101
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van Beek N, Zillikens D, Schmidt E. Diagnosis of autoimmune bullous diseases. J Dtsch Dermatol Ges 2019; 16:1077-1091. [PMID: 30179336 DOI: 10.1111/ddg.13637] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/28/2018] [Indexed: 12/25/2022]
Abstract
Autoimmune bullous disorders (AIBDs) are a heterogeneous group of rare diseases clinically characterized by erosions and/or blisters on the skin and mucous membranes. AIBDs can be categorized into two groups: pemphigus diseases, characterized by intraepidermal blistering and autoantibodies against desmosomal proteins such as desmoglein (Dsg) 1, Dsg3, members of the plakin family, and subepidermal AIBDs, comprised of pemphigoid diseases and dermatitis herpetiformis. Autoantibodies in dermatitis herpetiformis target transglutaminases 2 and 3, while in pemphigoid disease, autoantibodies are directed against structural proteins of the dermal-epidermal junction. Although analysis of a perilesional biopsy with direct immunofluorescence (IF) microscopy is still the diagnostic gold standard, several assays have become widely available that allow serological diagnosis in the majority of patients. Standard serological diagnosis includes indirect IF on monkey esophagus and salt-split human skin. Assays to further characterize autoantibody specificity include ELISA systems based on recombinant forms of the immunodominant regions of the target antigens as well as multivariant indirect IF microscopy tests with several miniature substrates. These serological assays are complemented by various in-house assays using immunoblotting and ELISA, which are only available in specialized laboratories. Here we review new developments in the diagnosis of AIBDs and describe state-of-the-art diagnostic procedures for this group of diseases.
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Affiliation(s)
- Nina van Beek
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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102
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Meijer JM, Diercks GFH, de Lang EWG, Pas HH, Jonkman MF. Assessment of Diagnostic Strategy for Early Recognition of Bullous and Nonbullous Variants of Pemphigoid. JAMA Dermatol 2019; 155:158-165. [PMID: 30624575 DOI: 10.1001/jamadermatol.2018.4390] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance A substantial number of patients with bullous pemphigoid do not develop skin blisters and may not have received the correct diagnosis. Diagnostic criteria and an optimal diagnostic strategy are needed for early recognition and trials. Objectives To assess the minimal requirements for diagnosis of bullous and nonbullous forms of pemphigoid and to evaluate the optimal diagnostic strategy. Design, Setting, and Participants This paired, multivariable, diagnostic accuracy study analyzed data from 1125 consecutive patients with suspected pemphigoid who were referred to the Groningen Center for Blistering Diseases from secondary and tertiary care hospitals throughout the Netherlands. Eligible participants were patients with paired data on at least (1) a skin biopsy specimen for the direct immunofluorescence (DIF) microscopy test; (2) indirect immunofluorescence on a human salt-split skin substrate (IIF SSS) test; and (3) 1 or more routine immunoserologic tests administered between January 1, 2002, and May 1, 2015. Samples were taken from patients at the time of first diagnosis, before introduction of immunosuppressive therapy, and within an inclusion window of a maximum of 4 weeks. Data analysis was conducted from October 1, 2015, to December 1, 2017. Main Outcomes and Measures Pairwise DIF, IIF SSS, IIF on monkey esophagus, BP180 and BP230 enzyme-linked immunosorbent assays, and immunoblot for BP180 and BP230 tests were performed. The results were reported in accordance with 2015 version of the Standards for Reporting Diagnostic Accuracy. Results Of the 1125 patients analyzed, 653 (58.0%) were women and 472 (42.0%) were men, with a mean (SD) age of 63.2 (19.9) years. In total, 343 participants received a pemphigoid diagnosis, with 782 controls. Of the 343 patients, 74 (21.6%, or 1 in 5) presented with nonbullous pemphigoid. The DIF microscopy was the most sensitive diagnostic test (88.3% [n = 303]; 95% CI, 84.5%-91.3%), whereas IIF SSS was less sensitive (77.0% [n = 263]; 95% CI, 72.2%-81.1%) but was highly specific (99.9%; 95% CI, 99.3%-100%) and complemented most cases with negative DIF findings. Results of the BP180 NC16A enzyme-linked immunosorbent assay did not add diagnostic value for initial diagnosis in multivariable logistic regression analysis of combined tests. These findings lead to the proposed minimal criteria for diagnosing pemphigoid: (1) pruritus and/or predominant cutaneous blisters, (2) linear IgG and/or C3c deposits (in an n-serrated pattern) by DIF on a skin biopsy specimen, and (3) positive epidermal side staining of IgG by IIF SSS on a serum sample; this proposal extends bullous pemphigoid with the unrecognized nonbullous form. Conclusions and Relevance Both DIF and IIF SSS tests should be performed for diagnosis of the bullous and nonbullous variants of pemphigoid, and the BP180 NC16A enzyme-linked immunosorbent assay is recommended as an add-on test for disease activity monitoring.
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Affiliation(s)
- Joost M Meijer
- Center for Blistering Diseases, Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Gilles F H Diercks
- Center for Blistering Diseases, Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Emma W G de Lang
- Center for Blistering Diseases, Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hendri H Pas
- Center for Blistering Diseases, Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marcel F Jonkman
- Center for Blistering Diseases, Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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103
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Kridin K, Bergman R. Assessment of the Prevalence of Mucosal Involvement in Bullous Pemphigoid. JAMA Dermatol 2019; 155:166-171. [PMID: 30624571 DOI: 10.1001/jamadermatol.2018.5049] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The prevalence of mucosal involvement in bullous pemphigoid (BP) is inconsistent. Nonoral mucosal involvement was reported anecdotally in few patients with BP. Objective To evaluate the prevalence of mucosal involvement in patients with BP, and to characterize the subgroup of patients with mucosal lesions. Design, Setting, and Participants A retrospective cohort study was performed including 328 consecutive patients diagnosed with immunopathologically validated BP at a tertiary care referral center for autoimmune bullous diseases in northern Israel between January 1, 2000, and December 31, 2017. Main Outcome and Measures The study was conducted to estimate the prevalence and distribution of mucosal involvement among patients with BP. Patients with mucosal involvement were compared with the remaining BP patients regarding clinical and immunological features, laboratory analyses, and treatments. Results The study cohort included 139 (42.4%) male and 189 (57.6%) female patients, with a mean (SD) age of 78.0 (11.8) years at presentation. Fifty-six patients (17.1%) presented with mucosal lesions. The oral mucosa was the most frequently affected mucosal surface (n = 44; 13.7%), followed by the laryngeal (n = 16; 4.9%) and the genital (n = 10; 3.0%) mucosae. Among patients with oral lesions, the most involved oral structures were the buccal mucosa (n = 25; 55.6%) and the soft palate (n = 24; 53.3%). Compared with other patients with BP, patients with mucosal involvement were younger (71.8 [14.4] years vs 79.3 [10.8] years; P < .001), presented more frequently with extensive disease (55.4% vs 39.7%; P = .002), had less peripheral eosinophilia (17.8% vs 41.9%; P < .001), and were treated with higher doses of corticosteroids (prednisone >1 mg/kg: 67.9% vs 51.8%; P = .03). Conclusions and Relevance Mucosal lesions are present in a notable subgroup of patients with BP and are associated with disease severity. Laryngeal involvement is more common than previously appreciated.
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel.,School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Reuven Bergman
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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104
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Olbrich M, Künstner A, Witte M, Busch H, Fähnrich A. Genetics and Omics Analysis of Autoimmune Skin Blistering Diseases. Front Immunol 2019; 10:2327. [PMID: 31749790 PMCID: PMC6843061 DOI: 10.3389/fimmu.2019.02327] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/16/2019] [Indexed: 12/18/2022] Open
Abstract
Autoimmune blistering diseases (AIBDs) of the skin are characterized by autoantibodies against different intra-/extracellular structures within the epidermis and at the basement membrane zone (BMZ). Binding of the antibodies to their target antigen leads to inflammation at the respective binding site and degradation of these structures, resulting in the separation of the affected skin layers. Clinically, blistering, erythema and lesions of the skin and/or mucous membranes can be observed. Based on the localization of the autoantigen, AIBDs can be divided into pemphigus (intra-epidermal blistering diseases) and pemphigoid diseases (sub-epidermal blistering diseases), respectively. Although autoantigens have been extensively characterized, the underlying causes that trigger the diseases are still poorly understood. Besides the environment, genetic factors seem to play an important role in a predisposition to AIBDs. Here, we review currently known genetic and immunological mechanisms that contribute to the pathogenesis of AIBDs. Among the most commonly encountered genetic predispositions for AIBDs are the HLA gene region, and deleterious mutations of key genes for the immune system. Particularly, HLA class II genes such as the HLA-DR and HLA-DQ alleles have been shown to be prevalent in patients. This has prompted further epidemiological studies as well as unbiased Omics approaches on the transcriptome, microbiome, and proteome level to elucidate common and individual genetic risk factors as well as the molecular pathways that lead to the pathogenesis of AIBDs.
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Affiliation(s)
- Michael Olbrich
- Medical Systems Biology, Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Institute of Cardiogenetics, University of Lübeck, Lübeck, Germany
| | - Axel Künstner
- Medical Systems Biology, Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Institute of Cardiogenetics, University of Lübeck, Lübeck, Germany
| | - Mareike Witte
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Hauke Busch
- Medical Systems Biology, Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Institute of Cardiogenetics, University of Lübeck, Lübeck, Germany
| | - Anke Fähnrich
- Medical Systems Biology, Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Institute of Cardiogenetics, University of Lübeck, Lübeck, Germany
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105
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Messingham KN, Crowe TP, Fairley JA. The Intersection of IgE Autoantibodies and Eosinophilia in the Pathogenesis of Bullous Pemphigoid. Front Immunol 2019; 10:2331. [PMID: 31636640 PMCID: PMC6787172 DOI: 10.3389/fimmu.2019.02331] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/16/2019] [Indexed: 12/13/2022] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease characterized by autoantibodies targeting cellular adhesion molecules. While IgE autoantibodies are occasionally reported in other autoimmune blistering diseases, BP is unique in that most BP patients develop an IgE autoantibody response. It is not known why BP patients develop self-reactive IgE and the precise role of IgE in BP pathogenesis is not fully understood. However, clinical evidence suggests an association between elevated IgE antibodies and eosinophilia in BP patients. Since eosinophils are multipotent effector cells, capable cytotoxicity and immune modulation, the putative interaction between IgE and eosinophils is a primary focus in current studies aimed at understanding the key components of disease pathogenesis. In this review, we provide an overview of BP pathogenesis, highlighting clinical and experimental evidence supporting central roles for IgE and eosinophils as independent mediators of disease and via their interaction. Additionally, therapeutics targeting IgE, the Th2 axis, or eosinophils are also discussed.
