1
|
Zhou W, Tan Y, Chen X, Zhang W, Sun Z, Shen Y, Yao Z, Cheng R, Gu Y. Successful treatment of infantile refractory bullous pemphigoid with baricitinib. Australas J Dermatol 2024. [PMID: 39031070 DOI: 10.1111/ajd.14345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/21/2024] [Accepted: 06/16/2024] [Indexed: 07/22/2024]
Abstract
Infantile bullous pemphigoid (BP) is a rare autoantibody-mediated skin disorder. We report the effective treatment of a 6-month-old infant with BP using baricitinib, a Janus kinase (JAK) inhibitor, after failure with steroids and intravenous immunoglobulin. The patient achieved full remission and discontinued all medications without any relapses. To our knowledge, this is the first case of baricitinib used in an infant with BP.
Collapse
Affiliation(s)
- Weinan Zhou
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Allergy, Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yidong Tan
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Allergy, Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xuanyi Chen
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Allergy, Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wenqing Zhang
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Allergy, Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhe Sun
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Allergy, Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yihang Shen
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Allergy, Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhirong Yao
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Allergy, Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ruhong Cheng
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Allergy, Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan Gu
- Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Allergy, Dermatology Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
2
|
Giacaman N, Abusaada RSN, Tos SM, Ibdah MG, Reid Mahagney AM, Rjoob A, Abukhalil M, Salim H, Musmar B, Zuwahreh S. Bullous pemphigoid in a previously healthy adolescent: a case report and literature review. Ann Med Surg (Lond) 2023; 85:5039-5042. [PMID: 37811084 PMCID: PMC10552980 DOI: 10.1097/ms9.0000000000000995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 06/10/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Bullous pemphigoid (BP) is considered the most common bullous autoimmune disorder, characterized by autoantibodies directed against hemidesmosomes in the skin and mucous membranes. It usually affects elderly individuals in the sixth through eighth decades of life, with an average age at onset of 65 years. Only a few cases have been reported in children and teenagers. Case presentation Herein, we report a 17-year-old boy who presented with a pruritic vesicular rash on his arms and legs accompanied by erythema. He was treated at the beginning with topical lotion and acyclovir, but the rash kept deteriorating and eventually bullae appeared, involving also his mouth. A dermatologist was consulted and diagnosed him with BP, and he was treated accordingly. Discussion BP is the most prevalent autoimmune bullous illness, caused by autoantibodies against hemidesmosomes in the basement membrane of skin and mucosal surfaces, which in turn attract immune cells, including T-cells and neutrophils, and activate them, which causes damage to and separation of keratinocytes, resulting in the bullous formation. Diagnosis can be accomplished by recognizing clinical symptoms supported by histopathological and immunofluorescence testing. Steroids, whether topical or systemic, are the cornerstone treatment; depending on the extent of the disease, other immunosuppressant drugs can be used as a second line. Conclusion BP manifestations are polymorphic; physicians should keep in mind that they may present with non-bullous, pruritic lesions, which may persist for some days to several months before bullae appear. Although this disease is rare in the young population, it should be considered in the differential diagnosis of bullous lesions.
Collapse
Affiliation(s)
| | | | - Salem M. Tos
- College of Medicine, Al-Quds University, Abu Dis
| | | | | | - Asmaa Rjoob
- College of Medicine, Al-Quds University, Abu Dis
| | | | - Hamza Salim
- An-Najah National University, Nablus, Palestine
| | | | - Sufyan Zuwahreh
- Internal Medicine Department, Beit-Jala Governmental Hospital, Bethlehem
| |
Collapse
|
3
|
Shakhashiro M, Bradley TR, Tobin S. Bullous Pemphigoid in a Centenarian Male Simulating Toxic Epidermal Necrolysis. Cureus 2023; 15:e45037. [PMID: 37829935 PMCID: PMC10566394 DOI: 10.7759/cureus.45037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
Bullous pemphigoid (BP) is one of the most common autoimmune blistering diseases and classically presents as large, tense bullae. We report a case of BP with toxic epidermal necrolysis (TEN)-like manifestations in a 103-year-old male, the oldest known patient to present with an acute onset of BP. Our patient presented with extensive erosive lesions comprising 12% of the total body surface area, raising suspicion of TEN and Staphylococcal scalded skin syndrome. Detailed clinical, histological, and immunofluorescence analyses were performed, confirming a diagnosis of BP. Atypical presentations of blistering disorders can be a diagnostic challenge and require the use of histologic and direct immunofluorescence testing to distinguish between clinically similar cutaneous diseases. Proper diagnosis is essential to ensure appropriate management and patient care.
Collapse
Affiliation(s)
- Muna Shakhashiro
- Dermatology, University of Kentucky College of Medicine, Lexington, USA
| | - Taylor R Bradley
- Dermatology, University of Kentucky College of Medicine, Lexington, USA
| | - Stuart Tobin
- Dermatology, Lexington Veterans Affairs (VA) Health Care System, Lexington, USA
| |
Collapse
|
4
|
Sabaté Ortega J, Fort Culillas R, Escoda Garcia M, Vásquez-Dongo CA, Sala González N. Case Report: A Presentation of Early-Onset Immune-Mediated Bullous Pemphigoid in a Patient with Urothelial Cancer. Curr Oncol 2023; 30:7802-7809. [PMID: 37754481 PMCID: PMC10529691 DOI: 10.3390/curroncol30090566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023] Open
Abstract
Cutaneous immune-related adverse events (cirAEs) are the most common side effects of immune checkpoint inhibitor (ICI) therapy (30-50% for all grades). The vast majority of them are low or mild and can be treated without ICI interruption. Autoimmune blistering disorders, such as immune-mediated bullous pemphigoid (IBP), are rare (<1%) but potentially serious conditions that must be early detected. The onset generally occurs within the first months of the treatment, and it appears to be more common with antiprogrammed death-1 or antiprogrammed ligand 1 (anti-PD1/PDL1) than with anticytotoxic T-lymphocyte-associated protein 4 (anti-CTLA4). We present a case of a three-day severe IBP onset after receiving the first cycle of atezolizumab. This exceptional early presentation could suggest the presence of some predisposing condition and demonstrates the need to better understand predictive toxicity-related biomarkers in candidate patients for immunotherapy.
Collapse
Affiliation(s)
- Josep Sabaté Ortega
- Oncology Department, Catalan Institute of Oncology, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
| | - Roser Fort Culillas
- Oncology Department, Catalan Institute of Oncology, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
| | - Marina Escoda Garcia
- Dermatology Department, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
| | | | - Núria Sala González
- Oncology Department, Catalan Institute of Oncology, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
| |
Collapse
|
5
|
Gasparini G, Tasso R, Palamà MEF, Ciferri MC, Gentili C, Di Zenzo G, Provini A, Salemme A, Quarto R, Parodi A, Cozzani E. Pilot study investigating BP-180 in extracellular vesicles derived from blister fluid of bullous pemphigoid patients. Arch Dermatol Res 2023; 315:1837-1841. [PMID: 36763158 PMCID: PMC10338600 DOI: 10.1007/s00403-023-02560-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 01/13/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023]
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease that targets the haemidesmosomal proteins, mainly BP180. Extracellular vesicles (EVs) have been demonstrated to carry tissue-specific autoantigens in the setting of autoimmune diseases and transplant organ rejection; this phenomenon was demonstrated to have pathogenic implications in autoimmune diseases and to correlate with transplant rejection severity. The purpose of this study was to identify the presence of BP targeted autoantigens in blister fluid derived EVs. We isolated, by size exclusion chromatography, EVs derived from blisters of BP-patients and from suction blisters of healthy donors. EV characterization was performed by flow cytometry and nanoparticle tracking analysis. Western blot analysis was used to investigate the presence of autoantigens. A suspension enriched in EVs was efficiently obtained from blister fluid from patients and healthy donors. EV-enriched fractions were enriched in particles with a size distribution characterizing small-EVs (main peak was present at 94.5 nm). BP180 was found, by western blot analysis, in EVs derived from blister fluid of 3 out 6 BP patients and in none of EVs isolated from suction blister fluid of healthy donors. BP230 and Dsg1 were not detectable in EVs of any of the samples. No specific clinical characteristics seemed to correlate to the presence of BP180 in EVs. The discovery of BP180 in EVs derived from blister fluid might help understanding BP pathogenesis.
Collapse
Affiliation(s)
- Giulia Gasparini
- Secction of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
- Dermatology Unit, Ospedale Policlinico San Martino IRCCS, Genoa, Italy.
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy.
| | - Roberta Tasso
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | | | | | - Chiara Gentili
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | | | | | - Adele Salemme
- Molecular and Cell Biology Laboratory, IDI-IRCCS, Rome, Italy
| | - Rodolfo Quarto
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
- UO Cellular Oncology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Aurora Parodi
- Secction of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Dermatology Unit, Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Emanuele Cozzani
- Secction of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Dermatology Unit, Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| |
Collapse
|
6
|
Huttelmaier J, Benoit S, Goebeler M. Comorbidity in bullous pemphigoid: up-date and clinical implications. Front Immunol 2023; 14:1196999. [PMID: 37457698 PMCID: PMC10346857 DOI: 10.3389/fimmu.2023.1196999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/19/2023] [Indexed: 07/18/2023] Open
Abstract
Bullous pemphigoid is the most common autoimmune blistering disease in industrialized countries and particularly affects the elderly. In this patient population, comorbid diseases are frequent and may complicate management and treatment of bullous pemphigoid. A better understanding why distinct diseases are more frequent in bullous pemphigoid patients may lead to new pathophysiological insights and - as a consequence - result in better patient care. The association of bullous pemphigoid with neurological and psychiatric diseases is well known and confirmed by several case-control studies. Association with further diseases such as malignancy and metabolic diseases are still discussed controversially. In recent years new relationships between bullous pemphigoid and autoimmune as well as inflammatory skin diseases have been reported. This review provides a systematic overview on studies addressing comorbidity in bullous pemphigoid patients. Increasing the awareness of both, common and rare comorbid diseases, may enable clinicians to optimize patient support and individualized treatment of bullous pemphigoid.
