Flame Figures Associated with Bullous Pemphigoid

Abstract

We report a case of bullous pemphigoid showing the histological features of flame figures. An 80-year-old man was admitted with multiple, tense, thumb-sized blisters among erythematous plaques on his trunk and limbs. A biopsy showed accumulations of eosinophil granules on the collagen fibers, forming characteristic "flame figures", in addition to the features of bullous pemphigoid. We retrospectively examined biopsy specimens from 34 patients with bullous pemphigoid treated in our department over the last 10 years for the presence of flame figures. They were observed in 3 of these patients (8.8%), all of whom were more than 80 years of age. Our retrospective study indicates that the association of flame figures with bullous pemphigoid is not rare, considering the fact that the present case is only the third report of this association. Our data also suggest that the degree of dermal eosinophilia and the formation of flame figures could be related.

Eosinophils as putative therapeutic targets in bullous pemphigoid

“…Immunofluorescence staining using antibodies directed against ECP or MBP allows a more sensitive detection of eosinophils and extracellular granular protein deposits than just H&E staining. In BP, extracellular granular proteins have been detected either as separate deposits, as a thin coating on collagen bundles, so‐called flame figures, or associated with EETs …”

Flame figures in histology associated with allergic contact dermatitis from a henna tattoo

“…In addition, the degree of tissue eosinophilia may be relevant to its formation. Watanabe et al . reported that flame figures were found in bullous pemphigoid with marked tissue eosinophilia.…”

Eosinophilic Cellulitis in a Newborn

“…The infiltrate may extend through the dermis and into the subcutaneous tissue. Classically, older lesions have granular material focally around collagen fibers called “flame figures,” but this is not pathognomonic, as flame figures can be found in other diseases such as bullous pemphigoid, insect bites, cutaneous mastocytoma, follicular mucinosis, herpes gestationis, eczema, urticaria, and dermatophyte infections (6–8). The eosinophilic material contains major basic protein, a protein that comprises more than 50% of the core of the major granules of the eosinophil.…”