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Affiliation(s)
- Kelly N Messingham
- Department of Dermatology, The University of Iowa, Iowa City, IA, United States
| | - Tyler P Crowe
- Department of Dermatology, The University of Iowa, Iowa City, IA, United States
| | - Janet A Fairley
- Department of Dermatology, The University of Iowa, Iowa City, IA, United States.,Iowa City VA Medical Center, Iowa City, IA, United States
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106
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Kridin K, Bergman R. Association of Bullous Pemphigoid With Dipeptidyl-Peptidase 4 Inhibitors in Patients With Diabetes: Estimating the Risk of the New Agents and Characterizing the Patients. JAMA Dermatol 2019; 154:1152-1158. [PMID: 30090931 DOI: 10.1001/jamadermatol.2018.2352] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance The association of bullous pemphigoid (BP) with the use of dipeptidyl-peptidase 4 (DPP-4) inhibitors among patients with diabetes has recently emerged. The risk of developing BP during treatment with new DPP-4 inhibitor agents like linagliptin is yet to be established. The clinical features and the prognostic outcomes of patients with DPP-4 inhibitor-associated BP are yet to be established. Objectives Primarily to estimate the association between DPP-4 inhibitor exposure and the development of BP, and secondarily to characterize the clinical features and history of patients with DPP-4 inhibitor-associated BP. Design, Setting, and Participants A retrospective case-control study of the intake of different DPP-4 inhibitor agents and metformin and occurrence of BP among patients with diabetes in a tertiary care referral center for autoimmune bullous diseases in northern Israel. Included were 82 consecutive patients with diabetes and immunopathologically validated BP diagnosed between January 1, 2011, and December 31, 2017, and 328 age-, sex-, and ethnicity-matched control participants with diabetes but without BP. Main Outcomes and Measures Patients with diabetes and BP and exposure to DPP-4 inhibitors were followed up for a median of 2.0 years and compared with other patients with diabetes and BP who were not exposed to DPP-4 inhibitors regarding clinical and immunological features, laboratory analyses, treatments, and clinical outcomes. Results Eighty-two patients with BP and 328 age- and sex-matched control participants were enrolled; mean (SD) age, 79.1 (9.1) years; and 44 patients were female (53.7%). Overall, DPP-4 inhibitor intake was associated with a 3-fold increased risk for BP (adjusted odds ratio [OR], 3.2; 95% CI, 1.9-5.4). The adjusted ORs for vildagliptin and linagliptin were 10.7 (95% CI, 5.1-22.4) and 6.7 (95% CI, 2.2-19.7), respectively. The association of DPP-4 inhibitor use with BP was independent of the use of metformin and was stronger among male (OR, 4.46; 95% CI, 2.11-9.40) than female (OR, 1.88; 95%, CI 0.92-3.86) patients and strongest in patients younger than 70 years (OR, 5.59; 95% CI, 1.73-18.01). Patients with DPP-4 inhibitor-associated BP presented with higher mucosal involvement (22.2% vs 6.5%; P = .04) and lower mean (SD) peripheral eosinophil counts (399.8 [508.0] vs 1117.6 [1847.6] cells/μL; P = .01) than those with BP who had not been exposed to DPP-4 inhibitor. Discontinuation of DPP-4 inhibitor treatment was followed by improved clinical outcomes. Conclusions and Relevance Vildagliptin and, to a lesser extent, linagliptin are associated with an increased risk of BP. This may partly explain the increasing incidence of BP in Israel. Discontinuation of DPP-4 inhibitor treatment in patients with diabetes should be considered when BP is diagnosed.
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
| | - Reuven Bergman
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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107
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van Beek N, Zillikens D, Schmidt E. Diagnostik blasenbildender Autoimmundermatosen. J Dtsch Dermatol Ges 2019; 16:1077-1092. [PMID: 30179341 DOI: 10.1111/ddg.13637_g] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/28/2018] [Indexed: 01/07/2023]
Abstract
Blasenbildende Autoimmundermatosen (BAIDs) sind eine heterogene Gruppe seltener Erkrankungen, die klinisch durch Erosionen und/oder Blasen an Haut und Schleimhäuten charakterisiert sind. BAIDs können in zwei Gruppen eingeteilt werden: Pemphigus-Erkrankungen, die durch intraepidermale Blasenbildung und Autoantikörper gegen desmosomale Proteine wie Desmoglein (Dsg) 1, Dsg3 und Mitglieder der Plakin-Familie charakterisiert sind, sowie subepidermale BAIDs, die Pemphigoid-Erkrankungen und die Dermatitis herpetiformis umfassen. Bei der Dermatitis herpetiformis greifen die Autoantikörper die Transglutaminasen 2 und 3 an, während sie bei Pemphigoid-Erkrankungen gegen Strukturproteine der dermoepidermalen Junktionszone gerichtet sind. Die Analyse einer periläsionalen Biopsie mittels direkter Immunfluoreszenzmikroskopie (IF-Mikroskopie) stellt zwar nach wie vor den diagnostischen Goldstandard dar, mittlerweile sind jedoch verschiedene Tests allgemein verfügbar, die eine serologische Diagnosefindung für den Großteil der Patienten ermöglichen. Zur serologischen Standarddiagnostik gehört die indirekte IF auf Affenösophagus und NaCl-separierter Spalthaut. Die Spezifität der Autoantikörper kann mit ELISA-Systemen, die auf rekombinanten Formen der immundominanten Regionen der Zielantigene basieren, sowie indirekter IF-Mikroskopie anhand multivarianter Tests mit mehreren multivariate näher charakterisiert werden. Diese serologischen Tests werden durch verschiedene hauseigene Immunoblotting- und ELISA-Systeme ergänzt, die nur in spezialisierten Laboratorien verfügbar sind. In diesem Review geben wir einen Überblick über neue Entwicklungen bei der Diagnose von BAIDs und beschreiben moderne Diagnoseverfahren für diese Krankheitsgruppe.
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Affiliation(s)
- Nina van Beek
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | - Detlef Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | - Enno Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck.,Lübecker Institut für Experimentelle Dermatologie (LIED), Universität zu Lübeck
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108
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Nesmond S, Muller C, Le Naour R, Viguier M, Bernard P, Antonicelli F, Le Jan S. Characteristic Pattern of IL-17RA, IL-17RB, and IL-17RC in Monocytes/Macrophages and Mast Cells From Patients With Bullous Pemphigoid. Front Immunol 2019; 10:2107. [PMID: 31572359 PMCID: PMC6749098 DOI: 10.3389/fimmu.2019.02107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/21/2019] [Indexed: 01/08/2023] Open
Abstract
Inflammation is largely implicated in bullous pemphigoid (BP), the most frequent skin auto-immune blistering disease. IL-17, essentially IL-17A/F, has been involved in blister formation through regulation of protease production, and its specific serum profile within BP was related to disease outcome. However, relationships between IL-17 family ligands and receptors are quite complex with six different IL-17 isoforms, and five different receptors. We here aimed at clarifying the contribution of the IL-17 axis in BP by characterizing not only the expression of IL-17 receptor (IL-17R) members within immune cells isolated from BP patients (PMNs, n = 9; T-lymphocytes, n = 10; and monocytes, n = 10) but also the expression of IL-17 isoforms in sera (n = 83), and blister fluid (n = 31) of BP patients. We showed that at diagnosis, IL-17RA and IL-17RC expression were significantly increased in monocytes isolated from BP patients as compared to those from control subjects (p = 0.006 and p = 0.016, respectively). Notably, both IL-17RA and IL-17RC mRNA expression remained elevated in BP monocytes at time of relapse. We further demonstrated a significant increase of all IL-17 isoforms tested in BP blister fluid compared with BP serum (IL-17A, p < 0.0001; IL-17A/F, p < 0.0001; IL-17B, p = 0.0023; IL-17C, p = 0.0022; IL-17E, p < 0.0001). Among all, IL-17B was the only cytokine for which a significant decreased concentration within blister fluid was observed in BP patients with severe disease compared to patients with moderate disease (p = 0.012). We further evidenced a significant negative correlation between IL-17B levels and blister/erosion BPDAI subscore (r = −0.52, p = 0.003). We finally identified mast cells as a potential target of IL-17B in lesional skin of BP patients. In conclusion, we showed here that IL-17RA and IL-17RC expression in monocyte was associated with disease activity and evidenced in situ a negative correlation between BP disease activity and IL-17B, whose effects could be mediated by IL-17RB expressed by mast cell in BP lesional skin.
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Affiliation(s)
- Stéphane Nesmond
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France
| | - Céline Muller
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France
| | - Richard Le Naour
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France.,Department of Biological Sciences, UFR Pharmacy, University of Reims Champagne-Ardenne, Reims, France
| | - Manuelle Viguier
- Department of Dermatology, University Hospital, University of Reims-Champagne-Ardenne, Reims, France
| | - Philippe Bernard
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France.,Department of Dermatology, University Hospital, University of Reims-Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims-Champagne-Ardenne, Reims, France
| | - Sébastien Le Jan
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France
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109
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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.
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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
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110
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Messingham KN, Miller AD, Narayanan NS, Connell SJ, Fairley JA. Demographics and Autoantibody Profiles of Pemphigoid Patients with Underlying Neurologic Diseases. J Invest Dermatol 2019; 139:1860-1866.e1. [PMID: 30876802 PMCID: PMC6910721 DOI: 10.1016/j.jid.2019.01.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 12/25/2022]
Abstract
Bullous pemphigoid (BP) is an autoantibody-mediated blistering disease that is often associated with neurologic disease. BP antibodies target two epidermal adhesion molecules, known as BP180 and BP230. Homologues to these proteins are found in the brain, and it is hypothesized that neurologic disease leads to the production of autoantibodies that can cross-react with their cutaneous forms. To better understand the link between BP and neurologic disease, we evaluated primary demographic features (age, sex, race, ethnicity, and elapsed time between onset of skin symptoms and BP diagnosis), severity of BP, and IgG and IgE autoantibody levels in BP control individuals and patients with BP with preceding Parkinson disease, dementia, and stroke. The main findings of this study are that patients with BP with preceding neurologic disease have a shorter elapsed time between onset of skin disease and BP diagnosis and that patients with preceding Parkinson disease or dementia, but not stroke, are significantly older than patients with BP without neurologic disease. However, no significant differences in clinical presentation, BP severity scores, or autoantibody (IgG and IgE) responses were observed among the groups. These findings suggest that, despite the age difference, the clinical phenotype of BP is not affected by preceding neurologic disease.
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Affiliation(s)
| | - Adam D Miller
- Department of Dermatology, University of Iowa, Iowa City, Iowa, USA
| | | | - Samuel J Connell
- Department of Dermatology, University of Iowa, Iowa City, Iowa, USA
| | - Janet A Fairley
- Department of Dermatology, University of Iowa, Iowa City, Iowa, USA; Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA.
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111
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Wang M, Lehman JS, Camilleri MJ, Drage LA, Wieland CN. Circulating bullous pemphigoid autoantibodies in the setting of negative direct immunofluorescence findings for bullous pemphigoid: A single-center retrospective review. J Am Acad Dermatol 2019; 81:472-479. [PMID: 30928465 DOI: 10.1016/j.jaad.2019.03.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/11/2019] [Accepted: 03/24/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) autoantibody levels are generally elevated in patients with BP but can be present nonspecifically in patients without BP. OBJECTIVE To analyze the clinical findings of patients with elevated BP180 or BP230 autoantibody levels and negative direct immunofluorescence (DIF) study findings. METHODS We retrospectively reviewed records of patients seen at our institution during January 1, 2005-December 31, 2015, who were positive for BP180 or BP230 autoantibodies and had a negative DIF study finding. These patients' demographic characteristics and BP180 and BP230 levels were compared with those of a BP control group who were positive for BP180 or BP230 autoantibodies and had positive DIF study findings. RESULTS We identified 208 patients with BP autoantibodies but without positive DIF study findings. These patients' mean age and enzyme-linked immunosorbent assay values were significantly lower than those of the control group. Dermatitis was the most common final clinical diagnosis. Of the 208 patients, 41 (19.7%) had at least 2 years' follow-up. Four patients had positive DIF results upon repeating the test and ultimately received pemphigoid diagnoses. LIMITATIONS Retrospective design with limited follow-up. CONCLUSION Patients might harbor serum BP autoantibodies in the context of a wide range of dermatoses. Low positive BP180 and BP230 autoantibody levels should not be overinterpreted as evidence for BP in the setting of a negative DIF.
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Affiliation(s)
- Michael Wang
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Camilleri
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Lisa A Drage
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Carilyn N Wieland
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota.
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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.