Collapse
|
7
|
Wu PC, Wu CY, Lyu YS, Chang YT, Wu CY. Association between bullous pemphigoid and atopic dermatitis: a population-based case-control study in Taiwan. Arch Dermatol Res 2023; 315:419-427. [PMID: 35834038 DOI: 10.1007/s00403-022-02372-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/30/2022] [Accepted: 07/01/2022] [Indexed: 01/18/2023]
Abstract
Although bullous pemphigoid (BP) and atopic dermatitis (AD) share pathogenic mechanisms, their relationship remains controversial. Therefore, we conducted a population-based case-control study to investigate the association between BP and AD in Taiwan. Based on the Taiwan National Health Insurance Research Database, 9344 patients with BP and 18,688 age- and sex-matched controls were enrolled between 2000 and 2013. Furthermore, the study included 7,196 BP patients and 14,392 controls, matched for age, sex, and propensity score of comorbidities, with a case to controls ratio of 1:2. Logistic regression analysis was performed to examine the association between AD and BP. In the age- and sex-matched cohorts, AD (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.50-1.95) was independently associated with BP. In the age, sex, and comorbidities-matched cohorts, AD (OR 1.76, 95% CI 1.55-2.00) remained a significant risk factor for BP. Other significant risk factors included psoriasis, hypertension, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, neuropsychiatric diseases, and autoimmune connective tissue disease. Limitations of this study include the lack of information on disease severity and phenotypes of BP and misclassification of diseases as potential sources of bias. In conclusion, AD increased the risk of developing BP by 76%, and this association was independent of many BP comorbidities. Further studies are warranted to investigate the clinical and pathophysiological relevance of factors contributing to BP and AD.
Collapse
Affiliation(s)
- Po-Chien Wu
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chun-Ying Wu
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
- College of Public Health, China Medical University, Taichung, Taiwan
| | - Ying-Syuan Lyu
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yun-Ting Chang
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Dermatology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chen-Yi Wu
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan.
- Department of Dermatology, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Institute of Public Health and Department of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| |
Collapse
|
8
|
Xu Y, Song W, Cai Y, Huang R, Wei J, Liu H, Peng X, Zeng K, Li C. Successful treatment of eczema-like bullous pemphigoid and typical bullous pemphigoid with dupilumab: two case reports. Int J Dermatol 2023; 62:e144-e146. [PMID: 36214412 DOI: 10.1111/ijd.16451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/24/2022] [Accepted: 09/29/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Yanqin Xu
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Weicheng Song
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yan Cai
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Rong Huang
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junxiao Wei
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hui Liu
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoming Peng
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Kang Zeng
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Changxing Li
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| |
Collapse
|
9
|
Abstract
Annular bullous dermatoses represent an etiologically diverse group of cutaneous phenomena that present with a figurate morphology in association with vesicles and bullae. This group of diverse conditions consists of bullous pemphigoid; pemphigoid gestationis; epidermolysis bullosa simplex, Dowling-Meara type; linear immunoglobulin A bullous dermatosis; chronic bullous disease of childhood; anti-p200 pemphigoid; subcorneal pustular dermatosis; and immunoglobulin A pemphigus. Astute examination of clinical, histopathologic, and serologic features is crucial in distinguishing these bullous dermatoses. We review the clinical presentation, pathophysiology, histopathology, and treatments for each bullous annular disease to aid physicians in their recognition, diagnosis, and management.
Collapse
Affiliation(s)
- Morgan Sussman
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Lisa Zhai
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Alexandra Morquette
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Simo Huang
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA.
| | - Sylvia Hsu
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
10
|
Ahmed AR, Aksoy M, Kinane TB. Pemphigoid of the pulmonary system (POPS): A review of a less recognized feature. Clin Exp Rheumatol 2022; 21:103180. [PMID: 35981700 DOI: 10.1016/j.autrev.2022.103180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/02/2022]
Abstract
This review of Pemphigoid of the Pulmonary System (POPS) is a comprehensive description of pulmonary involvement in patients with mucous membrane pemphigoid (MMP), which is an orphan autoimmune blistering disease. The objective of the review was to analyze clinical features of pulmonary involvement in MMP. This POPS review is a case series in which multiple search engines were utilized from inception to June 2022 for cases of MMP with biopsy and immunopathology proven tracheal and bronchial pemphigoid. Clinical profiles prior to pulmonary involvement, bronchoscopy findings, clinical course and therapy were recorded and cause of death was analyzed. Patients with documented MMP who developed tracheal, bronchial and pulmonary involvement were included in the POPS review. Histology and immunopathology documentation were essential diagnostic criteria. Comparison groups were not possible. Patients were treated with immunosuppressive therapy. Some required surgical interventions. Six of the 11 patients attained complete or partial remission on or off therapy. Five patients died from pulmonary complications. The POPS review had six females and five males. The mean age at onset was 20 years (range 4-76), while 80% of the patients were under 40 years. All had severe widespread MMP involving three to five mucosal tissues. 100% had oral, 82% had ocular and cutaneous involvement. Pulmonary involvement occurred at 24 mo (range 2-372) after the onset of MMP. Bronchoscopy revealed acute inflammation during active disease and scarring of the trachea and bronchi in the later stages. Systemic infections occurred in 45%, while pulmonary infection occurred in 36%. Mortality due to respiratory failure, at the median age of 20 years (range 18-76), occurred in 45% of the patients, and was considered disease related. In spite of the young age, while there are some similarities in the clinical profile and response to systemic therapy, there are definitive differences from other patients with MMP. Early diagnosis with appropriate management could produce better clinical outcomes and prevent mortality in this orphan disease. Consequently, there is a critical need for early identification and diagnosis of POPS.
Collapse
Affiliation(s)
- A Razzaque Ahmed
- Center for Blistering Diseases, Department of Dermatology, Tufts University School of Medicine, Boston, MA, USA.
| | - Merve Aksoy
- Center for Blistering Diseases, Department of Dermatology, Tufts University School of Medicine, Boston, MA, USA
| | - T Bernard Kinane
- Chief Pediatric Pulmonary Medicine, Mass General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
11
|
Mai Y, Izumi K, Mai S, Ujiie H. The significance of preclinical anti-BP180 autoantibodies. Front Immunol 2022; 13:963401. [PMID: 36003369 PMCID: PMC9393388 DOI: 10.3389/fimmu.2022.963401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease. Although the pathomechanism of BP onset has yet to be elucidated in detail, BP autoantibodies targeting two hemidesmosomal components, BP180 and BP230, are known to play a pivotal role in BP pathogenesis. Thus, the detection and measurement of BP autoantibodies are necessary for diagnosing BP and monitoring the disease activity. Immune assays such as immunofluorescence microscopy, immunoblotting, and ELISAs using BP180 and BP230 detect BP autoantibodies in most BP cases with high specificity; however, BP autoantibodies are sometimes detected in BP patients before the onset of this disease. BP autoantibodies that are detected in patients without typical tense blisters are defined as “preclinical BP autoantibodies”. These preclinical BP autoantibodies are detected even in a low percentage of normal healthy individuals. Although the importance of preclinical BP autoantibodies remains elusive, these autoantibodies might be a potential risk factor for subsequent BP development. Therefore, previous comparative epidemiological studies have focused on the prevalence of preclinical BP autoantibodies in populations susceptible to BP (e.g., the elderly) or in diseases with a higher risk of comorbid BP. This mini-review summarizes the literature on the prevalence of preclinical BP autoantibodies in patients with various conditions and diseases, and we discuss the significance of preclinical BP autoantibody detection.
Collapse
|
12
|
Cole C, Borradori L, Amber KT. Deciphering the Contribution of BP230 Autoantibodies in Bullous Pemphigoid. Antibodies (Basel) 2022; 11:antib11030044. [PMID: 35892704 PMCID: PMC9326648 DOI: 10.3390/antib11030044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/09/2022] [Accepted: 06/17/2022] [Indexed: 11/18/2022] Open
Abstract
Bullous pemphigoid (BP) is a subepidermal autoimmune blistering disease predominantly affecting elderly patients and carries significant morbidity and mortality. Patients typically suffer from severe itch with eczematous lesions, urticarial plaques, and/or tense blisters. BP is characterized by the presence of circulating autoantibodies against two components of the hemidesmosome, BP180 and BP230. The transmembrane BP180, also known as type XVII collagen or BPAG2, represents the primary pathogenic autoantigen in BP, whereas the intracellular BP230 autoantigen is thought to play a minor role in disease pathogenesis. Although experimental data exist suggesting that anti-BP230 antibodies are secondarily formed following initial tissue damage mediated by antibodies targeting extracellular antigenic regions of BP180, there is emerging evidence that anti-BP230 IgG autoantibodies alone directly contribute to tissue damage. It has been further claimed that a subset of patients has a milder variant of BP driven solely by anti-BP230 autoantibodies. Furthermore, the presence of anti-BP230 autoantibodies might correlate with distinct clinical features. This review summarizes the current understanding of the role of BP230 and anti-BP230 antibodies in BP pathogenesis.
