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Didona D, Schmidt MF, Maglie R, Solimani F. Pemphigus and pemphigoids: Clinical presentation, diagnosis and therapy. J Dtsch Dermatol Ges 2023; 21:1188-1209. [PMID: 37587612 DOI: 10.1111/ddg.15174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/11/2023] [Indexed: 08/18/2023]
Abstract
Pemphigus and pemphigoid are two potentially life-threatening groups of autoimmune diseases, characterized by autoantibodies targeting structural components of desmosomes or hemidesmosomes, respectively. Affected patients typically show itchy/painful plaques or blistering skin lesions and/or impairing mucosal blistering and erosions, which may strongly impact their quality of life. Since the milestone work of Walter Lever in 1953, who differentiated these two groups of diseases by histopathological analysis of the level of antibody-mediated skin cleavage, enormous progresses occurred. Achievements made in laboratory diagnostics now allow to identify antigen specific structural proteins of the skin that are targeted by pathogenic autoantibodies. These progresses were accompanied by an increased understanding of the pathogenesis of these diseases thanks to the establishment of animal models reproducing disease and on studies on skin and blood of affected individuals, which have been leading to novel and disease-specific treatments. Yet, given their phenotypical overlap with more common dermatological diseases, correct diagnosis and appropriate treatment are often delayed, in some cases leading to irreversible sequelae, including organ dysfunction (i.e., loss of vision in mucous membrane pemphigoid). Here, we provide a concise overview of the clinical appearance, diagnosis and therapeutic management of pemphigus and pemphigoid diseases.
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Affiliation(s)
- Dario Didona
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Morna F Schmidt
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Aachen, Germany
| | - Roberto Maglie
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - Farzan Solimani
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Germany
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Didona D, Schmidt MF, Maglie R, Solimani F. Pemphigus- und Pemphigoid-Erkrankungen: Klinik, Diagnostik und Therapie: Pemphigus and pemphigoids: Clinical presentation, diagnosis and therapy. J Dtsch Dermatol Ges 2023; 21:1188-1211. [PMID: 37845066 DOI: 10.1111/ddg.15174_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/11/2023] [Indexed: 10/18/2023]
Abstract
ZusammenfassungPemphigus und Pemphigoid sind seltene Autoimmunkrankheiten der Haut mit potenziell lebensbedrohlichem Verlauf. Autoantikörper gegen epidermale und junktionale Strukturproteine (Desmosomen sowie Hemidesmosomen) führen bei Betroffenen typischerweise zu juckenden, schmerzhaften Plaques oder Blasen an der Haut und/oder Blasenbildung und Erosionen der Schleimhäute mit möglicher Einschränkung der Lebensqualität. Seit der bahnbrechenden Arbeit von Walter Lever im Jahr 1953, dem es gelang, mittels histopathologischer Untersuchung diese beiden Krankheitsgruppen anhand des Musters der Antikörper‐vermittelten Blasenbildung zu differenzieren, wurden enorme Fortschritte im Verständnis der Erkrankungen erzielt. Die Errungenschaften in der Labordiagnostik ermöglichten die Identifikation von Zielstrukturen zur präzisen Unterscheidung verschiedener Varianten der bullösen Autoimmunerkrankungen. Diese Fortschritte gingen dank der Entwicklung von Tiermodellen mit einem besseren Verständnis der Pathogenese einher. Außerdem haben Studien an Haut und Blut betroffener Patienten zu neuen und krankheitsspezifischen Behandlungen geführt. Aufgrund ihrer Seltenheit und der klinischen Ähnlichkeit mit anderen dermatologischen Erkrankungen verzögern sich die korrekte Diagnosestellung und die Einleitung einer entsprechenden Therapie häufig, was in einigen Fällen zu irreversiblen Folgeerscheinungen, einschließlich Funktionsstörungen von Organen (zum Beispiel Verlust des Sehvermögens beim Schleimhautpemphigoid) führt. Wir geben hier einen Überblick über das klinische Erscheinungsbild, den Diagnosealgorithmus und das therapeutische Management von Pemphigus‐ und Pemphigoid‐Erkrankungen.