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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
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113
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Daniel B, Murrell D. Review of autoimmune blistering diseases: the Pemphigoid diseases. J Eur Acad Dermatol Venereol 2019; 33:1685-1694. [DOI: 10.1111/jdv.15679] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/03/2019] [Indexed: 12/30/2022]
Affiliation(s)
- B.S. Daniel
- St Vincent's Hospital Melbourne Australia
- St George Hospital Sydney Australia
- University of New South Wales Sydney Australia
| | - D.F. Murrell
- St George Hospital Sydney Australia
- University of New South Wales Sydney Australia
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114
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Polansky M, Eisenstadt R, DeGrazia T, Zhao X, Liu Y, Feldman R. Rituximab therapy in patients with bullous pemphigoid: A retrospective study of 20 patients. J Am Acad Dermatol 2019; 81:179-186. [DOI: 10.1016/j.jaad.2019.03.049] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/18/2019] [Accepted: 03/20/2019] [Indexed: 10/27/2022]
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115
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Tasanen K, Varpuluoma O, Nishie W. Dipeptidyl Peptidase-4 Inhibitor-Associated Bullous Pemphigoid. Front Immunol 2019; 10:1238. [PMID: 31275298 PMCID: PMC6593303 DOI: 10.3389/fimmu.2019.01238] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/16/2019] [Indexed: 12/18/2022] Open
Abstract
Bullous pemphigoid (BP) is an organ-specific autoantibody-mediated blistering skin disease that mainly affects the elderly. Typical clinical features include the widespread blisters, often preceded by and/or associated with itchy urticarial or eczema-like lesions. BP patients have circulating autoantibodies against BP180 and/or the plakin family protein BP230 both of which are components of hemidesmosomes in basal keratinocytes. Most BP autoantibodies particularly target the epitopes within the non-collagenous NC16A domain of BP180. Clinical findings and murine models of BP have provided evidence of a pathogenic role of anti-NC16A autoantibodies. However, it is largely unknown what triggers the breakage of immunotolerance against BP180 in elderly individuals. The incidence of BP has been increased over the past two decades in several countries. Aside from aging populations, the factors behind this phenomenon are still not fully understood. Neurodegenerative diseases such as multiple sclerosis, Parkinson's disease, and certain dementias are independent risk factors for BP. Recently several case reports have described BP in patients with diabetes mellitus (DM) patients who have been treated with dipeptidyl peptidase-4 inhibitors (DPP-4i or gliptins), which are a widely used class of anti-DM drugs. The association between the use of DPP-4is, particularly vildagliptin, and BP risk has been confirmed by several epidemiological studies. Evidence suggests that cases of gliptin-associated BP in Japan display certain features that set them apart from cases of “regular” BP. These include a “non-inflammatory” phenotype, targeting by antibodies of different immunodominant BP180 epitopes, and a specific association with the human leukocyte antigen (HLA) types. However, recent studies in European populations have found no major differences between the clinical and immunological characteristics of gliptin-associated BP and “regular” BP. The DPP-4 protein (also known as CD26) is ubiquitously expressed and has multiple functions in various cell types. The different effects of the inhibition of DPP-4/CD26 activity include, for example, tissue modeling and regulation of inflammatory cells such as T lymphocytes. Although the pathomechanism of gliptin-associated BP is currently largely unknown, investigation of the unique effect of gliptins in the induction of BP may provide a novel route to better understanding of how immunotolerance against BP180 breaks down in BP.
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Affiliation(s)
- Kaisa Tasanen
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Outi Varpuluoma
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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116
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Lamberts A, Rashid H, Pas HH, Diercks GFH, Meijer JM, Horváth B. Pemphigoid variants affecting the skin. Clin Exp Dermatol 2019; 44:721-727. [PMID: 31099084 DOI: 10.1111/ced.13984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2019] [Indexed: 11/29/2022]
Abstract
Pemphigoid diseases are autoimmune subepidermal blistering diseases affecting the skin and mucous membranes, which are caused by autoantibodies targeting structural hemidesmosomal proteins or hemidesmosome-associated proteins. Variants of pemphigoid can be differentiated based on targeted antigens and clinical aspects. In this review, we will discuss pemphigoid variants that predominantly affect the skin, and provide clinicians with clues to diagnosis.
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Affiliation(s)
- A Lamberts
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - H Rashid
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - H H Pas
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - G F H Diercks
- 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
| | - J M Meijer
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - B Horváth
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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117
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Berkani N, Joly P, Golinski ML, Colliou N, Lim A, Larbi A, Riou G, Caillot F, Bernard P, Bedane C, Delaporte E, Chaby G, Dompmartin A, Hertl M, Calbo S, Musette P. B-cell depletion induces a shift in self antigen specific B-cell repertoire and cytokine pattern in patients with bullous pemphigoid. Sci Rep 2019; 9:3525. [PMID: 30837635 PMCID: PMC6401188 DOI: 10.1038/s41598-019-40203-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 02/04/2019] [Indexed: 11/08/2022] Open
Abstract
Bullous Pemphigoid is the most common auto-immune bullous skin disease. It is characterized by the production of auto-antibodies directed against 2 proteins of the hemi-desmosome (BP180 and BP230). We assessed the efficacy and mechanisms of action of rituximab, an anti-CD20 monoclonal antibody, in 17 patients with severe and relapsing type of bullous pemphigoid. The phenotype, cytokine gene expression, and rearrangement of BP180-specific B-cell receptor genes were performed over 2 years following treatment. At the end of the study, 5 patients had died, 3 had withdrawn from the study, and 9 patients were in complete remission. The one- and two-year relapse rates were 44.1% (95% Confidence Interval (CI): 21.0-76.0%) and 66.5%, (95% CI: 38.4-91.4%), respectively. Phenotypic analyses confirmed dramatic B-cell depletion, which lasted for 9 to 12 months. The ELISA values of serum anti-BP180 antibodies and the frequency of BP180-specific circulating B cells decreased dramatically following treatment, which paralleled the improvement of skin lesions. During B-cell reconstitution, a polyclonal IgM repertoire appeared and a shift in the rearrangement of the B-cell receptor genes of BP180-specific circulating B cells was observed. Concurrently, we observed a decrease of IL-15, IL-6 and TNFα expressing BP180-specific B cells, and the emergence of IL-10 and IL-1RA-expressing BP180-specific IgM+ B cells in patients in complete remission off therapy, suggesting the functional plasticity of BP180-specific auto-immune B cells after rituximab treatment.
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Affiliation(s)
| | - Pascal Joly
- Normandie University, UNIROUEN, INSERM U1234, Rouen, France
- Normandie University, UNIROUEN, Rouen University Hospital, Department of Dermatology, French reference center for autoimmune bullous diseases, F76000, Rouen, France
| | - Marie-Laure Golinski
- Normandie University, UNIROUEN, INSERM U1234, Rouen, France
- Normandie University, UNIROUEN, Rouen University Hospital, Department of Dermatology, French reference center for autoimmune bullous diseases, F76000, Rouen, France
| | | | - Annick Lim
- Immunoscope plateform, Pasteur Institute, Paris, France
| | - Anis Larbi
- Singapore Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Gaetan Riou
- Normandie University, UNIROUEN, INSERM U1234, Rouen, France
| | | | - Philippe Bernard
- Department of Dermatology, Reims University Hospital, Reims, France
| | - Christophe Bedane
- Department of Dermatology, Limoges University Hospital, Limoges, France
| | | | - Guillaume Chaby
- Department of Dermatology, Amiens University Hospital, Amiens, France
| | - Anne Dompmartin
- Department of Dermatology, Caen University Hospital, Caen, France
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | | | - Philippe Musette
- Normandie University, UNIROUEN, Rouen University Hospital, Department of Dermatology, French reference center for autoimmune bullous diseases, F76000, Rouen, France.
- INSERM U976, Saint Louis Hospital, Paris, France.
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118
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Abstract
Subepidermal autoimmune bullous diseases of the skin and mucosae comprise a large group of chronic diseases, including bullous pemphigoid, pemphigoid gestationis, mucous membrane pemphigoid, linear IgA bullous dermatosis, epidermolysis bullosa acquisita, and anti-p200 pemphigoid. These diseases are characterized by an antibody response toward structural components of the basement membrane zone, resulting in subepidermal blistering. The epidemiological features of these diseases vary substantially in different regions of the world. Observational studies investigating comorbidities and associations among patients with these diseases are inconsistent and sometimes inconclusive. This review provides a brief overview regarding each one of the subepidermal autoimmune bullous diseases. In addition, it summarizes the most recent understanding of the epidemiological features and associations of this group of organ-specific autoimmune diseases.
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, POB 9602, 31096, Haifa, Israel.
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119
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Plaquevent M, Tétart F, Fardet L, Ingen-Housz-Oro S, Valeyrie-Allanore L, Bernard P, Hebert V, Roussel A, Avenel-Audran M, Chaby G, D'Incan M, Ferrier-Le-Bouedec MC, Duvert-Lehembre S, Picard-Dahan C, Jeudy G, Collet E, Labeille B, Morice C, Richard MA, Bourgault-Villada I, Litrowski N, Bara C, Mahe E, Prost-Squarcioni C, Alexandre M, Quereux G, Bernier C, Soria A, Thomas-Beaulieu D, Pauwels C, Dereure O, Benichou J, Joly P. Higher Frequency of Dipeptidyl Peptidase-4 Inhibitor Intake in Bullous Pemphigoid Patients than in the French General Population. J Invest Dermatol 2018; 139:835-841. [PMID: 30543900 DOI: 10.1016/j.jid.2018.10.045] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 10/17/2018] [Accepted: 10/29/2018] [Indexed: 12/13/2022]
Abstract
Dipeptidyl peptidase-4 inhibitors have been suspected to induce bullous pemphigoid (BP). The objective of this study was to compare the observed frequency of gliptin intake in a large sample of 1,787 BP patients diagnosed between 2012 and 2015 in France, with the expected frequency after indirect age standardization on 225,412 individuals extracted from the database of the National Healthcare Insurance Agency. The secondary objective was to assess the clinical characteristics and the course of gliptin-associated BP, depending on whether gliptin was continued or stopped. The observed frequencies of intake of the whole gliptin class and that of vildagliptin in the BP population were higher than those in the general population after age standardization (whole gliptin class: 6.0%; 95% confidence interval = 4.9-7.1% vs. 3.6%, observed-to-expected drug intake ratio = 1.7; 95% confidence interval = 1.4-2.0; P < 0.0001; vildagliptin = 3.3%; 95% confidence interval = 2.5-4.1% vs. 0.7%, ratio = 4.4; 95% confidence interval = 3.5-5.7; P < 0.0001). The association of any gliptin+metformin was also higher than in the general population, ratio = 1.8 (95% confidence interval = 1.3-2.4; P < 0.0001). Gliptin-associated BP had no specific clinical characteristics. Gliptin was stopped in 48 (45.3%) cases. Median duration to achieve disease control, rate, and delay of relapse were not different whether gliptin was stopped or continued. This study strongly supports the association between gliptin intake, particularly vildagliptin, and the onset of BP.