Collapse
Affiliation(s)
- Connor Cole
- Division of Dermatology, Rush University Medical Center, Chicago, IL 60612, USA;
- Correspondence:
| | - Luca Borradori
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Kyle T. Amber
- Division of Dermatology, Rush University Medical Center, Chicago, IL 60612, USA;
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL 60612, USA
| |
Collapse
|
13
|
Farooq MM, Miloslavsky EM, Konikov N, Ahmed AR. Use of rituximab in the treatment of mucous membrane pemphigoid: An analytic review. Autoimmun Rev 2022; 21:103119. [PMID: 35688385 DOI: 10.1016/j.autrev.2022.103119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/15/2022] [Indexed: 11/26/2022]
Abstract
Mucous Membrane Pemphigoid (MMP) is a potentially fatal mucocutaneous autoimmune blistering disease. Autoantibodies are produced against various components of the dermo-epidermal or mucosal-submucosal junction are referred to as basement membrane zone (BMZ). The hallmark is deposition of of Ig and C3 on the perilesional tissues and in some patients detection of anti-BMZ autoantibodies. A unique characteristic of MMP is that as the blisters or erosions heal, they leave irreversible scarring. This scarring results in serious and catastrophic sequelae that affect the quality of life. Conventional therapy consists of anti-inflammatory and immunosuppressive agents (ISA). In patients who fail conventional therapy or develop significant side effects to them, rituximab (RTX) has been used off label. In this review, the clinical outcomes of patients with MMP treated with RTX were studied. 124 patients were identified, 47.58% being male. 72 patients were treated by the Lymphoma Protocol and 51 by Rheumatoid Arthritis (RA) protocol. Follow up for the entire cohort was 36 months (range 0.5-72). On follow-up 64 patients (51.61%) achieved complete clinical remission (CR) off therapy, 25 patients (20.16%) were in CR on therapy, 5 patients (4.03%) were non-responders, and 9 patients (7.25%) were failures. 52 patients (41.93%) experienced a relapse, after 36 months follow-up. Duration between last RTX infusion and relapse was 10.5 months (range 1-30). Most patients with relapses were treated with additional RTX. A statistically significant better outcome was observed in patients treated with RTX as monotherapy compared to those who received RTX with ISA. Clinical outcomes in patients treated with Lymphoma protocol were better than RA protocol at a statistically significant level. Data on CD20+ B cell depletion and repopulation was limited. Interestingly relapses were seen in patients with CD20+ B cell depletion and after repopulation. In the final analysis, 89 patients (71.77%) were in complete remission. Data in this review indicated that RTX was a useful agent to treat MMP. While a randomized control trial may not be practically possible, better and disease specific protocols need to be developed. When publishing, authors should attempt to provide complete and detailed information. In doing so, they will benefit their colleagues and the patients with MMP they treat with RTX.
Collapse
Affiliation(s)
| | - Eli M Miloslavsky
- Massachusetts General Hospital, Department of Medicine, Division of Rheumatology, Boston, MA 02114, USA; Harvard Medical School, Boston, MA 02215, USA
| | - Nellie Konikov
- Boston VA health Care System, Jamaica Plain, Boston, MA 02130, USA
| | - A Razzaque Ahmed
- Center for Blistering Diseases, Boston, MA 02135, USA; Department of Dermatology, Tufts University School of Medicine, Boston, MA 02111, USA.
| |
Collapse
|
14
|
Shanshal M. Dyshidrosiform Bullous Pemphigoid Triggered by COVID-19 Vaccination. Cureus 2022; 14:e26383. [PMID: 35911257 PMCID: PMC9329707 DOI: 10.7759/cureus.26383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/05/2022] Open
Abstract
Vaccination has made a substantial contribution to global health improvement throughout history. The coronavirus disease 2019 (COVID-19) vaccinations have provided us with a ray of hope for combatting the ongoing pandemic and saving lives. However, following COVID-19 vaccination, a wide spectrum of cutaneous adverse effects have been observed. We report a case of dyshidrosiform bullous pemphigoid, a rare clinical variant of bullous pemphigoid, following COVID-19 vaccination in an elderly female patient. The biopsy revealed subepidermal splitting with positive direct and indirect immunofluorescence studies.
Collapse
|
15
|
Ruggiero A, Megna M, Villani A, Comune R, Fabbrocini G, di Vico F. Strategies to Improve Outcomes of Bullous Pemphigoid: A Comprehensive Review of Clinical Presentations, Diagnosis, and Patients' Assessment. Clin Cosmet Investig Dermatol 2022; 15:661-673. [PMID: 35444441 PMCID: PMC9014958 DOI: 10.2147/ccid.s267573] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/07/2022] [Indexed: 01/27/2023]
Abstract
Bullous pemphigoid (BP) is the most frequent autoimmune bullous disease mainly affecting elderlies. Diagnosis usually results from clinical features, histological examination, and the quantification of circulating typical autoantibodies, due to its higher incidence in elderly patients, bullous pemphigoid treatment and management still represents a challenge due to the higher frequency of several comorbidities in this group of patients, which may also be linked to a reduced tolerance to BP treatments. Hence, an early diagnosis and a prompt correct treatment are mandatory to reach better clinical outcomes and improve as much as possible BP outcomes. Herein, we carried out a comprehensive literature review about the known clinical presentations, diagnosis, assessment and monitoring procedures used in daily clinical practice in patients with BP, to better define strategies to improve as much as possible BP clinical outcomes.
Collapse
Affiliation(s)
- Angelo Ruggiero
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Matteo Megna
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Alessia Villani
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Rosita Comune
- Section of Radiology and Radiotherapy, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, 80138, Italy
| | - Gabriella Fabbrocini
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Francesca di Vico
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, 80131, Italy
| |
Collapse
|
16
|
Chouchane K, Di Zenzo G, Pitocco D, Calabrese L, De Simone C. Bullous pemphigoid in diabetic patients treated by gliptins: the other side of the coin. J Transl Med 2021; 19:520. [PMID: 34930319 PMCID: PMC8691092 DOI: 10.1186/s12967-021-03192-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 12/10/2021] [Indexed: 12/12/2022] Open
Abstract
Bullous pemphigoid (BP) is the most common autoimmune bullous skin disease that affects primarily patients older than 60 years. The majority of BP cases are spontaneous, but BP can also be triggered by certain drugs’ exposures. Since 2011, a growing number of observations has been reporting cases of BP in Type 2 diabetic patients. These forms have been linked to the use of a new category of anti-diabetic drugs called dipeptidyl peptidase inhibitors (DPP-4i) or gliptins, but to date, the exact pathophysiological mechanisms underlying this association are not completely elucidated. Although conventional and gliptin-associated BP are thought to share similar clinical and histopathological features, our thorough review of the most recent literature, shows that these 2 forms are quite distinct: DPP-4-i-associated BP seems to appear at an earlier age than spontaneous BP, it may manifest either as a noninflammatory or inflammatory phenotype, while the conventional form presents with a typical inflammatory phenotype. Additionally, an important distinctive histological feature was recently shown in Gliptin-associated BP: these forms may present a less significant eosinophils infiltrate in the upper dermis of peri-blister lesions compared to the skin of patients with spontaneous BP, and this seems a specific feature of the clinically non-inflammatory forms. In accordance with previous literature, we found that the direct immunofluorescence (DIF) gives identical findings in both DPP-4i-associated and conventional forms of BP which is an IgG and complement C3 deposition as a linear band at the dermal–epidermal junction in perilesional skin. Indirect immunofluorescence shows the presence of IgG circulating autoantibodies in the patient's serum which titer does not differ between spontaneous and DPP-4i-associated BP, while the specificity of these autoantibodies, may be different in spontaneous, induced non-inflammatory and induced inflammatory forms, epitope spreading phenomenon seems to play a role in determining these specificities. Further research, based on integrated epidemiological, clinical, histo-immunological and pharmacogenomic approaches, may give more insight into these forms of BP. This combined approach will allow to better define BP endotypes and to unveil the mechanism of spontaneous or drug-induced breakage of the immunotolerance to skin self-antigens.
Collapse
Affiliation(s)
- Karim Chouchane
- Whittington Health NHS Trust, Magdala Ave, London, N19 5NF, UK.
| | - Giovanni Di Zenzo
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell'Immacolata (IDI) IRCCS, Rome, Italy
| | - Dario Pitocco
- Diabetes Care Unit, Endocrinology, University Hospital "A. Gemelli", Catholic University of the Sacred Heart, Rome, Italy
| | - Laura Calabrese
- Institute of Dermatology, University Hospital "A. Gemelli", Catholic University of the Sacred Heart, Rome, Italy.,Department of Dermatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Clara De Simone
- Institute of Dermatology, University Hospital "A. Gemelli", Catholic University of the Sacred Heart, Rome, Italy. .,Department of Dermatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| |
Collapse
|
17
|
Gao Z, Cao Y, Zeng X, Song X. Valsartan-associated bullous pemphigoid initially presenting as erythema multiforme. Health Sci Rep 2021; 4:e452. [PMID: 34984237 PMCID: PMC8691486 DOI: 10.1002/hsr2.452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 09/27/2021] [Accepted: 11/05/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Zhe Gao
- Department of DermatologyThe Third People's Hospital of HangzhouHangzhouChina
| | - Yongping Cao
- Department of DermatologyThe Third People's Hospital of HangzhouHangzhouChina
| | - Xiaofang Zeng
- Department of DermatologyThe Third People's Hospital of HangzhouHangzhouChina
| | - Xiuzu Song
- Department of DermatologyThe Third People's Hospital of HangzhouHangzhouChina
| |
Collapse
|
18
|
Hiroyasu S, Hiroyasu A, Mine M, Kotobuki Y, Tsuruta D. Case of pemphigoid nodularis with immunoglobulin (Ig)G deposition accompanied by postinflammatory hypopigmentation without IgG deposition on the same forearm. J Dermatol 2021; 49:e99-e101. [PMID: 34806225 DOI: 10.1111/1346-8138.16244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/03/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Sho Hiroyasu
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Aoi Hiroyasu
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Mako Mine
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yorihisa Kotobuki
- Department of Dermatology, Course of Integrated Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Daisuke Tsuruta
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
19
|
Pratasava V, Sahni VN, Suresh A, Huang S, Are A, Hsu S, Motaparthi K. Bullous Pemphigoid and Other Pemphigoid Dermatoses. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57101061. [PMID: 34684098 PMCID: PMC8539012 DOI: 10.3390/medicina57101061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022]
Abstract
The pemphigoid family of dermatoses is characterized by autoimmune subepidermal blistering. The classic paradigm for pemphigoid, and the most common member, is bullous pemphigoid. Its variable clinical presentation, with or without frank bullae, is linked by significant pruritus afflicting the elderly. Mucous membrane pemphigoid is an umbrella term for a group of subepidermal blistering dermatoses that favor the mucosal membranes and can scar. Epidermolysis bullosa acquisita is a chronic blistering disorder characterized by skin fragility, sensitivity to trauma, and its treatment-refractory nature. Clinicians that encounter these pemphigoid disorders may benefit from an overview of their clinical presentation, diagnostic work-up, and therapeutic management, with an emphasis on the most frequently encountered pemphigoid disease, bullous pemphigoid.
