustained remission is not assessed before month eight.
If your situation cannot tolerate that timeframe, then whatever you need, it is not this.
The Grey Middle
Many people are not cleanly on either list.
Moderate pemphigoid, controlled but not quiet, on a steroid dose that will not come down, in a seventy-eight-year-old with diabetes and hypertension and a dermatologist who is doing a competent job — that is the ordinary case, and we do not know in advance how it will go.
What we do instead of guessing is measure. The decision gates are published: week six is a movement check, week twelve is continue-modify-or-stop, and month four is the point by which surface disease should have changed in someone who is responding. If the numbers do not move, we say so, and stopping is a permitted and expected outcome rather than an admission we avoid.
The Test You Can Apply Yourself
Ask what happens if this does not work.
If the honest answer is I keep doing what my dermatologist tells me, and I have lost some money and some months — then the downside is bounded, and you can make a considered decision.
If the honest answer involves your eyesight, your ability to eat, or a steroid you were quietly planning to reduce on your own — then the downside is not bounded, and the decision has already been made for you.
We do not promise a cure, and there is not one. What is on the table is sustained remission in a subset of people, an honest attempt in a larger group, and a clear statement of failure in the rest.
If that is not what you were looking for, it is better to discover it on this page than in month five.