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Affiliation(s)
- Dario Didona
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Marburg, Deutschland
| | - Morna F Schmidt
- Klinik für Dermatologie und Allergologie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Roberto Maglie
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Marburg, Deutschland
- Abteilung für Gesundheitswissenschaften, Abteilung für Dermatologie, Universität Florenz, Florenz, Italien
| | - Farzan Solimani
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, Korporatives Mitglied der Freien Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Deutschland
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Deutschland
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Yaïci R, Roth M, Juergens L, Nawaiseh SA, Burkhard D, Besgen V, Fuest M, Girbardt C, Hampel U, Heichel J, Heiligenhaus A, Herwig-Carl MC, Kakkassery V, Kontopoulou K, Löffler KU, Maier PC, Nölle B, Pach J, Paul S, Pleyer U, Pöllmann M, Saeger M, Schmidt E, Siebelmann S, Sokolenko E, Strudel L, Stübiger N, Tarhan M, Theuersbacher J, van Oterendorp C, Walker M, Wiecha C, Wykrota AA, Geerling G. On the Current Care Situation and Treatment of Ocular Mucous Membrane Pemphigoid in Germany. Klin Monbl Augenheilkd 2023; 240:1077-1083. [PMID: 35609814 DOI: 10.1055/a-1720-1819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Ocular involvement in mucous membrane pemphigoid (MMP) is relatively rare, with a prevalence of 25 cases per million population, equating to approx. 2,100 patients throughout Germany. Diagnosis can be difficult - especially in cases of isolated ocular involvement - and treatment can be complex and lengthy. Immunosuppressants or immunomodulatory drugs are often used. Due to the complexity of diagnosis and treatment, MMP patients are usually referred to specialized centers. The aim of this project was to evaluate the current care situation of patients with ocular MMP in Germany. METHODS A paper-based survey was designed and sent to all university eye clinics and other specialized centers in Germany in April 2020. The survey asked about the existence of a specialized outpatient service, the total annual number of patients with MMP, the annual number of newly diagnosed patients, any interdisciplinary collaboration for diagnostic or therapeutic purposes, as well as the local and systemic therapy used. RESULTS Of a total of 44 clinics, 28 (64%) responded, reporting a total average of 27 ± 42 (0 - 200) patients and 3.6 ± 2.2 (0 - 10) new cases per year. This corresponds to a total of 741 patients. Only nine (32%) of the responding clinics offer specialized MMP clinics. 93% of the centers collaborate with the local dermatology department. 79% perform serological and histological diagnostics in-house. About half of the centers (n = 16) apply a standardized treatment regime. Systemic glucocorticoids (66.7%) are most commonly used, followed by mycophenolate mofetil and dapsone (57.1%), rituximab (33.3%), azathioprine and cyclophosphamide (28.6%), as well as methotrexate (19.0%). The least frequently used treatment is intravenous immunoglobulin (14.3%). CONCLUSION This survey of German ophthalmology departments obtained data from about one third of the estimated total cohort of all patients with MMP in Germany. These are presumed to be exclusively patients with at least one ocular involvement. The complex care of these patients is usually provided in collaboration with a dermatologist and with the use of systemic anti-inflammatory medication. Currently, an ophthalmological MMP register is being established to better record the epidemiology and care situation of this rare disease in Germany and to improve it in the long term.
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Affiliation(s)
- Rémi Yaïci
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Deutschland
| | - Mathias Roth
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Deutschland
| | - Lukas Juergens
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Deutschland
| | - Sami Al Nawaiseh
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Deutschland
| | - Dick Burkhard
- Klinik für Augenheilkunde, Universitätsklinikum der Ruhr-Universität Bochum, Deutschland
| | - Volker Besgen
- Klinik für Augenheilkunde, Universitätsklinikum Gießen und Marburg - Standort Marburg, Deutschland
| | - Matthias Fuest
- Augenheilkunde, Universitätsklinikum Aachen, Deutschland
| | | | - Ulrike Hampel
- Klinik für Augenheilkunde, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Deutschland
| | - Jens Heichel
- Klinik für Augenheilkunde, Universitätsklinikum Halle, Deutschland
| | - Arnd Heiligenhaus
- Uveitis Zentrum, Augenzentrum am St Franziskus-Hospital Münster, Deutschland
| | | | - Vinodh Kakkassery