Collapse
Affiliation(s)
- Valeryia Pratasava
- College of Medicine, Drexel University, Philadelphia, PA 19129, USA; (V.P.); (V.N.S.); (A.S.)
| | - Vikram N. Sahni
- College of Medicine, Drexel University, Philadelphia, PA 19129, USA; (V.P.); (V.N.S.); (A.S.)
| | - Aishwarya Suresh
- College of Medicine, Drexel University, Philadelphia, PA 19129, USA; (V.P.); (V.N.S.); (A.S.)
| | - Simo Huang
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (S.H.); (S.H.)
| | - Abhirup Are
- College of Medicine, University of Florida, Gainesville, FL 32606, USA;
| | - Sylvia Hsu
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (S.H.); (S.H.)
| | - Kiran Motaparthi
- Department of Dermatology, College of Medicine, University of Florida, Gainesville, FL 32606, USA
- Correspondence:
| |
Collapse
|
20
|
Dbouk S, Bazzi N, Saad WA, Toribio A, Habre M, Salloum A. Atypical Bullous Pemphigoid After Linagliptin Intake. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932356. [PMID: 34584063 PMCID: PMC8488187 DOI: 10.12659/ajcr.932356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Bullous pemphigoid is a common pruritic skin lesion reported in elderly patients. It is caused by an immunologic reaction between autoantibodies and hemidesmosome proteins of epithelial cells. The disease is characterized by a symmetrical blister distribution on the body. Diagnosis should be suspected in elderly patients presenting with a tense blister on normal-appearing skin or on an erythematous base. In the literature, several forms of typical bullous pemphigoid after treatment with linagliptin have been reported. However, this is the first reported case of atypical nonbullous pemphigoid after linagliptin intake. CASE REPORT A 77-year-old woman presented with multiple erythematous papules and nodules on the upper extremities and trunk. The patient was being treated with linagliptin for diabetes. Diagnosis was made with biopsy and histopathological studies, followed by direct immunofluorescence. The histopathological study showed a subepidermal blister with an underlying polymorphous infiltrate, mainly of an eosinophilic profile. Direct immunofluorescence showed linear IgG and C3 antibodies to hemidesmosomes at the lamina lucida of the basement membrane. Thus, the diagnosis of atypical nonbullous pemphigoid was made. CONCLUSIONS This report emphasizes the great variety of bullous pemphigoid presentation and the need for a greater level of awareness of the adverse effects of linagliptin. Thus, atypical nonbullous pemphigoid should be considered among the potential differential diagnoses in patients with multiple erythematous papules and nodules on the upper extremities and trunk.
Collapse
Affiliation(s)
- Samer Dbouk
- Department of General Surgery, Al Zahraa Hospital University Medical Center, Lebanese University, Beirut, Lebanon
| | - Nagham Bazzi
- Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Wajih Abdulrassoul Saad
- Department of Oncology, Al Zahraa Hospital University Medical Center, Lebanese University, Beirut, Lebanon
| | - Adderly Toribio
- Department of Internal Medicine, Roger William Medical Center, Providence, RI, USA
| | - Maya Habre
- Department of Dermatology, Saint Georges Hospital University Medical Center (UMC), Beirut, Lebanon
| | - Antoine Salloum
- Department of Internal Medicine, Roger William Medical Center, Providence, RI, USA.,Department of Dermatology, Saint Georges Hospital University Medical Center (UMC), Beirut, Lebanon
| |
Collapse
|
21
|
Wang X, Sun J. High-frequency ultrasound features of pemphigoid nodularis: A case report. Skin Res Technol 2021; 28:171-172. [PMID: 34532896 PMCID: PMC9907708 DOI: 10.1111/srt.13077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 06/23/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Xiaopo Wang
- Department of Pathology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital of Skin Diseases and Institute of Dermatology, Nanjing, China
| | - Jianfang Sun
- Department of Pathology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital of Skin Diseases and Institute of Dermatology, Nanjing, China
| |
Collapse
|
22
|
Wang S, Lu M, Zhao Z, Peng X, Li L, Cheng C, Fang M, Xia Y, Liu Y. Plasma levels of D-dimer and fibrin degradation products correlate with bullous pemphigoid severity: a cross-sectional study. Sci Rep 2021; 11:17746. [PMID: 34493780 PMCID: PMC8423823 DOI: 10.1038/s41598-021-97202-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022] Open
Abstract
Bullous pemphigoid (BP), the most frequent blistering dermatosis in the elderly, is associated with increased mortality. The severity of BP can be assessed by detecting the anti-BP180 immunoglobulin G (IgG) concentration, but the lab test is not available in many community clinics. BP patients are usually in a hypercoagulable state with increased levels of D-dimer and fibrin degradation products (FDPs). We aimed to evaluate the use of D-dimer and FDPs in assessing BP severity. We compared the levels of plasma D-dimer, plasma FDPs, eosinophil counts, eosinophil cationic protein, and serum anti-BP180 IgG concentration between 48 typical BP patients and 33 Herpes zoster (HZ) patients (control group). Correlational analyses were conducted to determine the relationships between the lab values and common BP severity markers. The plasma D-dimer and FDP levels were higher in BP patients than in HZ controls (D-dimer: 3297 ± 2517 µg/L vs. 569.70 ± 412.40 µg/L; FDP: 9.74 ± 5.88 mg/L vs. 2.02 ± 1.69 mg/L, respectively, P < 0.0001). Significant positive correlations were found between D-dimer/FDP levels and BP severity markers (i.e. anti-BP180 IgG concentration [D-dimer: r = 0.3928, P = 0.0058; FDP: r = 0.4379, P = 0.0019] and eosinophil counts [D-dimer: r = 0.3625, P = 0.0013; FDP: r = 0.2880, P = 0.0472]) in BP patients. We also found an association between FDP and urticaria/erythema lesions (r = 0.3016, P = 0.0372), but no other BPDAI components. In 19 BP patients with complete remission after systemic glucocorticoid treatment, D-dimer and FDP levels decreased post-therapy (D-dimer: 5559 ± 7492 µg/L vs. 1738 ± 1478 µg/L; P < 0.0001; FDP: 11.20 ± 5.88 mg/L vs. 5.13 ± 3.44 mg/L; P = 0.0003), whereas they did not in BP patients with treatment resistant. Plasma D-dimer and FDP are convenient markers to evaluate BP severity assistant on BPDAI and eosinophil counts. FDP is also helpful for inflammatory lesions in BP patients.
Collapse
Affiliation(s)
- Sijia Wang
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, 157 Xiwu Road, Xincheng District, Xi'an, 710004, Shaanxi Province, China
| | - Mei Lu
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, 157 Xiwu Road, Xincheng District, Xi'an, 710004, Shaanxi Province, China
| | - Zijun Zhao
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Xueting Peng
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, 157 Xiwu Road, Xincheng District, Xi'an, 710004, Shaanxi Province, China
| | - Liang Li
- Department of Thoracic Surgery, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Chuantao Cheng
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, 157 Xiwu Road, Xincheng District, Xi'an, 710004, Shaanxi Province, China
| | - Min Fang
- Department of Health Checkup, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Yumin Xia
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, 157 Xiwu Road, Xincheng District, Xi'an, 710004, Shaanxi Province, China.
| | - Yale Liu
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, 157 Xiwu Road, Xincheng District, Xi'an, 710004, Shaanxi Province, China.