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Affiliation(s)
- Marthe Plaquevent
- Department of Dermatology, Rouen University Hospital and Institut National de la Santé et de la Recherche Médicale U1234, Centre de Référence des Maladies Bulleuses Autoimmunes, Normandie University, Rouen, France.
| | - Florence Tétart
- Department of Dermatology, Rouen University Hospital and Institut National de la Santé et de la Recherche Médicale U1234, Centre de Référence des Maladies Bulleuses Autoimmunes, Normandie University, Rouen, France
| | - Laurence Fardet
- Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France
| | - Saskia Ingen-Housz-Oro
- Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France
| | - Laurence Valeyrie-Allanore
- Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France
| | | | - Vivien Hebert
- Department of Dermatology, Rouen University Hospital and Institut National de la Santé et de la Recherche Médicale U1234, Centre de Référence des Maladies Bulleuses Autoimmunes, Normandie University, Rouen, France
| | - Aude Roussel
- Department of Dermatology, Orleans Hospital, Orléans, France
| | | | - Guillaume Chaby
- Department of Dermatology, University of Amiens, Amiens, France
| | - Michel D'Incan
- Department of Dermatology, University of Clermont-Ferrand, Clermont-Ferrand, France
| | | | | | | | - Geraldine Jeudy
- Department of Dermatology Dijon University Hospital, Dijon, France
| | - Evelyne Collet
- Department of Dermatology Dijon University Hospital, Dijon, France
| | - Bruno Labeille
- Department of Dermatology, University of Saint Etienne, Saint Etienne, France
| | - Cécile Morice
- Department of Dermatology, University of Caen, Caen, France
| | - Marie-Aleth Richard
- Department of Dermatology, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Unité Mixte de Recherche 911, Institut National de la Santé et de la Recherche Médicale CRO2, Marseille, France
| | | | - Noémie Litrowski
- Department of Dermatology, Jacques Monod Hospital, Montivilliers, France
| | - Corina Bara
- Department of Dermatology, Le Mans General Hospital, Le Mans, France
| | - Emmanuel Mahe
- Department of Dermatology, Argenteuil Hospital, Argenteuil, France
| | | | - Marina Alexandre
- Department of Dermatology, University of Paris XIII, Bobigny, France
| | - Gaelle Quereux
- Department of Dermatology, University of Nantes, Nantes, France
| | - Claire Bernier
- Department of Dermatology, University of Nantes, Nantes, France
| | - Angèle Soria
- Department of Dermatology and Allergology, Tenon Hospital, Paris, France
| | | | - Christine Pauwels
- Department of Dermatology, Poissy-Saint Germain Hospital, Saint-Germain-en-Laye, France
| | - Olivier Dereure
- Department of Dermatology, University of Montpellier, Montpellier, France
| | - Jacques Benichou
- Department of Biostatistics, Rouen University Hospital and Institut National de la Santé et de la Recherche Médicale U1219, Normandie University, Rouen, France
| | - Pascal Joly
- Department of Dermatology, Rouen University Hospital and Institut National de la Santé et de la Recherche Médicale U1234, Centre de Référence des Maladies Bulleuses Autoimmunes, Normandie University, Rouen, France
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Downregulation of aquaporin 3 in bullous pemphigoid patients. Arch Dermatol Res 2018; 311:93-97. [DOI: 10.1007/s00403-018-1884-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/24/2018] [Accepted: 11/30/2018] [Indexed: 11/24/2022]
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121
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Witte M, Zillikens D, Schmidt E. Diagnosis of Autoimmune Blistering Diseases. Front Med (Lausanne) 2018; 5:296. [PMID: 30450358 PMCID: PMC6224342 DOI: 10.3389/fmed.2018.00296] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/05/2018] [Indexed: 12/11/2022] Open
Abstract
Autoimmune skin blistering diseases (AIBD) are characterized by autoantibodies that are directed against structural proteins in the skin and adjacent mucous membranes. Some clinical signs are typical for a specific AIBD, however, correct diagnosis requires the detection of tissue-bound or circulating autoantibodies. The gold standard for diagnosis of AIBD is the detection of autoantibodies or complement component 3 by direct immunofluorescence (DIF) microscopy of a perilesional biopsy. Circulating antibodies can be detected via indirect immunofluorescence (IIF) microscopy of different tissue substrates including human skin, monkey esophagus, and more recently, recombinant forms of the different target antigens. Latter are also employed in various commercial ELISA systems and by immunoblotting in in-house assays available in specialized laboratories. ELISA systems are also particularly valuable for monitoring of the disease activity during the disease course which can be helpful for treatment decisions. Exact diagnosis is essential for both treatment and prognosis, since some AIBD are associated with malign tumors such as paraneoplastic pemphigus and anti-laminin 332 mucous membrane pemphigoid. This review presents clinical and immunopathological features of AIBD for the state-of the art diagnosis of these disorders.
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Affiliation(s)
- Mareike Witte
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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122
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Rozenblat M, Halaj A, Rozenblat T, Fisher S, Sah M, Dodiuk-Gad RP, Ziv M. Mortality and risk factors among Israeli bullous pemphigoid patients. Arch Dermatol Res 2018; 311:19-27. [PMID: 30382340 DOI: 10.1007/s00403-018-1875-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 10/25/2018] [Accepted: 10/27/2018] [Indexed: 10/28/2022]
Abstract
There are differences concerning reported mortality rates and prognostic factors of bullous pemphigoid (BP) patients in different studies. Our objectives were to evaluate the mortality rates and prognostic factors among Israeli BP patients compared to matched control subjects. Three age- and sex-matched patients without BP (n = 261) who were treated in our clinic were selected and compared to BP patients (n = 87). Mean survival period of the BP group was 4.1 years (95% CI: 3.3-4.8 years) and 5.9 years among the non-BP group (95% CI: 5.6-6.3 years). The 1-year mortality rate was 24.1% for the BP group and 6.5% for the control group. In multivariate analysis, age above 80 was a significant risk factor for mortality [HR 3.22 (95% CI, 1.15-8.96), p = 0.03], while statins intake had a protective role [HR 0.36 (95% CI, 0.15-0.88), p = 0.03]. In univariant analysis, dementia [HR 2.44 (95% CI, 1.02-5.99), p = 0.04] was a risk factor. In conclusion, BP patients' mortality is correlated to increasing age at diagnosis, dementia, and statins use. Statins' protective role is newly discussed in the literature.
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Affiliation(s)
- Mati Rozenblat
- Department of Dermatology, Emek Medical Center, Afula, Israel.
| | - Awad Halaj
- Department of Dermatology, Emek Medical Center, Afula, Israel
| | - Tal Rozenblat
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shani Fisher
- Department of Dermatology, Emek Medical Center, Afula, Israel
| | - Mohammad Sah
- Department of Dermatology, Emek Medical Center, Afula, Israel
| | | | - Michael Ziv
- Department of Dermatology, Emek Medical Center, Afula, Israel
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123
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Dermatitis Herpetiformis and Celiac Disease Increase the Risk of Bullous Pemphigoid. J Invest Dermatol 2018; 139:600-604. [PMID: 30612975 DOI: 10.1016/j.jid.2018.10.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 12/21/2022]
Abstract
Bullous pemphigoid (BP) and dermatitis herpetiformis (DH) are autoimmune bullous skin diseases. DH has been described to evolve into BP and the two diseases can have overlapping clinical appearances and diagnostic findings, but the association between DH and BP has not previously been studied in a large population. To evaluate DH and celiac disease as risk factors for BP, we conducted a retrospective case-control study of patients with BP and matched controls with basal cell carcinoma diagnosed in Finland between 1997 and 2013. A total of 3,397 patients with BP and 12,941 controls were included in the study. Forty-one (1.2%) BP patients and 7 (0.1%) controls had preceding DH. Diagnosed DH increased the risk of BP 22-fold (odds ratio = 22.30; 95% confidence interval = 9.99-49.70) and celiac disease 2-fold (odds ratio = 2.54; 95% confidence interval = 1.64-3.92) compared to controls. Eighteen (43.9%) of the patients who had DH and subsequent BP had bought dapsone during the 2 years prior to their BP diagnosis. Mean time between diagnosed DH and BP was 3 years. We conclude that diagnosis of DH is associated with a striking increase in the risk for BP.
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124
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Skin Disease and Neurological Conditions of the Elderly. CURRENT GERIATRICS REPORTS 2018. [DOI: 10.1007/s13670-018-0263-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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125
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Holtsche MM, Goletz S, van Beek N, Zillikens D, Benoit S, Harman K, Walton S, English J, Sticherling M, Chapman A, Levell NJ, Groves R, Williams HC, König IR, Schmidt E. Prospective study in bullous pemphigoid: association of high serum anti-BP180 IgG levels with increased mortality and reduced Karnofsky score. Br J Dermatol 2018; 179:918-924. [PMID: 29607480 DOI: 10.1111/bjd.16553] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is a subepidermal blistering disease characterized by autoantibodies against the two hemidesmosomal proteins, BP180 (type XVII collagen) and BP230. The multicentre prospective BLISTER (Bullous Pemphigoid Steroids and Tetracyclines) trial randomized 253 patients with BP to compare the benefits and harms between initial treatment with doxycycline or prednisolone. OBJECTIVES To analyse distinct autoantibody profiles for the prediction of the disease course in a well-characterized cohort of BP sera. METHODS One hundred and forty-three patients of the BLISTER trial consented to participate in this serological study. Sera taken at baseline were analysed by (i) indirect immunofluorescence, (ii) anti-BP180 NC16A (16th noncollagenous domain) and anti-BP230 enzyme-linked immunosorbent assay and (iii) immunoblotting with various substrates. Results were then linked with clinical parameters including age, Karnofsky score, number of blisters, related adverse events and mortality. RESULTS Disease activity correlated with immunoglobulin (Ig)G anti-BP180 levels but not with levels of anti-BP230 IgG and anti-BP180 IgE. High levels of both anti-BP180 IgG and anti-BP230 IgG were associated with a low Karnofsky score. The presence of anti-BP230 IgG was more frequent in older patients. Those with higher total IgE serum levels suffered from fewer adverse events. Higher IgG anti-BP180 levels were associated with an increased 1-year mortality rate. CONCLUSIONS Analysis of the autoantibody profile is not only of diagnostic relevance but may also be helpful in predicting the course of the disease.
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Affiliation(s)
- M M Holtsche
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - S Goletz
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - N van Beek
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - S Benoit
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - K Harman
- Department of Dermatology, University Hospitals Leicester, Leicester Royal Infirmary, Leicester, U.K
| | - S Walton
- Castle Hill Hospital, Cottingham, U.K
| | - J English
- Queen's Medical Centre, University Hospital, Nottingham, U.K
| | - M Sticherling
- Department of Dermatology, University of Erlangen, Erlangen, Germany
| | - A Chapman
- Queen Elizabeth Hospital, Greenwich, London, U.K
| | - N J Levell
- Norfolk and Norwich University Hospital, Norwich, U.K
| | - R Groves
- Department of Immunodermatology, St John's Institute of Dermatology, St Thomas' Hospital, London, U.K
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
| | - I R König
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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126
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Zumelzu C, Alexandre M, Le Roux C, Weber P, Guyot A, Levy A, Aucouturier F, Mignot-Grootenboer S, Caux F, Maubec E, Prost-Squarcioni C. Mucous Membrane Pemphigoid, Bullous Pemphigoid, and Anti-programmed Death-1/ Programmed Death-Ligand 1: A Case Report of an Elderly Woman With Mucous Membrane Pemphigoid Developing After Pembrolizumab Therapy for Metastatic Melanoma and Review of the Literature. Front Med (Lausanne) 2018; 5:268. [PMID: 30320114 PMCID: PMC6170650 DOI: 10.3389/fmed.2018.00268] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 09/03/2018] [Indexed: 12/15/2022] Open
Abstract
An 83-year-old patient developed erosions and a blister of the gingival mucous membrane, 6 months after discontinuation of the anti-programmed death-1 (anti PD-1) pembrolizumab therapy administered for 10 months for a metastatic melanoma. A diagnosis of mild mucous membrane pemphigoid (MMP) was made. Complete remission of MMP was rapidly obtained with minimal therapy (doxycycline). MMP remained in complete remission after a 3-month follow-up since discontinuation of the doxycycline therapy and no evidence of relapse of the melanoma was observed after a 14-month follow-up since discontinuation of the pembrolizumab therapy. The widespread use of anti PD-1 and anti-programmed death-ligand-1 (PD-L1) in several malignancies reveals new adverse events. MMP describes a group of chronic, inflammatory, mucous membrane-predominant, subepithelial auto-immune blistering diseases. It is clinically distinct from bullous pemphigoid another autoimmune blistering disease but shares some immunological similarities with it. Twenty-nine cases of bullous pemphigoid associated with anti PD-1/PD-L1 have been reported in the literature and one of MMP. Here, we described the case of a MMP developed after pembrolizumab and discussed the accountability of anti PD-1/PD-L1 in our case and the previous reported bullous pemphigoid and MMP cases using the Begaud system scoring.
