An erosion is a wound, and it deserves to be treated like one
Itch is the complaint that gets you a moisturiser. Pain is the one that should get you admitted.
When the roof comes off a blister, what is left is an open wound. The epidermis — the layer that keeps water in and bacteria out — is gone, and the nerve endings beneath it are exposed to air, clothing, sweat and every movement you make. In pemphigus, where blisters rupture almost immediately, this is not a complication of the disease. It is the disease.
What raw skin actually costs you
- Pain on everything. Sitting, lying, dressing, washing, being touched. Sleep goes, and with it whatever repair capacity you had left.
- Infection. Open skin is colonised, usually by Staphylococcus aureus. Colonisation becomes impetiginisation (golden crust); impetiginisation becomes cellulitis; cellulitis can become sepsis. Infection — not the blisters — is what makes severe, poorly controlled pemphigus a disease that kills people. That is the most important sentence on this page.
- Fluid, protein and heat loss. Extensive erosion behaves like a burn: the body leaks. Widespread disease is nursed accordingly, in hospital.
- Slower healing, caused by the treatment. Long-term steroid treatment thins the skin, weakens its structure, raises blood sugar, blunts the fever and pain that would otherwise warn you about infection, and slows wound repair. That is not an argument against steroid treatment — untreated pemphigus is far more dangerous than treated pemphigus. It is an argument for getting the disease quiet enough that your dermatologist can bring the dose down.
Red flags — stop reading and make the call
- Fever, chills, or feeling systemically unwell
- Redness spreading outward from a wound, or a red line tracking away from it
- Foul smell, or thick green or yellow discharge
- A sudden, sharp increase in pain out of proportion to what you can see
- Confusion or drowsiness — in an older person this can be the only sign of sepsis
- Large areas of skin coming away
- Being unable to drink
Any of these means same-day medical care. Not tomorrow.
The one that gets missed: herpes on top of pemphigus
Someone on immunosuppressive treatment can develop herpes simplex infection inside their erosions. It presents as a sudden, painful deterioration — uniform, punched-out, monotonously round erosions, sometimes with fever, in a patient who was previously stable.
It is repeatedly mistaken for a disease flare, and then treated with more immunosuppression, which makes it worse. If your disease deteriorates abruptly and the pain is out of character, ask your dermatologist to consider viral swabs. This is a specific, checkable and treatable thing, and knowing it exists is worth more than most of what you will read tonight.
What genuinely helps — and what it cannot do
Wound care in blistering disease belongs to your dermatologist, and a specialist nurse is worth more than any website:
- Leave the blister roof on. It is a sterile biological dressing. If a large tense blister needs draining, it is drained with a sterile needle and the roof is left in place — by a clinician, not by you.
- Non-adherent dressings. Ordinary gauze dries into the wound bed and rips the new epithelium off when it is changed. Ask specifically about non-adherent or silicone contact layers.
- Gentle cleansing, loose cotton clothing, pressure relief, and attention to the surfaces you sit and lie on.
- Protein and calories. You cannot rebuild epidermis out of nothing. If your mouth is involved and your intake has collapsed, that is a reason to ask for a dietitian.
- Pain relief is a legitimate request. Undertreated wound pain is not stoicism — it wrecks sleep, appetite and healing, and it is a reasonable thing to raise.
Where our work sits, and what it is not
Everything we do is formulation-based: oral compounds and topicals, couriered to you, taken and applied at home. There is no procedure, no in-clinic therapy, and no clinic visit at any stage. It is supportive care alongside your dermatologist.
Phase E — External Care — is the topical part, and it is deliberately fourth. The sequence is L → I → F → E → S: Lowering Inflammatory Load, then Internal Healing and Gut Repair, then Functional Detox and Immune Balancing, then External Care, then Sustaining Remission. The surface is where this disease shows itself; it is not where it is decided. A topical does not stop an autoantibody. What External Care can do is support a barrier that is trying to close — and it is introduced once the internal phases are stable, not before.
Two things this is not:
- It is not a wound-care service. If large areas of your skin are open right now, your first call is your dermatologist or a hospital — not a courier.
- It is not a substitute for antibiotics, antivirals, dressings, or immunosuppressive treatment. Nobody reduces any of those except the doctor who prescribed them, and abrupt withdrawal of steroid treatment is dangerous in its own right.
The timeline, since you will ask: the first four to eight weeks are internal work, and we do not expect the surface to change. From months two to four the disease should begin to change — fewer new blisters, faster closure, less pain. Stable remission is assessed from month eight onward. We do not promise a cure, and we publish no success rate.
What to count while you wait
Pain out of ten, daily. Nights woken. New erosions this week — not the total. How many days a single photographed erosion takes to close. These are the numbers that tell you whether anything is actually changing, and they are the numbers we will ask you for. A protocol that cannot be measured cannot be held to account, and one that cannot be held to account is not worth your money.