| |
Collapse
|
23
|
Bhandari M, Khullar G. Target and targetoid lesions in dermatology. Indian J Dermatol Venereol Leprol 2021; 88:430-434. [PMID: 34379958 DOI: 10.25259/ijdvl_901_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 01/01/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Molisha Bhandari
- Department of Dermatology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Geeti Khullar
- Department of Dermatology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| |
Collapse
|
24
|
Gu A, Zhang L, Ma F, Kong X. Induction of localized bullous pemphigoid on a young woman following a chemical peel. Indian J Dermatol Venereol Leprol 2021; 87:706-708. [PMID: 34379953 DOI: 10.25259/ijdvl_1116_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 05/01/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Ankang Gu
- Department of Pathology, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Hongqiao, Tianjin, China
| | - Litao Zhang
- Department of Dermatology, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Hongqiao, Tianjin, China
| | - Faku Ma
- Department of Pathology, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Hongqiao, Tianjin, China
| | - Xiangjun Kong
- Department of Dermatology, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Hongqiao, Tianjin, China
| |
Collapse
|
25
|
Moar A, Azzolini A, Tessari G, Schena D, Girolomoni G. Non-Bullous Pemphigoid: A Single-Center Retrospective Study. Dermatology 2021; 237:1039-1045. [PMID: 33979792 DOI: 10.1159/000515954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/12/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Bullous pemphigoid (BP) is an autoimmune disease that typically presents with blisters, but sometimes early lesions may be eczematous, maculopapular, or urticarial. The aim of the present study was to highlight possible differences between typical bullous and non-bullous pemphigoid (NBP) and compare results with the literature. Material & methods: Patients receiving a diagnosis of BP between January 2000 and December 2019 were analyzed. Patients who developed a blister after 3 months from the onset of pruritus were considered as NBP. Demographic features, clinical findings at diagnosis and at 2-year follow-up, histological features, auto-antibodies titers, comorbidities and their treatment were retrieved. Categorical variables were evaluated for normal distribution using a histogram and a Q-Q plot. The χ2 and Fisher's exact tests were used to compare categorical variables between the groups. Continuous variables were compared between the groups using analysis of variance and the independent-samples t test. For multivariate analysis, logistic regression was performed. RESULTS A total of 532 patients received a diagnosis of BP. A total of 122 patients were enrolled in the study; 63 were females, and the mean age at the diagnosis was 77.2 years (±11.9 SD). 98 were affected by BP and 24 were categorized as NBP. Mean time to diagnosis was 2.9 months (±5.8 SD) for BP and 30.4 months (±59.8 SD) for NBP (p = 0.0001). Skin manifestations in NBP patients were, in order of frequency: urticarial, papular or nodular, eczematous, and excoriations. Pruritus intensity was high but similar in the two groups (Numerical Rating Scale - NRS, 9.3 vs. 8.9). Seven out of 24 NBP patients (29%) never developed blisters; the other patients developed blisters after a mean follow-up time of 24.9 months (±54.9 SD). NBP patients had a more frequent history of myocardial infarction than BP patients (37.5 vs. 10.2%; p < 0.003). More NBP patients were taking diuretics than BP patients (66.7 vs. 49%; p = 0.03). NBP patients had a worse response to pruritus compared to BP patients at 2 years (NRS 3.7 vs. 11; p 0.001). CONCLUSIONS NBP patients have a delayed diagnosis and may be at an increased risk of cardiovascular disease, especially myocardial infarction. Severely and persistently itchy skin disorders in aged patients should be investigated for BP diagnosis.
Collapse
Affiliation(s)
- Agata Moar
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
| | - Alan Azzolini
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
| | - Gianpaolo Tessari
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
| | - Donatella Schena
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
| | - Giampiero Girolomoni
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
| |
Collapse
|
26
|
Morimoto K, Yoshida T, Washida N, Uchiyama K, Nakayama T, Itoh H, Oya M. Bullous pemphigoid in patients receiving peritoneal dialysis: a case series and a literature survey. Ren Fail 2021; 43:651-657. [PMID: 33820495 PMCID: PMC8032334 DOI: 10.1080/0886022x.2021.1910045] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disease. Although several cases of BP in end-stage renal disease patients receiving peritoneal dialysis (PD) or hemodialysis have been reported, the incidence of BP in these patients remains unknown. We recently experienced three PD patients diagnosed with BP. The skin injury was likely to be a trigger of BP in all the three PD patients. Nifedipine and icodextrin exposures were possible factors directly or indirectly affecting the onset of BP, because they were common in the three cases. We also report that the incidence of BP in PD patients was 3/478.3 person-years in a single-center 10-year study. This case series with a literature survey describes that the skin and tissue injuries are potential triggers responsible for the onset of BP in dialysis patients and that the incidence of BP in these patients seems to be much higher than that in the general population.
Collapse
Affiliation(s)
- Kohkichi Morimoto
- Apheresis and Dialysis Center, School of Medicine, Keio University, Tokyo, Japan
| | - Tadashi Yoshida
- Apheresis and Dialysis Center, School of Medicine, Keio University, Tokyo, Japan
| | - Naoki Washida
- Department of Nephrology, School of Medicine, International University of Health and Welfare, Otawara, Japan.,Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Kiyotaka Uchiyama
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Takashin Nakayama
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroshi Itoh
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Mototsugu Oya
- Apheresis and Dialysis Center, School of Medicine, Keio University, Tokyo, Japan.,Department of Urology, School of Medicine, Keio University, Tokyo, Japan
| |
Collapse
|
27
|
Subepithelial autoimmune blistering dermatoses: Clinical features and diagnosis. J Am Acad Dermatol 2021; 85:1-14. [PMID: 33684496 DOI: 10.1016/j.jaad.2020.11.076] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 01/19/2023]
Abstract
Subepithelial autoimmune blistering dermatoses are a group of rare skin disorders that are characterized by the disruption of the dermal-epidermal junction through the action of autoantibodies. The third article in this continuing medical education series explores the background, epidemiology, clinical features, and diagnostic criteria of each of the major subepithelial autoimmune blistering dermatoses, including bullous pemphigoid, pemphigoid gestationis, lichen planus pemphigoides, mucous membrane pemphigoid, linear IgA bullous dermatosis, and dermatitis herpetiformis.
Collapse
|
28
|
Ivyanskiy I, Dave D, Dweik A, Yeary J, Naguib TM. Bullous Pemphigoid Mimicking Cellulitis. J Investig Med High Impact Case Rep 2021; 9:23247096211008585. [PMID: 33847152 PMCID: PMC8059041 DOI: 10.1177/23247096211008585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 01/31/2021] [Accepted: 03/09/2021] [Indexed: 11/23/2022] Open
Abstract
Bullous pemphigoid (BP) is the most prevalent autoimmune blistering skin disease in the Western world affecting mainly the elderly population. The diagnosis is based on clinical assessment along with specific immunopathologic findings on skin biopsy. Risk factors include genetic factors, environmental exposures, and several infections including hepatitis B, hepatitis C, Helicobacter pylori, Toxoplasma gondi, and cytomegalovirus. A variety of drugs have been associated with BP including but not limited to dipeptidyl peptidase-4 inhibitors, loop diuretics, spironolactone, and neuroleptics. Associated neurologic disorders (dementia, Parkinson's disease, bipolar disorder, previous stroke history, and multiple sclerosis) have also been described. Common clinical presentation consists of extremely pruritic inflammatory plaques that resemble eczematous dermatitis or urticaria, followed by formation of tense bullae with subsequent erosions. Typical distribution involves the trunk and extremities. Mucosa is typically spared affecting only 10% to 30% of patients. Several unusual clinical presentations of BP have been described such as nonbullous forms with erythematous excoriated papules, plaques, and nodules. Other reported findings include urticarial lesions, prurigo-like nodules, multiple small vesicles resembling dermatitis herpetiformis or pompholyx, vegetating and purulent lesions localized in intertriginous areas, and even exfoliative erythroderma. Recognition and management of such cases can present a diagnostic challenge to clinicians. In this article, we describe another variant which to our knowledge is the first case to present with a cellulitis-like presentation in a patient with a known history of BP.
Collapse
Affiliation(s)
- Ilya Ivyanskiy
- Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - Dhara Dave
- Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - Anass Dweik
- Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - James Yeary
- Amarillo VA Health Care System, Amarillo, TX, USA
| | - Tarek M. Naguib
- Texas Tech University Health Sciences Center, Amarillo, TX, USA
| |
Collapse
|
29
|
Negrini S, Guadagno A, Greco M, Parodi A, Burlando M. An unusual case of bullous haemorrhagic vasculitis in a COVID-19 patient. J Eur Acad Dermatol Venereol 2020; 34:e675-e676. [PMID: 32558979 PMCID: PMC7323396 DOI: 10.1111/jdv.16760] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 11/26/2022]
Affiliation(s)
- S Negrini
- Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - A Guadagno
- Anatomic Pathology Unit, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - M Greco
- Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - A Parodi
- Di.S.Sal. Section of Dermatology, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - M Burlando
- Di.S.Sal. Section of Dermatology, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| |
Collapse
|
30
|
Di Lernia V, Casanova DM, Goldust M, Ricci C. Pemphigus Vulgaris and Bullous Pemphigoid: Update on Diagnosis and Treatment. Dermatol Pract Concept 2020; 10:e2020050. [PMID: 32642305 DOI: 10.5826/dpc.1003a50] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 12/11/2022] Open
Abstract
Autoimmune bullous disorders are a heterogeneous spectrum of skin disorders characterized by the production of autoantibodies against adhesion molecules of the skin. The 2 major groups of diseases are "pemphigus diseases" and "autoimmune bullous diseases of the pemphigoid type." Pemphigus diseases are a group of autoimmune blistering diseases of the skin and mucous membranes characterized by intraepithelial cleft and acantholysis. The main subtypes of pemphigus include pemphigus vulgaris, pemphigus foliaceus, and paraneoplastic pemphigus. Diagnosis is based on clinical manifestations and confirmed with histological, immunofluorescence, and serological testing. Recently multivariant enzyme-linked immunosorbent assay systems have been developed as practical screening tools for patients with suspected autoimmune bullous dermatoses. The current first-line treatment of pemphigus is based on systemic corticosteroids that are often combined with immunosuppressive adjuvants, such as azathioprine, mycophenolate mofetil, and the anti-CD20 monoclonal antibody rituximab, usually at initiation of treatment. Rituximab efficacy is higher when it is administered early in the course of the disease. Therefore, it should be used as first-line treatment to improve efficacy and reduce cumulative doses of corticosteroids and their side effects. Treatment of bullous pemphigoid is based on disease extension. Localized and mild forms can be treated with superpotent topical corticosteroids or with nonimmunosuppressive agents. In patients with generalized disease or whose disease is resistant to the treatments described above, systemic corticosteroids are preferred and effective. Adjuvant immunosuppressants are often combined with steroids for their steroid-sparing effect.