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Affiliation(s)
- Coralie Zumelzu
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Marina Alexandre
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Christelle Le Roux
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Patricia Weber
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Alexis Guyot
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Annie Levy
- Department of Pathology, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Françoise Aucouturier
- Department of Immunology and Referral Center for Auto-Immune Bullous Diseases MALIBUL, Saint-Louis Hospital, AP-HP, Paris, France
| | - Sabine Mignot-Grootenboer
- Department of Immunology and Referral Center for Auto-Immune Bullous Diseases MALIBUL, Bichat Hospital, AP-HP, Paris, France
| | - Frédéric Caux
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Eve Maubec
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Catherine Prost-Squarcioni
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France.,Department of Pathology, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France.,Department of Histology, UFR Léonard de Vinci, University Paris 13, Bobigny, France
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Chakievska L, Holtsche MM, Künstner A, Goletz S, Petersen BS, Thaci D, Ibrahim SM, Ludwig RJ, Franke A, Sadik CD, Zillikens D, Hölscher C, Busch H, Schmidt E. IL-17A is functionally relevant and a potential therapeutic target in bullous pemphigoid. J Autoimmun 2018; 96:104-112. [PMID: 30219389 DOI: 10.1016/j.jaut.2018.09.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/04/2018] [Accepted: 09/07/2018] [Indexed: 01/19/2023]
Abstract
IL-17A has been identified as key regulatory molecule in several autoimmune and chronic inflammatory diseases followed by the successful use of anti-IL-17 therapy, e.g. in ankylosing spondylitis and psoriasis. Bullous pemphigoid (BP) is the most frequent autoimmune blistering disease with a high need for more specific, effective and safe treatment options. The aim of this study was to clarify the pathophysiological importance of IL-17A in BP. We found elevated numbers of IL-17A+ CD4+ lymphocytes in the peripheral blood of BP patients and identified CD3+ cells as major source of IL-17A in early BP skin lesions. IL17A and related genes were upregulated in BP skin and exome sequencing of 51 BP patients revealed mutations in twelve IL-17-related genes in 18 patients. We have subsequently found several lines of evidence suggesting a significant role of IL-17A in the BP pathogenesis: (i) IL-17A activated human neutrophils in vitro, (ii) inhibition of dermal-epidermal separation in cryosections of human skin incubated with anti-BP180 IgG and subsequently with anti-IL-17A IgG-treated leukocytes, (iii) close correlation of serum IL-17A levels and diseases activity in a mouse model of BP, (iv) IL17A-deficient mice were protected against autoantibody-induced BP, and (v) pharmacological inhibition of lL-17A reduced the induction of BP in mice. Our data give evidence for a pivotal role of IL-17A in the pathophysiology of BP and advocate IL-17A inhibition as potential novel treatment for this disease.
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Affiliation(s)
- Lenche Chakievska
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Maike M Holtsche
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Axel Künstner
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Stephanie Goletz
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | | | - Diamant Thaci
- Institute for Inflammation Medicine, University of Lübeck, Lübeck, Germany
| | - Saleh M Ibrahim
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Ralf J Ludwig
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Andre Franke
- Institute of Clinical Molecular Biology, University of Kiel, Kiel, Germany
| | | | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Christoph Hölscher
- Division of Infection Immunology, Research Center Borstel, Borstel, Germany
| | - Hauke Busch
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany; Department of Dermatology, University of Lübeck, Lübeck, Germany.
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128
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Hübner F, Kasperkiewicz M, Knuth-Rehr D, Shimanovich I, Hübner J, Süfke S, Muck P, Zillikens D, Schmidt E. Adjuvante Behandlung des schweren/refraktären bullösen Pemphigoids mit Protein-A-Immunadsorption. J Dtsch Dermatol Ges 2018; 16:1109-1119. [PMID: 30179332 DOI: 10.1111/ddg.13642_g] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 02/27/2018] [Indexed: 11/28/2022]
Abstract
HINTERGRUND Mittels Immunadsorption (IA) können Immunglobuline und Immunkomplexe aus dem Plasma entfernt werden. Während dieses therapeutische Verfahren beim Pemphigus vulgaris bereits etabliert ist, wird es bei anderen blasenbildenden Autoimmundermatosen bislang nur sporadisch eingesetzt. Das bullöse Pemphigoid (BP) spricht zwar meist gut auf eine Therapie mit topischen und systemischen Kortikosteroiden an, jedoch könnte bei Patienten mit ausgedehnten Läsionen oder bei einem Rezidiv die rasche Reduktion der pathogenen Autoantikörper eine effektive adjuvante Therapie darstellen. PATIENTEN UND METHODIK Fallserie mit 20 Patienten (13 Frauen, 7 Männer; mittleres Alter 78,6 Jahre; 56-94 Jahre) mit schwerem oder refraktärem BP, die zusätzlich zur Basistherapie bestehend aus Prednisolon (0,25-0,5 mg/kg/d), Dapson (1,0-1,5 mg/kg/d) und Clobetasolpropionat 0,05 % Salbe (läsional 2 x/d) mit Protein-A-IA (3 IAs an aufeinander folgenden Tagen) behandelt wurden. Die durchschnittliche Nachbeobachtungszeit betrug 33,6 Monate (1-84 Monate). ERGEBNISSE Bei der Mehrzahl der Patienten zeigte sich ein rascher und langandauernder Therapieeffekt. Nach einem Monat befanden sich acht Patienten (von 19 nachbeobachteten, 42 %) und zum Zeitpunkt des letzten Kontakts (nach 1-84 Monaten) 13 Patienten (68 %) in kompletter Remission. Die Anti-BP180-Autoantikörper wurden nicht nur initial (um 92 %) gesenkt, sondern lagen auch nach ein und drei Monaten im Mittel bei 26 % und 13 % des Wertes vor Therapiebeginn (p < 0,001). Bei Differenzierung in vortherapierte bzw. therapienaive Patienten zeigten sich in beiden Subgruppen signifikante Absenkungen der Anti-BP180NC16A-Antikörper-Spiegel zu allen Zeitpunkten. Unerwünschte Ereignisse traten bei dreizehn (65 %) der 20 Patienten auf, Drei der Ereignisse waren schwer und zwei davon wahrscheinlich oder möglicherweise in Zusammenhang mit der IA. SCHLUSSFOLGERUNGEN Die IA ist eine effektive adjuvante Therapieoption bei den in aller Regel älteren Patienten mit einem schweren und/oder therapierefraktären BP.
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Affiliation(s)
- Franziska Hübner
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | | | - Diana Knuth-Rehr
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | - Iakov Shimanovich
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | - Joachim Hübner
- Institut für Sozialmedizin und Epidemiologie, Universität zu Lübeck
| | - Sven Süfke
- Medizinische Klinik I, Universität zu Lübeck
| | - Philip Muck
- Medizinische Klinik I, Universität zu Lübeck
| | - Detlef Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | - Enno Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck.,Lübecker Institut für Experimentielle Dermatologie (LIED), Universität zu Lübeck
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129
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Goebeler M. Blasenbildende Autoimmunerkrankungen: zielgerichtete Diagnostik und multimodale Therapie. J Dtsch Dermatol Ges 2018; 16:1071-1072. [DOI: 10.1111/ddg.13645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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130
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Kridin K, Ludwig RJ. The Growing Incidence of Bullous Pemphigoid: Overview and Potential Explanations. Front Med (Lausanne) 2018; 5:220. [PMID: 30177969 PMCID: PMC6109638 DOI: 10.3389/fmed.2018.00220] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/17/2018] [Indexed: 12/25/2022] Open
Abstract
Bullous pemphigoid (BP) is the most common type of subepidermal autoimmune bullous diseases. BP characteristically affects the elderly and is seen mainly in patients older than 70 years. While the annual incidence of BP has been estimated to be between 2.4 and 23 cases per million in the general population, it rises exponentially to 190-312 cases per million in individuals older than 80 years. In addition, a growing body of evidence reports a remarkable trend of increased incidence of BP, showing a 1.9- to 4.3-fold rise over the past two decades. This demonstrable increase warrants a higher awareness of the increased risk to develop BP. This review summarizes the current understanding of the epidemiological features of BP and sheds light on the putative explanations for its growing incidence.
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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131
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Amber KT, Murrell DF, Schmidt E, Joly P, Borradori L. Autoimmune Subepidermal Bullous Diseases of the Skin and Mucosae: Clinical Features, Diagnosis, and Management. Clin Rev Allergy Immunol 2018; 54:26-51. [PMID: 28779299 DOI: 10.1007/s12016-017-8633-4] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Autoimmune subepidermal blistering diseases of the skin and mucosae constitute a large group of sometimes devastating diseases, encompassing bullous pemphigoid, gestational pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, and anti-p200 pemphigoid. Their clinical presentation is polymorphic. These autoimmune blistering diseases are associated with autoantibodies that target distinct components of the basement membrane zone of stratified epithelia. These autoantigens represent structural proteins important for maintenance of dermo-epidermal integrity. Bullous pemphigoid (BP) is the most common subepidermal autoimmune blistering disease of the skin and mucosae. Although the disease typically presents with a generalized blistering eruption associated with itch, atypical variants with either localized bullous lesions or "non-bullous" presentations are observed in approximately 20% of patients. A peculiar form of BP typically associated with pregnancy is pemphigoid gestationis. In anti-p200 pemphigoid, patients present with tense blisters on erythematosus or normal skin resembling BP, with a predilection for acral surfaces. These patients have antibodies targeting the 200-kDa basement membrane protein. Epidermolysis bullosa is a rare autoimmune blistering disease associated with autoantibodies against type VII collagen that can have several phenotypes including a classical form mimicking dystrophic epidermolysis bullosa, an inflammatory presentation mimicking BP, or mucous membrane pemphigoid-like lesions. Mucous membrane pemphigoid (MMP) is the term agreed upon by international consensus for an autoimmune blistering disorder, which affects one or more mucous membrane and may involve the skin. The condition involves a number of different autoantigens in the basement membrane zone. It may result in severe complications from scarring, such as blindness and strictures. Diagnosis of these diseases relies on direct immunofluorescence microscopy studies and immunoserological assays. Management of affected patients is often challenging. We will here review the clinical and immunopathological features as well as the pathophysiology of this group of organ-specific autoimmune diseases. Finally, we will discuss the diagnostic approach and the principles of management in clinical practice.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of California Irvine Health, 118 Med Surg 1, Irvine, CA, 92697, USA.
