Introduction:

Pemphigus vulgaris can show non-textbook clinical peculiarities, “pearls”.

Case report:

A middle-aged male presented with a single desquamating crust with impetiginisation in the parietal area of the scalp present for over 2 years. Clinicians initially suspected microbial causes of the disease, including folliculitis decalvans. The patient was prescribed oral itraconazole, and rifampicin with clindamycin without improvement. Since the H + E examination revealed unequivocal features of pemphigus vulgaris, the patient was referred for proper immunopathological diagnostics. Based on the clinical picture, H + E evaluation, direct immunofluorescence, which showed pemphigus IgG4 deposits, and multiparametric ELISA (increased level of anti-desmoglein 3 IgG antibodies), a cutaneous form of pemphigus vulgaris of the pemphigus chancre type was diagnosed. The patient received intralesional injections of betamethasone dipropionate/betamethasone phosphate and rituximab intravenously (total dose of 2 g) with significant improvement.

Conclusions:

This patient illustrates that appropriate treatment, in non-emergency cases, should be implemented only after diagnosing patients at the clinical-laboratory level.