- Klinik für Augenheilkunde, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Deutschland
| | | | - Karin U Löffler
- Universitäts-Augenklinik, Universitätsklinikum Bonn, Deutschland
| | | | - Bernhard Nölle
- Klinik für Ophthalmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | | | - Sebastian Paul
- Klinik für Augenheilkunde, Universitätsklinikum Greifswald, Deutschland
| | - Uwe Pleyer
- Universitäts-Augenklinik, Charité - Universitätsmedizin Berlin, Deutschland
| | - Michael Pöllmann
- Klinik für Augenheilkunde, Universitätsklinikum Regensburg, Deutschland
| | - Mark Saeger
- Klinik für Ophthalmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Enno Schmidt
- Klinik für Dermatologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Deutschland
| | | | | | - Lisa Strudel
- Klinik für Augenheilkunde, Universitätsklinikum Tübingen, Deutschland
| | - Nicole Stübiger
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Hamburg-Eppendorf, Deutschland
| | - Melih Tarhan
- Klinik für Augenheilkunde, Universitätsklinikum Jena, Deutschland
| | | | | | - Marten Walker
- Universitätsklinik für Augenheilkunde, Klinikum Oldenburg AöR, Deutschland
| | - Carolin Wiecha
- Klinik für Augenheilkunde, Klinikum der Universität München, Deutschland
| | - Agata Anna Wykrota
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes, Homburg/Saar, Deutschland
| | - Gerd Geerling
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Deutschland
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Yaïci R, Roth M, Geerling G. [Ocular mucous membrane pemphigoid]. DIE OPHTHALMOLOGIE 2023; 120:779-790. [PMID: 37318615 DOI: 10.1007/s00347-023-01880-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/16/2023]
Abstract
Mucous membrane pemphigoid refers to a heterogeneous group of autoimmune diseases with subepidermal blister formation that can affect all mucous membranes with varying frequencies. This is a rare disease without any geographic or sexual predisposition that is characterized by recurrent inflammation and progressive scarring. The specific diagnostics can be negative in up to 50% of cases. The diagnosis is predominantly made in patients aged 60-80 years. Ophthalmologists play an important role in the care of affected individuals as the conjunctiva is the second most frequent site of involvement. The treatment is often tedious and primarily consists of long-term systemic immunosuppression.
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Affiliation(s)
- R Yaïci
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - M Roth
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - G Geerling
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
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5
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Johnson KB, Rosenbaum JT, Yarter JT, Broadbent T, Michels KS. A 10-Year Review of the Management of Ocular Mucous Membrane Pemphigoid: A Private Practice Experience. Cornea 2023; 42:565-571. [PMID: 37000702 DOI: 10.1097/ico.0000000000003071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/12/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Ocular mucous membrane pemphigoid (OcMMP) is a rare and potentially blinding condition for which consensus treatment guidelines do not exist. The purpose of this study was to assess the effectiveness and safety of various immunomodulatory agents in the treatment of OcMMP in a private practice setting. METHODS We conducted a 10-year retrospective chart review of patients managed with OcMMP (n = 22). The median age at diagnosis was 73 (range: 35-91) years, and 59% (13/22) of patients were female. Visual acuity, Foster stage, and adverse effects (AEs) were documented. Treatment outcomes for each treatment episode were qualified at 3 months as complete response (CR), response (R), or failure (F). After 3 months, CR was then further subqualified as sustained CR, reactivation after initial CR, or AE after initial CR. The Fisher exact test P values were calculated for each outcome in comparison with mycophenolate. RESULTS Twenty patients were treated with an immunomodulatory agent for a total of 55 treatment episodes. In comparison to dapsone, mycophenolate was more likely to achieve sustained CR (50% vs. 0%, P = 0.022) and R (100% vs. 50%, P = 0.007), and less likely to fail (0% vs. 50%, P = 0.007). Dapsone was also more likely to be discontinued because of AEs than mycophenolate (40% vs. 6%, P = 0.041). CONCLUSIONS Mycophenolate is a superior first-line agent to dapsone in the treatment of OcMMP. Although not statistically significant, mycophenolate trends toward superiority over methotrexate as well. Mycophenolate is very effective when used in combination with rituximab. Azathioprine remains a reasonable second-line agent.