| | - Dedee F Murrell
- Department of Dermatology, St. George Hospital, Gray Street, Kogarah, Sydney, NSW, Australia
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Pascal Joly
- Department of Dermatology, INSERM U901, University of Rouen, Rouen, France
| | - Luca Borradori
- Department of Dermatology, University of Bern, Bern, Switzerland
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132
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Amber KT, Valdebran M, Kridin K, Grando SA. The Role of Eosinophils in Bullous Pemphigoid: A Developing Model of Eosinophil Pathogenicity in Mucocutaneous Disease. Front Med (Lausanne) 2018; 5:201. [PMID: 30042946 PMCID: PMC6048777 DOI: 10.3389/fmed.2018.00201] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease which carries a significant mortality and morbidity. While historically BP has been characterized as an IgG driven disease mediated by anti-BP180 and BP230 IgG autoantibodies, developments in recent years have further elucidated the role of eosinophils and IgE autoantibodies. In fact, eosinophil infiltration and eosinophilic spongiosis are prominent features in BP. Several observations support a pathogenic role of eosinophils in BP: IL-5, eotaxin, and eosinophil-colony stimulating factor are present in blister fluid; eosinophils line the dermo-epidermal junction (DEJ) in the presence of BP serum, metalloprotease-9 is released by eosinophils at the site of blisters; eosinophil degranulation proteins are found on the affected basement membrane zone as well as in serum corresponding with clinical disease; eosinophil extracellular DNA traps directed against the basement membrane zone are present, IL-5 activated eosinophils cause separation of the DEJ in the presence of BP serum; and eosinophils are the necessary cell required to drive anti-BP180 IgE mediated skin blistering. Still, it is likely that eosinophils contribute to the pathogenesis of BP in numerous other ways that have yet to be explored based on the known biology of eosinophils. We herein will review the role of eosinophils in BP and provide a framework for understanding eosinophil pathogenic mechanisms in mucocutaneous disease.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of California, Irvine, Irvine, CA, United States
| | - Manuel Valdebran
- Department of Dermatology, University of California, Irvine, Irvine, CA, United States
| | - Khalaf Kridin
- Department of Dermatology, Rambam Healthcare Campus, Haifa, Israel
| | - Sergei A Grando
- Department of Dermatology, University of California, Irvine, Irvine, CA, United States.,Departments of Dermatology and Biological Chemistry, Institute for Immunology, University of California, Irvine, Irvine, CA, United States
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133
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Kridin K, Schwartz N, Cohen AD, Zelber-Sagi S. Mortality in bullous pemphigoid: A systematic review and meta-analysis of standardized mortality ratios. J Dermatol 2018; 45:1094-1100. [DOI: 10.1111/1346-8138.14503] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 05/07/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Khalaf Kridin
- Department of Dermatology; Rambam Health Care Campus; Haifa Israel
| | - Naama Schwartz
- School of Public Health; University of Haifa; Haifa Israel
| | - Arnon D. Cohen
- Department of Quality Measurements and Research; Chief Physician's Office; Clalit Health Services; Tel Aviv Israel
- Siaal Research Center for Family Medicine and Primary Care; Faculty of Health Sciences; Ben-Gurion University of the Negev; Beer-Sheeva Israel
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134
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Wang CX, Anadkat MJ. SnapshotDx Quiz: May 2018. J Invest Dermatol 2018; 138:e39. [PMID: 29681391 DOI: 10.1016/j.jid.2018.03.1506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Cynthia X Wang
- Washington University School of Medicine, St. Louis, Missouri
| | - Milan J Anadkat
- Washington University School of Medicine, St. Louis, Missouri; Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri.
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135
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Abstract
Chronic pruritus (>6 week's duration) in the geriatric population (≥65 years old), is an increasing health care problem. The pathophysiologic predisposing factors are abnormalities of the epidermal barrier, immune system, and nervous system. Causes can be dichotomized into histaminergic and nonhistaminergic pruritus. Topical treatments are generally safe. Systemic treatments are chosen depending on the condition, comorbid diseases, and drug interactions. Treatment options are limited. Progress has been made in identifying itch-selective mediators over the last decade. Numerous new medications are currently undergoing clinical trials and they are anticipated to enter the clinics in the near future.
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136
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Karsten CM, Beckmann T, Holtsche MM, Tillmann J, Tofern S, Schulze FS, Heppe EN, Ludwig RJ, Zillikens D, König IR, Köhl J, Schmidt E. Tissue Destruction in Bullous Pemphigoid Can Be Complement Independent and May Be Mitigated by C5aR2. Front Immunol 2018; 9:488. [PMID: 29599777 PMCID: PMC5862877 DOI: 10.3389/fimmu.2018.00488] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/23/2018] [Indexed: 12/12/2022] Open
Abstract
Bullous pemphigoid (BP), the most frequent autoimmune bullous disorder, is a paradigmatic autoantibody-mediated disease associated with autoantibodies against BP180 (type XVII collagen, Col17). Several animal models have been developed that reflect important clinical and immunological features of human BP. Complement activation has been described as a prerequisite for blister formation, however, the recent finding that skin lesions can be induced by anti-Col17 F(ab')2 fragments indicates complement-independent mechanisms to contribute to blister formation in BP. Here, C5-/- mice injected with anti-Col17 IgG showed a reduction of skin lesions by about 50% associated with significantly less skin-infiltrating neutrophils compared to wild-type mice. Reduction of skin lesions and neutrophil infiltration was seen independently of the employed anti-Col17 IgG dose. Further, C5ar1-/- mice were protected from disease development, whereas the extent of skin lesions was increased in C5ar2-/- animals. Pharmacological inhibition of C5a receptor 1 (C5aR1) by PMX53 led to reduced disease activity when applied in a prophylactic setting. In contrast, PMX-53 treatment had no effect when first skin lesions had already developed. While C5aR1 was critically involved in neutrophil migration in vitro, its role for Col17-anti-Col17 IgG immune complex-mediated release of reactive oxygen species from neutrophils was less pronounced. Our data demonstrate that complement-dependent and -independent mechanisms coexist in anti-Col17-autoantibody-mediated tissue destruction. C5aR1 and C5aR2 seem to play opposing roles in this process with C5aR1 exerting its primary effect in recruiting inflammatory cells to the skin during the early phase of the disease. Further studies are required to fully understand the role of C5aR2 in autoantibody-mediated skin inflammation.
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MESH Headings
- Animals
- Autoantibodies/genetics
- Autoantibodies/immunology
- Autoantigens/genetics
- Autoantigens/immunology
- Complement C5/genetics
- Complement C5/immunology
- Mice
- Mice, Inbred BALB C
- Mice, Knockout
- Neutrophil Infiltration
- Neutrophils/immunology
- Neutrophils/pathology
- Non-Fibrillar Collagens/genetics
- Non-Fibrillar Collagens/immunology
- Pemphigoid, Bullous/chemically induced
- Pemphigoid, Bullous/genetics
- Pemphigoid, Bullous/immunology
- Pemphigoid, Bullous/pathology
- Peptides, Cyclic/pharmacology
- Reactive Oxygen Species/immunology
- Receptor, Anaphylatoxin C5a/antagonists & inhibitors
- Receptor, Anaphylatoxin C5a/genetics
- Receptor, Anaphylatoxin C5a/immunology
- Skin/immunology
- Skin/pathology
- Collagen Type XVII
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Affiliation(s)
| | - Tina Beckmann
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | | | - Jenny Tillmann
- Institute of Systemic Inflammation, University of Lübeck, Lübeck, Germany
| | - Sabrina Tofern
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Franziska S. Schulze
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Eva Nina Heppe
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Ralf J. Ludwig
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Inke R. König
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Jörg Köhl
- Institute of Systemic Inflammation, University of Lübeck, Lübeck, Germany
- Division of Immunobiology, Cincinnati Children’s Hospital and College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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137
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Clapé A, Muller C, Gatouillat G, Le Jan S, Barbe C, Pham BN, Antonicelli F, Bernard P. Mucosal Involvement in Bullous Pemphigoid Is Mostly Associated with Disease Severity and to Absence of Anti-BP230 Autoantibody. Front Immunol 2018; 9:479. [PMID: 29662486 PMCID: PMC5890137 DOI: 10.3389/fimmu.2018.00479] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 02/22/2018] [Indexed: 01/10/2023] Open
Abstract
Bullous pemphigoid (BP) is the most common autoimmune bullous disease and typically affects the elderly. Binding of specific autoantibodies to BP180/230 hemidesmosomal components induces an inflammatory response leading to skin blister formation. Unusual manifestations of BP include additional mucous membrane involvement, without pathophysiological knowledge associated to the formation of these lesions. We here performed a prospective study on series of consecutive BP patients with (n = 77) and without (n = 18) mucosal involvements at baseline to further investigate why some BP patients display mucosal lesion and other not. Analysis of disease activity showed that BP patients with mucosal involvement displayed a higher total BP Disease Area Index (BPDAI) score (P = 0.008), but also higher skin and blister/erosion BPDAI scores (P = 0.02 and P = 0.001, respectively). By contrast, the erythema/urticaria BPDAI score was identical between the two groups of patients. The erythema/urticaria BPDAI score, but not the blister/erosion BPDAI score, was correlated with the serum concentration of anti-BP180 NC16A autoantibodies in patients with mucosal involvement. In multivariate analysis, the absence of anti-BP230 autoantibody was the only factor independently associated with mucosal involvement (OR 7.8; 95% CI, 3.1–19.6) (P < 0.0001). Analysis of the distribution of BP patients according to BPDAI scores revealed a shift toward higher blister/erosion BPDAI scores for BP patients with mucosal involvement. This study indicates that mucosal lesions are clinically mainly related to disease severity and immunologically to the absence of anti-BP230 antibodies.
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Affiliation(s)
- Ariane Clapé
- Laboratory of Dermatology, Faculty of Medicine, EA7319, University of Reims Champagne-Ardenne, Reims, France.,Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Céline Muller
- Laboratory of Dermatology, Faculty of Medicine, EA7319, University of Reims Champagne-Ardenne, Reims, France
| | - Grégory Gatouillat
- Laboratory of Dermatology, Faculty of Medicine, EA7319, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Sébastien Le Jan
- Laboratory of Dermatology, Faculty of Medicine, EA7319, University of Reims Champagne-Ardenne, Reims, France
| | - Coralie Barbe
- Clinical Research Unit, Reims University Hospital, Reims, France
| | - Bach-Nga Pham
- Laboratory of Dermatology, Faculty of Medicine, EA7319, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, Faculty of Medicine, EA7319, University of Reims Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims Champagne-Ardenne, Reims, France
| | - Philippe Bernard
- Laboratory of Dermatology, Faculty of Medicine, EA7319, University of Reims Champagne-Ardenne, Reims, France.,Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
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138
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Shen S, Ke Y, Dang E, Fang H, Chang Y, Zhang J, Zhu Z, Shao S, Qiao P, Zhang T, Qiao H, Wang G. Semaphorin 4D from CD15 + Granulocytes via ADAM10-Induced Cleavage Contributes to Antibody Production in Bullous Pemphigoid. J Invest Dermatol 2018; 138:588-597. [PMID: 29054606 DOI: 10.1016/j.jid.2017.09.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 09/07/2017] [Accepted: 09/11/2017] [Indexed: 12/17/2022]
Abstract
Autoreactive B-cell activation and antibody production are critical events for the development of bullous pemphigoid (BP). However, the mechanism that is involved in the modulation of B-cell activation and autoantibody generation has not been fully understood. Semaphorin 4D (Sema4D, or CD100) plays important roles in immune regulation related to B cells, but its implications in BP remain obscure. The aim of our study was to characterize Sema4D and the underlying mechanism contributing to the autoimmune features of BP. We found that soluble Sema4D (sSema4D) levels were elevated and correlated with disease severity and activity in serum and blister fluids from patients with BP. Additionally, Sema4D-expressing cells accumulated in subepidermal blisters of BP lesions. In patient-derived peripheral blood mononuclear cells, by promoting the differentiation of B cells into plasmablasts, sSema4D boosted anti-BP180/anti-BP230 antibody production in a time- and dose-dependent manner, which may be attributed to CD72-mediated activation of Akt/NF-κB phosphorylated (p-)65/ERK cascades in B cells. We determined that a disintegrin and metalloproteinase 10 is a proteolytic enzyme for the cleavage of sSema4D from CD15+ granulocytes instead of T cells, which is probably responsible for the high concentration of sSema4D in BP blister fluid and serum. These findings suggest that Sema4D is a crucial participant in BP pathogenesis.
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Affiliation(s)
- Shengxian Shen
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yao Ke
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China; Department of Oral Medicine, School of Stomatology, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Erle Dang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hui Fang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yuqian Chang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jieyu Zhang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhenlai Zhu
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shuai Shao
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Pei Qiao
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Tongmei Zhang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hongjiang Qiao
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Gang Wang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China.
