# Bullous Diseases in the Perioperative Setting: Anesthetic Considerations

## TL;DR

This paper reviews anesthetic strategies for patients with bullous skin diseases, highlighting the need for careful handling and individualized care due to fragile skin and mucous membranes.

## Contribution

The study synthesizes contemporary data to identify common perioperative precautions for managing patients with autoimmune and inherited bullous diseases.

## Key findings

- Seventeen distinct intraoperative precautions were identified, focusing on minimizing trauma to fragile skin and mucosa.
- Airway-specific strategies like lubrication and smaller endotracheal tubes are recommended to reduce complications.
- Multisystem considerations such as steroid-related changes and infection risk are emphasized alongside dermatologic precautions.

## Abstract

Bullous skin disorders, including epidermolysis bullosa, pemphigus, and bullous pemphigoid, pose distinctive anesthetic challenges due to extreme cutaneous fragility, mucosal involvement, fluid imbalances, an increased risk of infection, and multisystem comorbidities. Although these patients frequently require surgical or procedural care, evidence guiding perioperative management is limited to isolated case reports and small series. This systematic review aimed to synthesize contemporary data on anesthetic and perioperative strategies for patients with autoimmune and inherited bullous diseases. We conducted a PROSPERO-registered review (CRD420251160409) of English-language studies published from 2015 to 2025 that reported perioperative management of patients with bullous skin disorders undergoing any form of anesthesia. A total of 26 studies met the inclusion criteria. Across these reports, we identified 17 distinct intraoperative precautions, most of which focused on minimizing shear, pressure, and adhesive trauma. The most frequently described interventions included padded or lubricated pulse oximetry, ocular lubrication, cotton interfaces under blood pressure cuffs, non-adhesive ECG monitoring, and extensive pressure-point padding. Airway-specific strategies, such as lubrication of equipment, smaller endotracheal tubes, and tape-free fixation, were consistently recommended to mitigate risks associated with mucosal erosions, bleeding, and airway narrowing. Less common measures addressed environmental warming, humidification, vascular access using ultrasound, and preoperative fluid or electrolyte optimization. The predominance of skin- and mucosa-directed precautions reflects the central role of dermatologic vulnerability in perioperative planning. However, reviewed studies also emphasized broader systemic considerations, including steroid-related metabolic changes, cardiovascular and neurologic comorbidities, renal impairment, infection risk, and the need for multidisciplinary coordination. Despite consistent themes, no standardized guidelines exist regarding preferred anesthetic techniques, agent selection, or postoperative monitoring. In conclusion, current evidence underscores the importance of atraumatic handling, meticulous airway planning, and individualized, multisystem assessment in the anesthetic care of patients with bullous diseases. Future prospective studies are needed to establish evidence-based protocols and optimize perioperative outcomes in this high-risk population.