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Affiliation(s)
- Kasey B Johnson
- Washington State University, Elson S. Floyd College of Medicine, Spokane, WA
| | - James T Rosenbaum
- Oregon Health and Science University, Casey Eye Institute, School of Medicine, Portland, OR
- Legacy Health System, Devers Eye Institute, Portland, OR
| | - Jason T Yarter
- University of Washington, School of Medicine, Spokane, WA; and
| | | | - Kevin S Michels
- Washington State University, Elson S. Floyd College of Medicine, Spokane, WA
- Northwest Eyelid and Orbital Specialists, Spokane, WA
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6
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Rousset L, Bohelay G, Gille T, Le Roux-Villet C, Kambouchner M, Levy A, Brauner M, Tandjaoui H, Aucouturier F, Mignot S, Caux F, Prost-Squarcioni C, Alexandre M. Bronchial involvement in mucous membrane pemphigoid: 2 cases and a literature review. Ann Dermatol Venereol 2023; 150:64-70. [PMID: 36435654 DOI: 10.1016/j.annder.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/05/2022] [Accepted: 08/30/2022] [Indexed: 11/25/2022]
Affiliation(s)
- L Rousset
- Department of Dermatology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France; Referral Centre for Autoimmune Blistering Diseases (MALIBUL), France
| | - G Bohelay
- Department of Dermatology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France; Referral Centre for Autoimmune Blistering Diseases (MALIBUL), France
| | - T Gille
- Department of Physiology and Functional Explorations, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France; Inserm U1272 "Hypoxia and the Lung", UFR SMBH Léonard de Vinci, Paris 13 University, France
| | - C Le Roux-Villet
- Department of Dermatology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France; Referral Centre for Autoimmune Blistering Diseases (MALIBUL), France
| | - M Kambouchner
- Department of Pathology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - A Levy
- Department of Pathology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - M Brauner
- Department of Radiology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - H Tandjaoui
- Department of Pulmonology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - F Aucouturier
- Department of Immunology, Saint-Louis Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 7 University, 75010 Paris, France
| | - S Mignot
- Department of Immunology, Bichat Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 7 University, 75018 Paris, France
| | - F Caux
- Department of Dermatology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France; Referral Centre for Autoimmune Blistering Diseases (MALIBUL), France
| | - C Prost-Squarcioni
- Department of Dermatology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France; Referral Centre for Autoimmune Blistering Diseases (MALIBUL), France; Histology Laboratory, UFR SMBH Léonard de Vinci, Paris 13 University, Bobigny, France
| | - M Alexandre
- Department of Dermatology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France; Referral Centre for Autoimmune Blistering Diseases (MALIBUL), France.
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7
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Huang SC, Chiu TM, Lee CY, Chang HC, Wu WJ, Gau SY. Researching trends in pemphigoid diseases: A bibliometric study of the top 100 most cited publications. Front Med (Lausanne) 2023; 9:1088083. [PMID: 36698818 PMCID: PMC9868262 DOI: 10.3389/fmed.2022.1088083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/09/2022] [Indexed: 01/11/2023] Open
Abstract
Background In the field of autoimmune and inflammatory disorders, different approaches were applied to provide information regarding disease activity, comorbidities, epidemiological reports and risk factors. However, no previous studies had thoroughly analyzed the research trend in the field, and the bibliometric analysis focusing on pemphigoid diseases was available. The objective of the current study was to evaluate the current research trend in the field. Methods A search has been conducted for the Web of Science database based on various subcategories of pemphigoid diseases. Detailed information including articles' publication types, Author information, citation, and publication information was attained for further analysis. Results Within the 6,995 studies, the top 100 most-cited articles were extracted for analysis. Among the top 100 studies, 70% of the studies focused on bullous pemphigoid. More than 60% of the top 100 studies were studies with original data. Furthermore, 30% of the studies were guidelines and narrative reviews. For the issues primarily focused on, most of the high-impact studies described the molecular mechanism of pemphigoid diseases (26%), managements (19%), risk factors of pemphigoid diseases (17%). Additionally, some other studies provided general review or discussed about the issue of epidemiology, diagnosis/definition, comorbidities and clinical characteristics of pemphigoid diseases. Conclusion This comprehensive bibliographic study of pemphigoid diseases provided an overview of current research focuses in the field. Topics such as disease management, molecular mechanism of pathogenesis, and drug-inducing pemphigoid diseases were highly mentioned in the most-cited studies. For researchers and clinicians, the researching trend and study focus in the top-100 cited studies could serve as a potential reference for future investigation and patient management.