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139
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Fang H, Zhang Y, Li N, Wang G, Liu Z. The Autoimmune Skin Disease Bullous Pemphigoid: The Role of Mast Cells in Autoantibody-Induced Tissue Injury. Front Immunol 2018; 9:407. [PMID: 29545809 PMCID: PMC5837973 DOI: 10.3389/fimmu.2018.00407] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/14/2018] [Indexed: 01/09/2023] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune and inflammatory skin disease associated with subepidermal blistering and autoantibodies directed against the hemidesmosomal components BP180 and BP230. Animal models of BP were developed by passively transferring anti-BP180 IgG into mice, which recapitulates the key features of human BP. By using these in vivo model systems, key cellular and molecular events leading to the BP disease phenotype are identified, including binding of pathogenic IgG to its target, complement activation of the classical pathway, mast cell degranulation, and infiltration and activation of neutrophils. Proteinases released by infiltrating neutrophils cleave BP180 and other hemidesmosome-associated proteins, causing DEJ separation. Mast cells and mast cell-derived mediators including inflammatory cytokines and proteases are increased in lesional skin and blister fluids of BP. BP animal model evidence also implicates mast cells in the pathogenesis of BP. However, recent studies questioned the pathogenic role of mast cells in autoimmune diseases such as multiple sclerosis, rheumatoid arthritis, and epidermolysis bullosa acquisita. This review highlights the current knowledge on BP pathophysiology with a focus on a potential role for mast cells in BP and mast cell-related critical issues needing to be addressed in the future.
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Affiliation(s)
- Hui Fang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yang Zhang
- Department of Dermatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Dermatology, The Second Hospital, School of Medicine, Xi’an Jiaotong University, Xi’an, China
| | - Ning Li
- Department of Dermatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Gang Wang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Zhi Liu
- Department of Dermatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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140
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Lamberts A, Euverman HI, Terra JB, Jonkman MF, Horváth B. Effectiveness and Safety of Rituximab in Recalcitrant Pemphigoid Diseases. Front Immunol 2018. [PMID: 29520266 PMCID: PMC5827539 DOI: 10.3389/fimmu.2018.00248] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction Rituximab (RTX) is a monoclonal antibody targeting CD20, a transmembrane protein expressed on B cells, causing B cell depletion. RTX has shown great efficacy in studies of pemphigus vulgaris, but data of pemphigoid diseases are limited. Objective To assess the effectiveness and safety of RTX in pemphigoid diseases. Methods The medical records of 28 patients with pemphigoid diseases that were treated with RTX were reviewed retrospectively. Early and late endpoints, defined according to international consensus, were disease control (DC), partial remission (PR), complete remission (CR), and relapses. Safety was measured by reported adverse events. Results Patients with bullous pemphigoid (n = 8), mucous membrane pemphigoid (n = 14), epidermolysis bullosa acquisita (n = 5), and linear IgA disease (n = 1) were included. Treatment with 500 mg RTX (n = 6) or 1,000 mg RTX (n = 22) was administered on days 1 and 15. Eight patients received additional 500 mg RTX at months 6 and 12. Overall, DC was achieved in 67.9%, PR in 57.1%, and CR in 21.4% of the cases. During follow-up, 66.7% patients relapsed. Repeated treatment with RTX led to remission (PR or CR) in 85.7% of the retreated cases. No significant difference in response between pemphigoid subtypes was found. IgA-dominant cases (n = 5) achieved less DC (20 vs. 81.3%; p = 0.007), less PR (20 vs. 62.5%; p = 0.149), and less CR (0 vs. 18.8%; p = 0.549) compared to IgG-dominant cases (n = 16). Five severe adverse events and three deaths were reported. One death was possibly related to RTX and one death was disease related. Conclusion RTX can be effective in recalcitrant IgG-dominant pemphigoid diseases, however not in those where IgA is dominant.
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Affiliation(s)
- Aniek Lamberts
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - H Ilona Euverman
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jorrit B Terra
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Marcel F Jonkman
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Barbara Horváth
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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141
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Vildagliptin Significantly Increases the Risk of Bullous Pemphigoid: A Finnish Nationwide Registry Study. J Invest Dermatol 2018; 138:1659-1661. [PMID: 29427585 DOI: 10.1016/j.jid.2018.01.027] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 01/31/2018] [Accepted: 01/31/2018] [Indexed: 01/22/2023]
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142
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Milinković MV, Janković S, Medenica L, Nikolić M, Reljić V, Popadić S, Janković J. Incidence of autoimmune bullous diseases in Serbia: a 20-year retrospective study. J Dtsch Dermatol Ges 2018; 14:995-1005. [PMID: 27767273 DOI: 10.1111/ddg.13081] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND OBJECTIVES While most previous surveys on the clinico-epidemiological features of autoimmune bullous diseases (AIBDs) have predominantly focused on a single disease entity or just one disease group, there have been only few studies examining the incidence of various AIBDs. In the present study, we set out to determine the spectrum of AIBDs, to estimate the incidence of the most common AIBDs, and to examine their temporal trends in Central Serbia over a period of 20 years. METHODS We retrospectively recruited 1,161 new AIBD cases diagnosed in Central Serbia during the period from January 1991 to December 2010. The diagnosis was based on strict clinical, histological, and immunohistological evaluation. RESULTS The incidence rates were: 4.35 per million population/year (pmp/year) for pemphigus, 4.47 pmp/year for pemphigoid, 1.42 pmp/year for dermatitis herpetiformis (DH), 0.25 pmp/year for linear IgA disease, and 0.08 pmp/year for epidermolysis bullosa acquisita. In the period observed, age-adjusted incidence rates significantly increased for pemphigus and particularly for pemphigoid, whereas they decreased, albeit not significantly, for DH. CONCLUSIONS For the first time, our study evaluates the incidence rates of the entire spectrum of AIBDs in Serbia, and examines their temporal trends over a 20-year period. To the best of our knowledge, our finding of similar incidence rates for pemphigus and pemphigoid has previously not been reported.
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Affiliation(s)
- Mirjana V Milinković
- Clinic of Dermatovenereology, Clinical Center of Serbia, Belgrade, Serbia. .,Department of Dermatovenereology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
| | - Slavenka Janković
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ljiljana Medenica
- Clinic of Dermatovenereology, Clinical Center of Serbia, Belgrade, Serbia.,Department of Dermatovenereology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miloš Nikolić
- Clinic of Dermatovenereology, Clinical Center of Serbia, Belgrade, Serbia.,Department of Dermatovenereology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vesna Reljić
- Clinic of Dermatovenereology, Clinical Center of Serbia, Belgrade, Serbia
| | - Svetlana Popadić
- Clinic of Dermatovenereology, Clinical Center of Serbia, Belgrade, Serbia.,Department of Dermatovenereology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Janko Janković
- Institute of Social Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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143
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Eckardt J, Eberle FC, Ghoreschi K. Diagnostic value of autoantibody titres in patients with bullous pemphigoid. Eur J Dermatol 2018; 28:3-12. [PMID: 29336324 DOI: 10.1684/ejd.2017.3166] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common autoimmune blistering disease of the skin requiring skin and serum tests for a precise diagnosis. OBJECTIVES We analysed the sensitivity and specificity of BP-relevant parameters and the value of autoantibody titres during follow-up of BP patients. MATERIALS & METHODS In a retrospective single-centre study, we included 200 consecutive patients with BP and 400 non-BP patients, and evaluated the test results of patients' serum and skin. In addition, we followed patients' autoantibody titres and clinical characteristics. RESULTS BP180-ELISA revealed the highest sensitivity (85.0%; specificity: 93.9%), while BP230-ELISA demonstrated the lowest sensitivity (55.5%; specificity: 92.9%). Direct and indirect immunofluorescence showed comparable results for sensitivity (77.2%/72.7%) and specificity (94.9%/93.7%). The sensitivity for skin histology was 76.3% (specificity: 81.3%). Longitudinal analysis showed significant changes in autoantibody titres. CONCLUSIONS BP diagnostics should include serum tests for BP autoantibodies and skin immunofluorescence. Skin histology is supportive for diagnosis. Autoantibody titres are markers for disease activity.
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Affiliation(s)
- Julia Eckardt
- Department of Dermatology, University Medical Centre, Eberhard Karls University Tübingen, Germany
| | - Franziska C Eberle
- Department of Dermatology, University Medical Centre, Eberhard Karls University Tübingen, Germany
| | - Kamran Ghoreschi
- Department of Dermatology, University Medical Centre, Eberhard Karls University Tübingen, Germany
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144
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Mason JM, Chalmers JR, Godec T, Nunn AJ, Kirtschig G, Wojnarowska F, Childs M, Whitham D, Schmidt E, Harman K, Walton S, Chapman A, Williams HC. Doxycycline compared with prednisolone therapy for patients with bullous pemphigoid: cost-effectiveness analysis of the BLISTER trial. Br J Dermatol 2018; 178:415-423. [PMID: 28940316 DOI: 10.1111/bjd.16006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune blistering skin disorder associated with significant morbidity and mortality. Doxycycline and prednisolone to treat bullous pemphigoid were compared within a randomized controlled trial (RCT). OBJECTIVES To compare the cost-effectiveness of doxycycline-initiated and prednisolone-initiated treatment for patients with BP. METHODS Quality-of-life (EuroQoL-5D-3L) and resource data were collected as part of the BLISTER trial: a multicentre, parallel-group, investigator-blinded RCT. Within-trial analysis was performed using bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, informing a probabilistic assessment of incremental treatment cost-effectiveness from a health service perspective. RESULTS In the base case, there was no robust difference in costs or QALYs per patient at 1 year comparing doxycycline- with prednisolone-initiated therapy [net cost £959, 95% confidence interval (CI) -£24 to £1941; net QALYs -0·024, 95% CI -0·088 to 0·041]. However, the findings varied by baseline blister severity. For patients with mild or moderate blistering (≤ 30 blisters) net costs and outcomes were similar. For patients with severe blistering (> 30 blisters) net costs were higher (£2558, 95% CI -£82 to £5198) and quality of life poorer (-0·090 QALYs, 95% CI -0·22 to 0·042) for patients starting on doxycycline. The probability that doxycycline would be cost-effective for those with severe pemphigoid was 1·5% at a willingness to pay of £20 000 per QALY. CONCLUSIONS Consistently with the clinical findings of the BLISTER trial, patients with mild or moderate blistering should receive treatment guided by the safety and effectiveness of the drugs and patient preference - neither strategy is clearly a preferred use of National Health Service resources. However, prednisolone-initiated treatment may be more cost-effective for patients with severe blistering.
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Affiliation(s)
- J M Mason
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, U.K
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
| | - T Godec
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, U.K
| | - A J Nunn
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, U.K
| | - G Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
| | - F Wojnarowska
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7BN, U.K
| | - M Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, QMC, Nottingham, NG7 2UH, U.K
| | - D Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, QMC, Nottingham, NG7 2UH, U.K
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - K Harman
- Dermatology Department, Leicester Royal Infirmary, University Hospitals Leicester, Leicester, LE1 5WW, U.K
| | - S Walton
- Castle Hill Hospital, Castle Road, Cottingham, Hull, HU16 5JQ, U.K
| | - A Chapman
- Queen Elizabeth Hospital, Greenwich, London, SE18 4QH, U.K
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
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145
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Jeon HW, Yun SJ, Lee SC, Won YH, Lee JB. Mortality and Comorbidity Profiles of Patients with Bullous Pemphigoid in Korea. Ann Dermatol 2017; 30:13-19. [PMID: 29386827 PMCID: PMC5762471 DOI: 10.5021/ad.2018.30.1.13] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 04/18/2017] [Accepted: 05/02/2017] [Indexed: 12/26/2022] Open
Abstract
Background Bullous pemphigoid (BP) is a common autoimmune-mediated blistering skin disease that is significantly associated with mortality and morbidity. However, few studies regarding the mortality and comorbidity profiles of BP have been reported in Korea. Objective To evaluate and compare the mortality, comorbidity profiles, and risk factors between patients with BP who visited our clinic and an age-matched general population of Korea. Methods We retrospectively evaluated 103 patients diagnosed with BP between 2006 and 2013 at Chonnam National University Hospital in Gwangju, Korea. Results The 1-year, 2-year, and 5-year mortality rates of the patients were 18.44%, 28.16%, and 42.00%, respectively. The median age was 76 years (range, 41~96 years). The standardized mortality ratio of patients with BP was 1.83 times that of the age- and sex-matched general population of Korea. Old age at the time of diagnosis, cardiac disease and renal disease were associated with increased 5-year mortality. In addition, the prevalence of diabetes, stroke, dementia, and Parkinson's disease was higher among BP patients than in the general population. Conclusion The mortality rate of patients with BP is higher than that of the general Korean population. Korean patients with BP are more likely to have dementia, Parkinson's disease, diabetes, and stroke. Risk factors for increased 5-year mortality include old age at the time of diagnosis and medical comorbidities, especially cardiac disease and renal disease.