Collapse
Affiliation(s)
- Vito Di Lernia
- Dermatology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Dahiana M Casanova
- Dermatology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Mohamad Goldust
- University Guglielmo Marconi, Rome, Italy & Department of Dermatology, University Hospital, Basel, Switzerland
| | - Cinzia Ricci
- Dermatology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, Italy
| |
Collapse
|
31
|
Vila-Payeras A, Domínguez-Mahamud C, Terrasa-Sagristà F, Vila-Mas A, Parera-Amer E, Nadal-Lladó C. Pemphigoid nodularis: An infrequent variant responding to rituximab. Australas J Dermatol 2020; 61:e438-e439. [PMID: 32408380 DOI: 10.1111/ajd.13331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/12/2020] [Accepted: 04/18/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Aina Vila-Payeras
- Department of Dermatology, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | | | | | - Antonia Vila-Mas
- Department of Dermatology, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | | | | |
Collapse
|
32
|
Autoimmune bullous skin diseases, pemphigus and pemphigoid. J Allergy Clin Immunol 2020; 145:1031-1047. [DOI: 10.1016/j.jaci.2020.02.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023]
|
33
|
Suo H, Su H, Lu C, Yang L, Tao J. Development of generalized bullous lesions after hemodialysis with polysulfone membrane dialyzer. J Dermatol 2020; 47:e119-e120. [PMID: 32067253 DOI: 10.1111/1346-8138.15261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Huinan Suo
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hua Su
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Changyu Lu
- Department of Dermatology, The First People's Hospital of Jingzhou, Jingzhou, China
| | - Liu Yang
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Juan Tao
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
34
|
Ujiie H, Iwata H, Yamagami J, Nakama T, Aoyama Y, Ikeda S, Ishii N, Iwatsuki K, Kurosawa M, Sawamura D, Tanikawa A, Tsuruta D, Nishie W, Fujimoto W, Amagai M, Shimizu H. Japanese guidelines for the management of pemphigoid (including epidermolysis bullosa acquisita). J Dermatol 2019; 46:1102-1135. [PMID: 31646663 DOI: 10.1111/1346-8138.15111] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/10/2019] [Indexed: 10/25/2022]
Abstract
The pemphigoid group is a category of autoimmune subepidermal blistering diseases in which autoantibodies deposit linearly at the epidermal basement membrane zone (BMZ). The main subtypes of pemphigoid mediated by immunoglobulin G autoantibodies are bullous pemphigoid (BP), mucous membrane pemphigoid (MMP) and epidermolysis bullosa acquisita (EBA). To establish the first guidelines approved by the Japanese Dermatological Association for the management of pemphigoid diseases, the Committee for Guidelines for the Management of Pemphigoid Diseases (Including EBA) was founded as part of the Study Group for Rare Intractable Skin Diseases under the Ministry of Health, Labor and Welfare Research Project on Overcoming Intractable Diseases. These guidelines aim to provide current information for the management of BP, MMP and EBA in Japan. Based on evidence, the guidelines summarize the clinical and immunological manifestations, pathophysiologies, diagnostic criteria, disease severity determination criteria, treatment algorithms and treatment recommendations. Because of the rarity of these diseases, there are few clinical studies with a high degree of evidence, so several parts of these guidelines were established based on the opinions of the Committee. To further optimize these guidelines, periodic revision in line with the new evidence is necessary.
Collapse
Affiliation(s)
- Hideyuki Ujiie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Jun Yamagami
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Takekuni Nakama
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - Yumi Aoyama
- Department of Dermatology, Kawasaki Medical School, Kurashiki, Japan
| | - Shigaku Ikeda
- Department of Dermatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - Keiji Iwatsuki
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Michiko Kurosawa
- Department of Epidemiology and Environmental Health, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Daisuke Sawamura
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Akiko Tanikawa
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Tsuruta
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Wataru Fujimoto
- Department of Dermatology, Kawasaki Medical School, Kurashiki, Japan
| | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Shimizu
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| |
Collapse
|
35
|
Singer S, Nelson CA, Lian CG, Dewan AK, LeBoeuf NR. Nonbullous pemphigoid secondary to PD-1 inhibition. JAAD Case Rep 2019; 5:898-903. [PMID: 31646161 PMCID: PMC6804458 DOI: 10.1016/j.jdcr.2019.07.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Key Words
- BP, bullous pemphigoid
- BP180, anti–bullous pemphigoid 180
- BP230, anti–bullous pemphigoid 230
- DIF, direct immunofluorescence
- ELISA, enzyme-linked immunosorbent assay
- ICI, immune checkpoint inhibitor
- IIF, indirect immunofluorescence
- Ig, immunoglobulin
- NBP, nonbullous pemphigoid
- PD-1
- PD-1, programmed cell death 1
- bullous pemphigoid
- immune checkpoint inhibitor
- immune-related adverse event
- nonbullous pemphigoid
Collapse
Affiliation(s)
- Sean Singer
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Caroline A Nelson
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Cutaneous Oncology, Department of Dermatology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Christian G Lian
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anna K Dewan
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nicole R LeBoeuf
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Cutaneous Oncology, Department of Dermatology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| |
Collapse
|
36
|
Ben Mordehai Y, Faibish H, Astman N, Greenberger S, Barzilai A, Baum S. Characteristics of patients with bullous pemphigoid: comparison of classic bullous pemphigoid to non-bullous pemphigoid. J Eur Acad Dermatol Venereol 2019; 34:161-165. [PMID: 31423677 DOI: 10.1111/jdv.15883] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/17/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common subepidermal autoimmune blistering disease. Patients occasionally present with a clinical picture of pruritus/urticaria alone for months and do not even develop blisters over time. Only few studies have investigated this subgroup of non-bullous pemphigoid (NBP). OBJECTIVE To evaluate the demographic and clinical characteristics of BP patients with or without blisters at the time of diagnosis. METHODS A retrospective study based on the medical records of 115 BP patients. Collected data included demographic characteristics, clinical presentation, treatment and response to treatment. RESULTS Thirty-six patients presented with pruritus/urticaria (31.3%), and 79 presented with blisters (68.7%), with mean ages of 77.5 and 76.0, respectively, at diagnosis and an equal female:male ratio. The level of immunoglobulin E (IgE) was 4.1 times higher, and the mean blood eosinophil count was significantly increased in the pruritus/urticaria group. Remission rate at 3 months and relapse rate were similar between the groups. Median follow-up period was 9 months (range 3-18). Only 23% of the patients with pruritus/urticaria developed blisters. CONCLUSIONS A significant number of BP patients present without blisters. We found no significant epidemiological or clinical differences from the classic BP patients aside from significantly elevated IgE and blood eosinophil levels. Similar results in larger cohort studies might be the foundation for a change in clinical protocols regarding the diagnosis and recommended treatment for the elderly presenting with pruritus/urticaria only.
Collapse
Affiliation(s)
- Y Ben Mordehai
- Department of Dermatology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Faibish
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - N Astman
- Department of Dermatology, Sheba Medical Center, Ramat Gan, Israel.,Israel Defense Forces Medical Corps, Ramat Gan, Israel
| | - S Greenberger
- Department of Dermatology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Barzilai
- Department of Dermatology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Baum
- Department of Dermatology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
37
|
Epidermolysis bullosa acquisita: A comprehensive review. Autoimmun Rev 2019; 18:786-795. [DOI: 10.1016/j.autrev.2019.06.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/26/2019] [Indexed: 02/07/2023]
|
38
|
Lamberts A, Meijer JM, Pas HH, Diercks GFH, Horváth B, Jonkman MF. Nonbullous pemphigoid: Insights in clinical and diagnostic findings, treatment responses, and prognosis. J Am Acad Dermatol 2019; 81:355-363. [PMID: 31009674 DOI: 10.1016/j.jaad.2019.04.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/12/2019] [Accepted: 04/13/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Nonbullous pemphigoid is an under-recognized phenotype of the autoimmune bullous disease pemphigoid, characterized by the absence of blisters. Several disease aspects have not been studied previously. OBJECTIVE To describe the characteristics of nonbullous pemphigoid. METHODS A retrospective review study of medical records. The diagnosis of pemphigoid was based on meeting 2 of the following 3 criteria: (1) pruritus, (2) positive direct immunofluorescence microscopy, or (3) positive indirect immunofluorescence microscopy on salt-split skin. RESULTS The review included 69 patients. The mean delay in diagnosis was 29 months. Skin examination most often showed pruritic papules/nodules (37%) or pruritus without primary skin lesions (22%). Histopathologic findings were mainly nonspecific. Results of direct and indirect immunofluorescence microscopy were positive in 60% and 69%, respectively. During follow-up, blisters formed in 17%, which was associated with a positive indirect immunofluorescence microscopy (P = .014) and a positive BP180 immunoblot result (P = .032). The Kaplan-Meier estimates of mortality at 1, 2, and 3 years were 14%, 34%, and 46%, respectively, with an 8.6-fold increased all-cause mortality risk. LIMITATIONS The retrospective study design. CONCLUSIONS Nonbullous pemphigoid presented with heterogeneous pruritic skin lesions, resulting in delayed diagnosis. Direct and indirect immunofluorescence microscopy are essential to diagnose nonbullous pemphigoid, in contrast to histopathology, mainly showing nonspecific findings. An increased all-cause mortality risk was observed during follow-up.