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Affiliation(s)
- Shih-Cheng Huang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Tsu-Man Chiu
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan,School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Department of Dermatology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chien-Ying Lee
- Department of Pharmacology, Chung Shan Medical University, Taichung, Taiwan,Department of Pharmacy, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Hui-Chin Chang
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Library, Chung Shan Medical University Hospital, Taichung, Taiwan,Evidence-Based Medicine Center, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Wen-Jun Wu
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan,Department of Microbiology and Immunology, School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan,*Correspondence: Wen-Jun Wu,
| | - Shuo-Yan Gau
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Shuo-Yan Gau,
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8
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Ly S, Nedosekin D, Wong HK. Review of an Anti-CD20 Monoclonal Antibody for the Treatment of Autoimmune Diseases of the Skin. Am J Clin Dermatol 2023; 24:247-273. [PMID: 36630066 PMCID: PMC9838371 DOI: 10.1007/s40257-022-00751-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 01/12/2023]
Abstract
Biologic therapies targeting B-cells are emerging as an effective strategy to treat a variety of immune-mediated diseases. One of the most studied B-cell-targeted therapies is rituximab, an anti-CD20 monoclonal antibody that exemplifies B-cell depletion therapy and has served as the prototype for other anti-CD20 monoclonal antibodies and the development of biosimilars. While there are multiple studies on the use of rituximab in dermatology, a comprehensive review of rituximab therapy in autoimmune skin conditions is lacking. In this literature review, we summarize indications, treatment efficacy, and safety of rituximab among common autoimmune diseases of the skin: pemphigus vulgaris, cutaneous lupus erythematous, dermatomyositis, systemic sclerosis, thyroid dermopathy, autoimmune pemphigoid diseases, and cutaneous vasculitis diseases. Existing data on rituximab support the approach of rituximab, biosimilars, and newer B-cell-targeting therapies in immune-mediated cutaneous diseases. Overall, rituximab, which targets CD20, provides an effective alternative or concomitant option to traditional immunosuppressants in the management of various autoimmune diseases of the skin. Further studies are necessary to expand the understanding and possible utility of B-cell-targeted therapies among autoimmune skin diseases.
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Affiliation(s)
- Sophia Ly
- grid.241054.60000 0004 4687 1637College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Dmitry Nedosekin
- grid.241054.60000 0004 4687 1637College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Henry K. Wong
- grid.241054.60000 0004 4687 1637Department of Dermatology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot #576, Little Rock, AR 72205 USA
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9
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Cole C, Amber KT. Off-Label Uses of Rituximab in Dermatology. CURRENT DERMATOLOGY REPORTS 2022; 11:209-220. [PMID: 36217351 PMCID: PMC9534735 DOI: 10.1007/s13671-022-00375-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review Rituximab has transformed the treatment of B-cell malignancies and rheumatoid arthritis in the past 2 decades. More recently, this anti-CD20 monoclonal antibody has seen increasing usage in the field of dermatology. This review highlights the evidence supporting its use in several important dermatologic conditions. Recent Findings Key recent findings include the 2018 FDA approval of rituximab for the treatment of moderate-to-severe pemphigus. Summary Data from randomized controlled trials have demonstrated the efficacy of rituximab in pemphigus, ANCA-associated vasculitis, and cryoglobulinemic vasculitis. More limited data suggests its use in recalcitrant cases of diseases such as pemphigoid, epidermolysis bullosa acquisita, and dermatomyositis. There is scarce evidence and mixed results for rituximab when studied in cutaneous polyarteritis nodosa and cutaneous lupus erythematosus.
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Affiliation(s)
- Connor Cole
- Division of Dermatology, Rush University Medical Center, Chicago, IL USA
| | - Kyle T. Amber
- Division of Dermatology, Rush University Medical Center, Chicago, IL USA
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL USA
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10
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Rituximab in Mucous Membrane Pemphigoid: A Monocentric Retrospective Study in 10 Patients with Severe/Refractory Disease. J Clin Med 2022; 11:jcm11144102. [PMID: 35887866 PMCID: PMC9325091 DOI: 10.3390/jcm11144102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/30/2022] [Accepted: 07/09/2022] [Indexed: 02/05/2023] Open
Abstract
Rituximab (RTX) is a monoclonal antibody directed against CD20 antigen indicated in an increasing number of immune-mediated diseases. While its efficacy in pemphigus vulgaris has been widely investigated, only a few data about its possible role in pemphigoid diseases have been reported in the literature. Accordingly, herein we evaluated a case series of patients with mucous membrane pemphigoid (MMP) treated with RTX. We included patients with a history of severe/refractory MMP who received at least one cycle of intravenous RTX between May 2018 and December 2021 and had 6 months of follow-up time. Disease control (DC) was our early endpoint, while complete remission (CR) and partial remission (PR) were late endpoints. CR off-therapy, relapses, and adverse events were evaluated as well. Our population included 10 MMP patients. Eight out of ten patients (80%) achieved DC in a mean of 8 weeks, while two patients with ocular MMP were non-responders. Among the eight patients who achieved DC, two reached CR off therapy, two CR on minimal therapy, and two achieved PR on minimal therapy. In our case series, the addition of RTX to conventional therapies was demonstrated to be safe and effective in reaching rapid disease control in the majority of refractory MMP patients.