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Affiliation(s)
- Hyeon Woo Jeon
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | - Sook Jung Yun
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | - Seung-Chul Lee
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | - Young Ho Won
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | - Jee-Bum Lee
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
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146
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Försti AK, Huilaja L, Schmidt E, Tasanen K. Neurological and psychiatric associations in bullous pemphigoid-more than skin deep? Exp Dermatol 2017; 26:1228-1234. [PMID: 28677172 DOI: 10.1111/exd.13401] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2017] [Indexed: 12/28/2022]
Abstract
In elderly patients, bullous pemphigoid (BP) is associated with several comorbidities; the strongest association occurs between BP and neurological diseases. Different types of dementia, Parkinson's disease, cerebrovascular disorders and epilepsy all have a significant association with BP, but patients with multiple sclerosis have the highest risk of BP. An existing neurological disorder appears to increase the risk for subsequent BP, but an increased risk for developing some neurological diseases has also been reported following BP diagnosis. BP seems to be associated with several psychiatric diseases such as schizophrenia, uni- and bipolar disorder, schizotypal and delusional disorders, and personality disorders, but the risk ratios are usually lower than with neurological diseases. In addition to the skin, the BP autoantigens BP180 and BP230 are expressed in the central nervous system. This finding together with the strong epidemiological association between neurological disorders and BP has led to an assumption that neurodegeneration or neuroinflammation could lead to a cross-reactive immunoresponse between neural and cutaneous antigens and the failure of self-tolerance. A subpopulation of patients with Alzheimer's disease or Parkinson's disease have circulating IgG autoantibodies against BP180, but currently their significance for the development of BP is unclear, because these antineural BP180 antibodies neither bind to the cutaneous basement membrane nor cause BP-like symptoms. Further studies analysing large and well-characterized populations of neurological and psychiatric patients are required to understand better the role of autoimmunization against neural BP autoantigens in the pathogenesis of BP.
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Affiliation(s)
- Anna-Kaisa Försti
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
- Department of Dermatology and Medical Research Center Oulu, Oulu University Hospital, Oulu University Hospital, Oulu, Finland
| | - Laura Huilaja
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
- Department of Dermatology and Medical Research Center Oulu, Oulu University Hospital, Oulu University Hospital, Oulu, Finland
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Kaisa Tasanen
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
- Department of Dermatology and Medical Research Center Oulu, Oulu University Hospital, Oulu University Hospital, Oulu, Finland
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147
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Brulefert A, Le Jan S, Plée J, Durlach A, Bernard P, Antonicelli F, Trussardi-Régnier A. Variation of the epidermal expression of glucocorticoid receptor-beta as potential predictive marker of bullous pemphigoid outcome. Exp Dermatol 2017; 26:1261-1266. [PMID: 28887823 DOI: 10.1111/exd.13444] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2017] [Indexed: 11/29/2022]
Abstract
Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease in Western countries. Although topical and/or systemic glucocorticoids treatment efficacy is widely recognized, up to 30% of patients with BP may undergo a relapse during the first year of treatment. We investigated the protein expression of the total glucocorticoid receptor and GRβ isoform in the skin biopsy specimens from patients with BP and wondered whether such investigation at baseline provided a tool to predict disease outcome. Total GR and GRβ protein expressions were detected by immunohistochemistry at baseline on 12 patients who later relapse and 11 patients who remained on remission in comparison with 14 control patients. The expression of GRβ in the epidermis of patients with BP who later relapse was significantly higher than that in the epidermis of patients with BP controlled upon corticosteroid treatment, which was also higher than control patients. Thus, our results suggest that increased protein expression of GRβ in skin epithelial cells is predictive of reduced steroid treatment efficacy, and therefore of increased risk of disease relapse in patients with BP.
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Affiliation(s)
- Adrien Brulefert
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France
| | - Sébastien Le Jan
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France
| | - Julie Plée
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Anne Durlach
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Laboratory Pol Bouin, Hospital Maison Blanche, University Hospital, Reims Cedex, France
| | - Philippe Bernard
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims Champagne-Ardenne, Reims, France
| | - Aurélie Trussardi-Régnier
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France
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148
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Nonbullous pemphigoid: A systematic review. J Am Acad Dermatol 2017; 78:989-995.e2. [PMID: 29102490 DOI: 10.1016/j.jaad.2017.10.035] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/17/2017] [Accepted: 10/20/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Bullous pemphigoid is an autoimmune disease that typically presents with tense bullae and severe pruritus. However, bullae can be lacking, a subtype termed nonbullous pemphigoid. OBJECTIVE To summarize the reported characteristics of nonbullous pemphigoid. METHODS The EMBASE and MEDLINE databases were searched using "nonbullous pemphigoid" and various synonyms. Case reports and series describing nonbullous pemphigoid were included. RESULTS The search identified 133 articles. After selection, 39 articles were included, presenting 132 cases. Erythematous, urticarial plaques (52.3%) and papules/nodules (20.5%) were the most reported clinical features. The mean age at presentation was 74.9 years. Histopathology was commonly nonspecific. Linear depositions of IgG and/or C3 along the basement membrane zone were found by direct immunofluorescence microscopy in 93.2%. Indirect immunofluorescence on salt-split skin was positive in 90.2%. The mean diagnostic delay was 22.6 months. A minority of patients (9.8%) developed bullae during the reported follow-up. LIMITATIONS Results are mainly based on case reports and small case series. CONCLUSION Nonbullous pemphigoid is an underdiagnosed variant of pemphigoid that most often does not evolve to bullous lesions and mimics other pruritic skin diseases. Greater awareness among physicians is needed to avoid delay in diagnosis.
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149
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Kridin K, Bergman R. Ethnic variations in the epidemiology of bullous pemphigoid in Israel. Int J Dermatol 2017; 57:34-39. [PMID: 29090462 DOI: 10.1111/ijd.13813] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 09/06/2017] [Accepted: 09/21/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND No ethnic or geographic predisposition to bullous pemphigoid (BP) was reported so far. OBJECTIVE To evaluate trends in the incidence of BP in northern Israel, shedding light on differences between two distinct ethnic populations who inhabit the same region, namely Jews and Arabs. METHODS Bullous pemphigoid incidence was retrospectively estimated from January 2000-December 2015 in two Israeli regions with a total population of 1.56 million inhabitants. RESULTS A total of 287 new-onset BP patients (mean age: 77.6 ± 12.1) were identified. The incidence rate was 11.4 per million inhabitants per year (95% CI, 10.2-12.9). The crude incidence rate in Jews was 4.8-fold higher than that in Arabs (16.4 vs. 3.4 cases per million per year, respectively [P < 0.0001]). After adjusting for age, the discrepancy between the two populations diminished (11.7 vs. 8.9 cases per million per year, respectively) but remained statistically significant (P = 0.032). The incidence increased consistently from 7.6 cases per million per year in the calendar period 2000-2005 to 12.6 and 14.3 cases in 2006-2010 and 2011-2015, respectively (P < 0.0001). Bullous pemphigoid patients of Arab ancestry presented with the disease significantly earlier than Jews (69.5 ± 15.3 vs. 78.7 ± 11.1 years, respectively, P = 0.002). CONCLUSIONS The incidence of BP in northern Israel has increased in the last 16 years and is significantly higher among Jews compared to Arabs. The age of presentation is remarkably different between patients belonging to the two populations.
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
| | - Reuven Bergman
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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150
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Sticherling M, Franke A, Aberer E, Gläser R, Hertl M, Pfeiffer C, Rzany B, Schneider S, Shimanovich I, Werfel T, Wilczek A, Zillikens D, Schmidt E. An open, multicentre, randomized clinical study in patients with bullous pemphigoid comparing methylprednisolone and azathioprine with methylprednisolone and dapsone. Br J Dermatol 2017; 177:1299-1305. [PMID: 28494097 DOI: 10.1111/bjd.15649] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Current treatment of bullous pemphigoid (BP) is based on the long-term use of topical and/or systemic corticosteroids, which are associated with a high rate of adverse events and increased mortality. OBJECTIVES To study the corticosteroid-sparing potential of azathioprine and dapsone. METHODS This was a prospective, multicentre, randomized, nonblinded clinical trial that compared the efficacy and safety of two parallel groups of patients with BP treated with oral methylprednisolone 0·5 mg kg-1 per day in combination with either azathioprine 1·5-2·5 mg kg-1 per day or dapsone 1·5 mg kg-1 per day. Nine German and Austrian departments of dermatology included 54 patients based on clinical lesions, positive direct immunofluorescence (IF) microscopy and detection of serum autoantibodies by indirect IF microscopy, immunoblotting or enzyme-linked immunosorbent assay. The primary end point was the time until complete tapering of methylprednisolone, and the most important secondary end point was the cumulative corticosteroid dose. RESULTS In eight patients (five azathioprine, three dapsone), methylprednisolone could be discontinued after a median time of 251 days in the azathioprine group and 81 days in the dapsone group. The median cumulative corticosteroid dose was 2·65 g for azathioprine compared with 1·92 g for dapsone (P = 0·06). The median numbers of days when corticosteroids were applied were 148 and 51, respectively (P = 0·24). No significant difference in the number of adverse events was seen between the treatment arms. Four patients (8%) died within the observation period of 12 months. CONCLUSIONS Due to the lower than intended number of patients, the results of the primary and secondary end points were not or only barely significant. Dapsone appeared to have a moderately higher corticosteroid-sparing potential than azathioprine. The combination regimen of either drug with oral methylprednisolone is associated with a relatively low 1-year mortality in this vulnerable patient population.
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Affiliation(s)
- M Sticherling
- Department of Dermatology, University of Leipzig, Leipzig, Germany.,Department of Dermatology, University of Erlangen, Ulmenweg 18, D-91054, Erlangen, Germany
| | - A Franke
- Center for Clinical Trials, University of Leipzig, Leipzig, Germany
| | - E Aberer
- Department of Dermatology, University of Graz, Graz, Austria
| | - R Gläser
- Department of Dermatology, University of Kiel, Kiel, Germany
| | - M Hertl
- Department of Dermatology, University of Erlangen, Ulmenweg 18, D-91054, Erlangen, Germany.,Department of Dermatology, University of Marburg, Marburg, Germany
| | - C Pfeiffer
- Department of Dermatology, University of Dresden, Dresden, Germany.,Department of Dermatology, University of Ulm, Ulm, Germany
| | - B Rzany
- Department of Dermatology, Charité-Medical University Berlin, Berlin, Germany
| | - S Schneider
- Department of Dermatology, University Münster, Münster, Germany.,Department of Dermatology, University of Mannheim, Mannheim, Germany
| | - I Shimanovich
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - T Werfel
- Department of Dermatology, Medical University, Hannover, Germany
| | - A Wilczek
- Department of Dermatology, University of Leipzig, Leipzig, Germany
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Department of Dermatology, University of Würzburg, Würzburg, Germany
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Department of Dermatology, University of Würzburg, Würzburg, Germany
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