Collapse
Affiliation(s)
- Aniek Lamberts
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Joost M Meijer
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hendri H Pas
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gilles F H Diercks
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Barbara Horváth
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marcel F Jonkman
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
39
|
Genovese G, Di Zenzo G, Cozzani E, Berti E, Cugno M, Marzano AV. New Insights Into the Pathogenesis of Bullous Pemphigoid: 2019 Update. Front Immunol 2019; 10:1506. [PMID: 31312206 PMCID: PMC6614376 DOI: 10.3389/fimmu.2019.01506] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/17/2019] [Indexed: 12/19/2022] Open
Abstract
There are several lines of evidence indicating that the physiopathological bases of bullous pemphigoid (BP), the most common subepidermal autoimmune bullous disease, are hallmarked by the production of autoantibodies directed against the hemidesmosomal anchoring proteins BP180 and BP230. In contrast to the robustness of the latter assumption, the multifaceted complexity of upstream and downstream mechanisms implied in the pathogenesis of BP remains an area of intense speculation. So far, an imbalance between T regulatory cells and autoreactive T helper (Th) cells has been regarded as the main pathogenic factor triggering the autoimmune response in BP patients. However, the contributory role of signaling pathways fostering the B cell stimulation, such as Toll-like receptor activation, as well as that of ancillary inflammatory mechanisms responsible for blister formation, such as Th17 axis stimulation and the activation of the coagulation cascade, are still a matter of debate. In the same way, the pathomechanisms implied in the loss of dermal-epidermal adhesion secondary to autoantibodies binding are not fully understood. Herein, we review in detail the current concepts and controversies on the complex pathogenesis of BP, shedding light on the most recent theories emerging from the literature.
Collapse
Affiliation(s)
- Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Di Zenzo
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell'Immacolata (IDI) IRCCS, Rome, Italy
| | - Emanuele Cozzani
- DISSAL Section of Dermatology, Università degli Studi di Genova, Genoa, Italy
| | - Emilio Berti
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Massimo Cugno
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Internal Medicine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
40
|
Abstract
Bullous pemphigoid is the most frequent autoimmune bullous disease and mainly affects elderly individuals. Increase in incidence rates in the past decades has been attributed to population aging, drug-induced cases and improvement in the diagnosis of the nonbullous presentations of the disease. A dysregulated T cell immune response and synthesis of IgG and IgE autoantibodies against hemidesmosomal proteins (BP180 and BP230) lead to neutrophil chemotaxis and degradation of the basement membrane zone. Bullous pemphigoid classically manifests with tense blisters over urticarial plaques on the trunk and extremities accompanied by intense pruritus. Mucosal involvement is rarely reported. Diagnosis relies on (1) the histopathological evaluation demonstrating eosinophilic spongiosis or a subepidermal detachment with eosinophils; (2) the detection of IgG and/or C3 deposition at the basement membrane zone using direct or indirect immunofluorescence assays; and (3) quantification of circulating autoantibodies against BP180 and/or BP230 using ELISA. Bullous pemphigoid is often associated with multiple comorbidities in elderly individuals, especially neurological disorders and increased thrombotic risk, reaching a 1-year mortality rate of 23%. Treatment has to be tailored according to the patient's clinical conditions and disease severity. High potency topical steroids and systemic steroids are the current mainstay of therapy. Recent randomized controlled studies have demonstrated the benefit and safety of adjuvant treatment with doxycycline, dapsone and immunosuppressants aiming a reduction in the cumulative steroid dose and mortality.
Collapse
Affiliation(s)
- Denise Miyamoto
- Division of Dermatology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP),
Brazil
| | - Claudia Giuli Santi
- Division of Dermatology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP),
Brazil
| | - Valéria Aoki
- Department of Dermatology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo (SP), Brazil
| | - Celina Wakisaka Maruta
- Department of Dermatology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo (SP), Brazil
| |
Collapse
|
41
|
Vornicescu C, Șenilă SC, Cosgarea R, Candrea E, Pop AD, Ungureanu L. Pemphigoid nodularis - rare presentation of bullous pemphigoid: A case report and literature review. Exp Ther Med 2019; 17:1132-1138. [PMID: 30679985 PMCID: PMC6327548 DOI: 10.3892/etm.2018.7057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 09/25/2018] [Indexed: 01/12/2023] Open
Abstract
Pemphigoid nodularis (PN) is a rare clinical variant of bullous pemphigoid characterized by the presence of nodular prurigo-like lesions and pemphigoid blisters. The diagnosis is confirmed by direct immunofluorescence (DIF)/ indirect immunofluorescence (IIF) and immunoserology tests. For some patients, with long mean duration of symptoms, the correct diagnosis of PN is delayed because the disease is not recognized. We present a case and summarize the reported characteristics of PN. The search in MEDLINE database, after selection, resulted in 36 articles presenting 47 cases of PN. Between published cases a female predominance was noted (female to male ratio of 1.8:1), almost half of the reported patients were non-Caucasian, and the mean age at presentation was 66.2 years. The mean duration until the diagnosis was almost 2 years. Sixteen patients also had other autoimmune diseases. Twenty-two patients developed vesicles/bullae/urticarial plaques before or after the diagnosis. Peripheral eosinophilia and high levels of serum total IgE were reported in 10.6 and 27.2% of patients, respectively. ELISA for either BP180, BP230 or both were positive in all tested cases. DIF and IIF microscopy were positive overall in 100 and 92.3% of cases, respectively. Corticosteroids, either topical or systemic, were the most efficient therapeutic option, although many others were used. PN remains a diagnostic and therapeutic challenge in elderly patients with unexplained refractory chronic pruritus associated with papulo-nodular lesions.
Collapse
Affiliation(s)
- Corina Vornicescu
- Department of Dermatology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Simona Corina Șenilă
- Department of Dermatology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Rodica Cosgarea
- Department of Dermatology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Elisabeta Candrea
- Department of Dermatology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Alexandra Dana Pop
- Department of Physiology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Loredana Ungureanu
- Department of Dermatology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| |
Collapse
|
42
|
Baldini E, Odorisio T, Tuccilli C, Persechino S, Sorrenti S, Catania A, Pironi D, Carbotta G, Giacomelli L, Arcieri S, Vergine M, Monti M, Ulisse S. Thyroid diseases and skin autoimmunity. Rev Endocr Metab Disord 2018; 19:311-323. [PMID: 29948572 DOI: 10.1007/s11154-018-9450-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The skin is the largest organ of the body, at the boundary with the outside environment. Primarily, it provides a physical and chemical barrier against external insults, but it can act also as immune organ because it contains a whole host of immune-competent cells of both the innate and the adaptive immune systems, which cooperate in eliminating invading pathogens following tissue injury. On the other hand, improper skin immune responses lead to autoimmune skin diseases (AISD), such as pemphigus, bullous pemphigoid, vitiligo, and alopecia. Although the interplay among genetic, epigenetic, and environmental factors has been shown to play a major role in AISD etiology and progression, the molecular mechanisms underlying disease development are far from being fully elucidated. In this context, epidemiological studies aimed at defining the association of different AISD with other autoimmune pathologies revealed possible shared molecular mechanism(s) responsible for disease progression. In particular, over the last decades, a number of reports have highlighted a significant association between thyroid diseases (TD), mainly autoimmune ones (AITD), and AISD. Here, we will recapitulate the epidemiology, clinical manifestations, and pathogenesis of the main AISD, and we will summarize the epidemiological evidence showing the associations with TD as well as possible molecular mechanism(s) underlying TD and AISD pathological manifestations.
Collapse
Affiliation(s)
- Enke Baldini
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Teresa Odorisio
- Laboratory of Molecular and Cell Biology, Istituto Dermopatico dell'Immacolata-IRCCS, Rome, Italy
| | - Chiara Tuccilli
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | | | - Salvatore Sorrenti
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Antonio Catania
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Daniele Pironi
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Giovanni Carbotta
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Laura Giacomelli
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Stefano Arcieri
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Massimo Vergine
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Massimo Monti
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Salvatore Ulisse
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy.
| |
Collapse
|
43
|
Lopez AT, Geskin L. A Case of Nivolumab-Induced Bullous Pemphigoid: Review of Dermatologic Toxicity Associated with Programmed Cell Death Protein-1/Programmed Death Ligand-1 Inhibitors and Recommendations for Diagnosis and Management. Oncologist 2018; 23:1119-1126. [PMID: 30018132 PMCID: PMC6263133 DOI: 10.1634/theoncologist.2018-0128] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/18/2018] [Indexed: 01/05/2023] Open
Abstract
Immunotherapy has emerged as a highly effective treatment for numerous cancers. Use of checkpoint inhibitors against various molecules including programmed cell death protein-1 (PD-1), programmed death ligand-1 (PD-L1), and cytotoxic T-lymphocyte-associated protein-4 have become widespread in clinical practice. Compared with conventional chemotherapy, immunotherapy is associated with a unique set of immune reactions known collectively as immune-related adverse events (irAEs). Of known irAEs, cutaneous toxicity is among the most frequently observed in patients treated with immunotherapy. Although often mild, dermatologic toxicity can occasionally be high grade and potentially life-threatening. In this article, we report a case of PD-1 inhibitor-induced bullous pemphigoid-a serious adverse event that has been increasingly observed with use of PD-1/PD-L1 inhibitors. We will also review diagnosis and management of low-grade cutaneous irAEs and bullous disease with checkpoint inhibitors. KEY POINTS PD-1/PD-L1 inhibitor-induced bullous pemphigoid (BP) is a rare but potentially serious dermatologic toxicity associated with checkpoint inhibitorsIn patients with pruritus or rash that is refractory to topical steroids, physicians should have a greater index of suspicion for higher-grade cutaneous immune-related adverse events.There is no standardized treatment algorithm for management of PD-1/PD-L1 inhibitor-induced BP, but patients frequently require topical and systemic steroids.