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Lytvyn Y, Rahat S, Mufti A, Witol A, Bagit A, Sachdeva M, Yeung J. Biologic treatment outcomes in mucous membrane pemphigoid: A systematic review. J Am Acad Dermatol 2022; 87:110-120. [PMID: 33422625 DOI: 10.1016/j.jaad.2020.12.056] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/24/2020] [Accepted: 12/19/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mucous membrane pemphigoid (MMP) is an autoimmune disease that can lead to fibrosis of mucous membranes and functional impairment. Biologic agents should be explored as alternative treatment options to improve outcomes. OBJECTIVE To conduct a systematic review of biologic treatment outcomes in patients with MMP. METHODS A MEDLINE and Embase search was conducted on July 23, 2020, to include 63 studies using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS Use of intravenous immunoglobulin (n = 154), rituximab (n = 112), tumor necrosis factor α inhibitors (n = 7), and combination treatments (n = 58) were reported in 331 patients with MMP. Intravenous immunoglobulin led to complete resolution in 61.7% (n = 95/154) of patients within 26.0 months, with a recurrence rate of 22.7% (n = 35/154) and headache as the most common adverse effect (8.4%, n = 13/154). Rituximab led to complete resolution in 70.5% (n = 79/112) of patients within 8.7 months, with a recurrence rate of 35.7% (n = 40/112). The most commonly reported adverse effects were urinary tract infections (4.5%, n = 5/112), leukocytopenia (2.7%, n = 3/112), and death due to severe infections (1.8%, n = 2/112). Tumor necrosis factor α inhibitors led to complete resolution in 71.4% (n = 5/7) of patients within 3.9 months of treatment without reported adverse events. CONCLUSIONS Randomized clinical trials with long-term follow-up are required to conclude the promising safety and efficacy of biologic agents in patients with MMP.
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Affiliation(s)
- Yuliya Lytvyn
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shahmina Rahat
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - Asfandyar Mufti
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Adrian Witol
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ahmed Bagit
- Faculty of Health Sciences, Brock University, St. Catharines, ON, Canada
| | | | - Jensen Yeung
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Dermatology, Women's College Hospital, Toronto, ON, Canada.
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12
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Bohelay G, Alexandre M, Le Roux-Villet C, Sitbon I, Doan S, Soued I, Shourick J, Rousset L, Mellottee B, Heller M, Lièvre N, Zumelzu C, Morin F, Grootenboer-Mignot S, Gabison E, Caux F, Prost-Squarcioni C, Musette P. Rituximab Therapy for Mucous Membrane Pemphigoid: A Retrospective Monocentric Study With Long-Term Follow-Up in 109 Patients. Front Immunol 2022; 13:915205. [PMID: 35844526 PMCID: PMC9281543 DOI: 10.3389/fimmu.2022.915205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Mucous membrane pemphigoid (MMP) is a heterogeneous group of rare, chronic, subepithelial autoimmune blistering diseases (AIBDs) with predominant involvement of mucous membranes that can be sight-threatening and life-threatening. Rituximab (RTX) has demonstrated its efficacy in severe MMP refractory to conventional immunosuppressants in small series that differed in RTX scheme, concomitant therapies, and outcome definitions. In a meta-analysis involving 112 patients with MMP treated with RTX, complete remission (CR) was reported in 70.5% of cases. Herein, we report the largest retrospective monocentric study on RTX efficacy in a series of 109 severe and/or refractory patients with MMP treated with RTX with a median follow-up period of 51.4 months. RTX was administered in association with immunomodulatory drugs (dapsone, salazopyrine) without any other systemic immunosuppressant in 104 patients. The RTX schedule comprised two injections (1 g, 2 weeks apart), repeated every 6 months until CR or failure, with a unique consolidation injection (1 g) after CR. The median survival times to disease control and to CR were 7.1 months and 12.2 months, respectively. The median number of RTX cycles required to achieve CR in 85.3% of patients was two. The larynx was the lesional site that took the longest time to achieve disease control. One year after RTX weaning, CR off RTX was obtained in 68.7% of cases. CR off RTX with only minimum doses of immunomodulatory drugs was achieved in 22.0% of patients. Further, 10.1% of patients were partial responders and 4.6% were non-responders to RTX. Relapse occurred in 38.7% of cases, of whom 91.7% had achieved CR again at the last follow-up. In MMP, CR was achieved in a longer time and after more rituximab cycles than in pemphigus, especially for patients with MMP with anti-type VII collagen reactivity. RTX with concomitant immunomodulatory drugs was not responsible for an unusual proportion of adverse events. This large study confirms that RTX is an effective therapy in patients with severe and/or refractory MMP, corroborating previous findings regarding the effects of RTX on AIBDs such as pemphigus.