Collapse
Affiliation(s)
- Adriana T Lopez
- Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Larisa Geskin
- Department of Dermatology, Columbia University Medical Center, New York, New York, USA
| |
Collapse
|
44
|
Ellenbogen E, Geller S, Azrielant S, Zeeli T, Goldberg I, Schmidt E, Zillikens D, Mrowietz U, Sherman S, Mercer S, Didkovsky E, Hodak E, Sprecher E. Grover disease and bullous pemphigoid: a clinicopathological study of six cases. Clin Exp Dermatol 2018; 44:524-527. [PMID: 30264538 DOI: 10.1111/ced.13789] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 11/29/2022]
Abstract
Grover disease (GD) is an idiopathic dermatosis that typically manifests as itchy papules over the trunk in middle-aged men. Bullous pemphigoid (BP) is an autoimmune bullous disease that affects older people. Not only are the two diseases easily distinguishable on clinical grounds, they are also characterized by differences in histopathology, pathogenesis and response to treatment Thus, the co-occurrence of these two conditions in the same patient is usually considered coincidental. In this report, we present a multicentre retrospective analysis of six patients who developed both GD and BP over a short period of time, and in all cases but one, GD preceded BP. We discuss the clinical and histopathological features of these patients, and the suggested mechanisms of the diseases. We conclude that GD might predispose to the development of BP.
Collapse
Affiliation(s)
- E Ellenbogen
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Geller
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Azrielant
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - T Zeeli
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - I Goldberg
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Germany
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Germany
| | - U Mrowietz
- Department of Dermatology, Venerology and Allergology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - S Sherman
- Department of Dermatology, Rabin Medical Center, Petach Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Mercer
- Department of Dermatology, Rabin Medical Center, Petach Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Didkovsky
- Institute of Pathology, Rabin Medical Center, Petach Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Hodak
- Department of Dermatology, Rabin Medical Center, Petach Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Sprecher
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Human Molecular Genetics & Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
45
|
Fania L, Didona D, Pacifico V, Mariotti F, De Luca N, Abeni D, Mazzanti C, Di Zenzo G, Didona B. Bullous pemphigoid with hyperkeratosis and palmoplantar keratoderma: Three cases. J Dermatol 2018; 45:1135-1140. [PMID: 30007013 DOI: 10.1111/1346-8138.14529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 06/04/2018] [Indexed: 11/27/2022]
Abstract
The clinical features of bullous pemphigoid are extremely polymorphous. Several atypical forms of bullous pemphigoid have been described, and the diagnosis critically relies on immunopathological findings. We describe three bullous pemphigoid patients characterized by palmoplantar keratoderma, diffused hyperkeratotic cutaneous lesions and extremely high levels of immunoglobulin E serum. The diagnosis of bullous pemphigoid should be taken into account in patients presenting diffused hyperkeratotic cutaneous lesions and palmoplantar keratoderma, even in the absence of blisters. Alteration of the keratinization process, that could occur in patients with genetic mutations in desmosomal and hemidesmosomal genes, may also be due to circulating autoantibodies against hemidesmosomal proteins in these bullous pemphigoid patients.
Collapse
Affiliation(s)
- Luca Fania
- Istituto Dermopatico dell'Immacolata-IRCCS, FLMM, Rome, Italy
| | - Dario Didona
- Istituto Dermopatico dell'Immacolata-IRCCS, FLMM, Rome, Italy
| | | | | | - Naomi De Luca
- Istituto Dermopatico dell'Immacolata-IRCCS, FLMM, Rome, Italy
| | - Damiano Abeni
- Istituto Dermopatico dell'Immacolata-IRCCS, FLMM, Rome, Italy
| | - Cinzia Mazzanti
- Istituto Dermopatico dell'Immacolata-IRCCS, FLMM, Rome, Italy
| | | | - Biagio Didona
- Istituto Dermopatico dell'Immacolata-IRCCS, FLMM, Rome, Italy
| |
Collapse
|
46
|
Genovese G, Muratori S, Berti E, Marzano AV. Bullous erythroderma: novel association of pityriasis rubra pilaris with bullous pemphigoid. Clin Exp Dermatol 2018; 44:73-75. [PMID: 30129048 DOI: 10.1111/ced.13718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2018] [Indexed: 11/29/2022]
Affiliation(s)
- G Genovese
- Dermatology Unit, Department of Physiopathology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy
| | - S Muratori
- Dermatology Unit, Department of Physiopathology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy
| | - E Berti
- Dermatology Unit, Department of Physiopathology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy
| | - A V Marzano
- Dermatology Unit, Department of Physiopathology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy
| |
Collapse
|
47
|
Clinical, histological, immunological presentations and outcomes of bullous systemic lupus erythematosus: 10 New cases and a literature review of 118 cases. Semin Arthritis Rheum 2018; 48:83-89. [DOI: 10.1016/j.semarthrit.2017.11.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 10/15/2017] [Accepted: 11/03/2017] [Indexed: 11/22/2022]
|
48
|
Lopez AT, Khanna T, Antonov N, Audrey-Bayan C, Geskin L. A review of bullous pemphigoid associated with PD-1 and PD-L1 inhibitors. Int J Dermatol 2018; 57:664-669. [PMID: 29630716 DOI: 10.1111/ijd.13984] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/16/2018] [Accepted: 03/05/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Dermatologic toxicity represents a substantial portion of all immune-related adverse events (irAEs) associated with PD-1/PD-L1 inhibitors. Bullous pemphigoid (BP) is a rare cutaneous side effect of these medications, which can initially be clinically indistinguishable from other, low-grade cutaneous toxicity. OBJECTIVE To better characterize the clinical features of BP associated with PD-1/PD-L1 inhibitors, evaluate the efficacy of various treatment regimens, determine the frequency of prodromal pruritus, and assess whether immunological diagnostic studies for BP are warranted in patients treated with checkpoint inhibitors who develop intractable pruritus. METHODS A comprehensive review of the English-language medical literature was performed using key terms. Papers published on any date and from all origins were considered. Fourteen publications, containing 21 patient cases, were selected independently by two reviewers and deemed relevant to the present publication. RESULTS Pruritus was a prominent feature of the majority (12/21) of cases and preceded or occurred concurrently with BP development. Bullae developed within 6-8 months of initiation of PD-1/PD-L1 inhibitors; however, a smaller subset of patients did not develop bullae for 1-1.5 years following initiation of therapy. Mean time to pruritus was similar for pembrolizumab and nivolumab at 19 and 21 weeks, respectively. Development of BP required discontinuation of immunotherapy in 76% (16/21) of cases. CONCLUSION Prodromal or "non-bullous" variants of BP must be considered in patients treated with checkpoint inhibitors who develop protracted or worsening pruritus. Early diagnostic immunological evaluation of the skin may lead to improved patient outcomes by facilitating timely initiation of treatment and prevent disruptions in cancer therapy.
Collapse
Affiliation(s)
- Adriana T Lopez
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Trisha Khanna
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Nina Antonov
- Department of Dermatology, Columbia University Medical Center, New York, NY, USA
| | | | - Larisa Geskin
- Department of Dermatology, Columbia University Medical Center, New York, NY, USA
| |
Collapse
|
49
|
Mandel V, Cinotti E, Benati E, Labeille B, Ciardo S, Vaschieri C, Cambazard F, Perrot J, Pellacani G. Reflectance confocal microscopy and optical coherence tomography for the diagnosis of bullous pemphigoid and pemphigus and surrounding subclinical lesions. J Eur Acad Dermatol Venereol 2018; 32:1562-1569. [DOI: 10.1111/jdv.14795] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 12/19/2017] [Indexed: 11/29/2022]
Affiliation(s)
- V.D. Mandel
- Dermatology Unit; Surgical, Medical and Dental Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine; University of Modena and Reggio Emilia; Modena Italy
| | - E. Cinotti
- Department of Dermatology; University Hospital of Saint-Étienne; Saint-Étienne France
| | - E. Benati
- Dermatology Unit; Surgical, Medical and Dental Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine; University of Modena and Reggio Emilia; Modena Italy
| | - B. Labeille
- Department of Dermatology; University Hospital of Saint-Étienne; Saint-Étienne France
| | - S. Ciardo
- Dermatology Unit; Surgical, Medical and Dental Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine; University of Modena and Reggio Emilia; Modena Italy
| | - C. Vaschieri
- Dermatology Unit; Surgical, Medical and Dental Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine; University of Modena and Reggio Emilia; Modena Italy
| | - F. Cambazard
- Department of Dermatology; University Hospital of Saint-Étienne; Saint-Étienne France
| | - J.L. Perrot
- Department of Dermatology; University Hospital of Saint-Étienne; Saint-Étienne France
| | - G. Pellacani
- Dermatology Unit; Surgical, Medical and Dental Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine; University of Modena and Reggio Emilia; Modena Italy
| |
Collapse
|
50
|
Liu Y, Li L, Xia Y. BP180 Is Critical in the Autoimmunity of Bullous Pemphigoid. Front Immunol 2017; 8:1752. [PMID: 29276517 PMCID: PMC5727044 DOI: 10.3389/fimmu.2017.01752] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/24/2017] [Indexed: 12/20/2022] Open
Abstract
Bullous pemphigoid (BP) is by far the most common autoimmune blistering dermatosis that mainly occurs in the elderly. The BP180 is a transmembrane glycoprotein, which is highly immunodominant in BP. The structure and location of BP180 indicate that it is a significant autoantigen and plays a key role in blister formation. Autoantibodies from BP patients react with BP180, which leads to its degradation and this has been regarded as the central event in BP pathogenesis. The consequent blister formation involves the activation of complement-dependent or -independent signals, as well as inflammatory pathways induced by BP180/anti-BP180 autoantibody interaction. As a multi-epitope molecule, BP180 can cause dermal-epidermal separation via combining each epitope with specific immunoglobulin, which also facilitates blister formation. In addition, some inflammatory factors can directly deplete BP180, thereby leading to fragility of the dermal-epidermal junction and blister formation. This review summarizes recent investigations on the role of BP180 in BP pathogenesis to determine the potential targets for the treatment of patients with BP.
Collapse
Affiliation(s)
- Yale Liu
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Liang Li
- National-Local Joint Engineering Research Center of Biodiagnostics and Biotherapy, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Yumin Xia
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
| |
Collapse
|