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Affiliation(s)
- Gérôme Bohelay
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
- Inserm UMR 1125 Li2P, UFR SMBH Léonard de Vinci, Université Sorbonne Paris Nord (USPN), Bobigny, France
| | - Marina Alexandre
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | - Christelle Le Roux-Villet
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | - Ishaï Sitbon
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | - Serge Doan
- Department of Ophthalmology, Bichat University Hospital, AP-HP, Université de Paris, Paris, France
| | - Isaac Soued
- Department of ENT and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Bobigny, France
| | - Jason Shourick
- Department of Epidemiology, Clinical Epidemiology and Public Health, UMR 1027 INSERM-University of Toulouse III, Toulouse University Hospital (CHU), Toulouse, France
| | - Laurie Rousset
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | - Benoît Mellottee
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | - Michel Heller
- Department of Histology, UFR SMBH Léonard de Vinci, Université Sorbonne Paris Nord (USPN), Bobigny, France
| | - Nicole Lièvre
- Department of Histology, UFR SMBH Léonard de Vinci, Université Sorbonne Paris Nord (USPN), Bobigny, France
| | - Coralie Zumelzu
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | - Florence Morin
- Department of Immunology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Saint Louis University Hospital, AP-HP, Université de Paris, Paris, France
| | - Sabine Grootenboer-Mignot
- Department of Immunology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Bichat University Hospital, AP-HP, Université de Paris, Paris, France
| | - Eric Gabison
- Department of Ophthalmology, Bichat University Hospital, AP-HP, Université de Paris, Paris, France
| | - Frédéric Caux
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
- Inserm UMR 1125 Li2P, UFR SMBH Léonard de Vinci, Université Sorbonne Paris Nord (USPN), Bobigny, France
| | - Catherine Prost-Squarcioni
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
- Department of Histology, UFR SMBH Léonard de Vinci, Université Sorbonne Paris Nord (USPN), Bobigny, France
- Department of Pathology, Avicenne University Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis (HUPSSD), AP-HP, Université Sorbonne Paris Nord (USPN), Bobigny, France
| | - Philippe Musette
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
- Inserm UMR 1125 Li2P, UFR SMBH Léonard de Vinci, Université Sorbonne Paris Nord (USPN), Bobigny, France
- *Correspondence: Philippe Musette,
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13
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Farooq MM, Miloslavsky EM, Konikov N, Ahmed AR. Use of rituximab in the treatment of mucous membrane pemphigoid: An analytic review. Autoimmun Rev 2022; 21:103119. [PMID: 35688385 DOI: 10.1016/j.autrev.2022.103119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/15/2022] [Indexed: 11/26/2022]
Abstract
Mucous Membrane Pemphigoid (MMP) is a potentially fatal mucocutaneous autoimmune blistering disease. Autoantibodies are produced against various components of the dermo-epidermal or mucosal-submucosal junction are referred to as basement membrane zone (BMZ). The hallmark is deposition of of Ig and C3 on the perilesional tissues and in some patients detection of anti-BMZ autoantibodies. A unique characteristic of MMP is that as the blisters or erosions heal, they leave irreversible scarring. This scarring results in serious and catastrophic sequelae that affect the quality of life. Conventional therapy consists of anti-inflammatory and immunosuppressive agents (ISA). In patients who fail conventional therapy or develop significant side effects to them, rituximab (RTX) has been used off label. In this review, the clinical outcomes of patients with MMP treated with RTX were studied. 124 patients were identified, 47.58% being male. 72 patients were treated by the Lymphoma Protocol and 51 by Rheumatoid Arthritis (RA) protocol. Follow up for the entire cohort was 36 months (range 0.5-72). On follow-up 64 patients (51.61%) achieved complete clinical remission (CR) off therapy, 25 patients (20.16%) were in CR on therapy, 5 patients (4.03%) were non-responders, and 9 patients (7.25%) were failures. 52 patients (41.93%) experienced a relapse, after 36 months follow-up. Duration between last RTX infusion and relapse was 10.5 months (range 1-30). Most patients with relapses were treated with additional RTX. A statistically significant better outcome was observed in patients treated with RTX as monotherapy compared to those who received RTX with ISA. Clinical outcomes in patients treated with Lymphoma protocol were better than RA protocol at a statistically significant level. Data on CD20+ B cell depletion and repopulation was limited. Interestingly relapses were seen in patients with CD20+ B cell depletion and after repopulation. In the final analysis, 89 patients (71.77%) were in complete remission. Data in this review indicated that RTX was a useful agent to treat MMP. While a randomized control trial may not be practically possible, better and disease specific protocols need to be developed. When publishing, authors should attempt to provide complete and detailed information. In doing so, they will benefit their colleagues and the patients with MMP they treat with RTX.
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Affiliation(s)
| | - Eli M Miloslavsky
- Massachusetts General Hospital, Department of Medicine, Division of Rheumatology, Boston, MA 02114, USA; Harvard Medical School, Boston, MA 02215, USA
| | - Nellie Konikov
- Boston VA health Care System, Jamaica Plain, Boston, MA 02130, USA
| | - A Razzaque Ahmed
- Center for Blistering Diseases, Boston, MA 02135, USA; Department of Dermatology, Tufts University School of Medicine, Boston, MA 02111, USA.
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14
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Rashid H, Meijer JM, Bolling MC, Horváth B. Clinical response to rituximab and improvement in quality of life in patients with bullous pemphigoid and mucous membrane pemphigoid. Br J Dermatol 2021; 186:721-723. [PMID: 34747507 PMCID: PMC9302996 DOI: 10.1111/bjd.20881] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/01/2021] [Accepted: 11/07/2021] [Indexed: 11/28/2022]
Affiliation(s)
- H Rashid
- Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - J M Meijer
- Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - M C Bolling
- Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - B Horváth
- Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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15
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Schmidt E, Rashid H, Marzano A, Lamberts A, Di Zenzo G, Diercks G, Alberti‐Violetti S, Barry R, Borradori L, Caproni M, Carey B, Carrozzo M, Cianchini G, Corrà A, Dikkers F, Feliciani C, Geerling G, Genovese G, Hertl M, Joly P, Meijer J, Mercadante V, Murrell D, Ormond M, Pas H, Patsatsi A, Rauz S, van Rhijn B, Roth M, Setterfield J, Zillikens D, C.Prost, Zambruno G, Horváth B, Caux F. European Guidelines (S3) on diagnosis and management of mucous membrane pemphigoid, initiated by the European Academy of Dermatology and Venereology - Part II. J Eur Acad Dermatol Venereol 2021; 35:1926-1948. [PMID: 34309078 PMCID: PMC8518905 DOI: 10.1111/jdv.17395] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/24/2021] [Indexed: 01/21/2023]
Abstract
This guideline has been initiated by the task force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology, including physicians from all relevant disciplines and patient organizations. It is a S3 consensus-based guideline that systematically reviewed the literature on mucous membrane pemphigoid (MMP) in the MEDLINE and EMBASE databases until June 2019, with no limitations on language. While the first part of this guideline addressed methodology, as well as epidemiology, terminology, aetiology, clinical presentation and outcome measures in MMP, the second part presents the diagnostics and management of MMP. MMP should be suspected in cases with predominant mucosal lesions. Direct immunofluorescence microscopy to detect tissue-bound IgG, IgA and/or complement C3, combined with serological testing for circulating autoantibodies are recommended. In most patients, serum autoantibodies are present only in low levels and in variable proportions, depending on the clinical sites involved. Circulating autoantibodies are determined by indirect IF assays using tissue substrates, or ELISA using different recombinant forms of the target antigens or immunoblotting using different substrates. The major target antigen in MMP is type XVII collagen (BP180), although in 10-25% of patients laminin 332 is recognized. In 25-30% of MMP patients with anti-laminin 332 reactivity, malignancies have been associated. As first-line treatment of mild/moderate MMP, dapsone, methotrexate or tetracyclines and/or topical corticosteroids are recommended. For severe MMP, dapsone and oral or intravenous cyclophosphamide and/or oral corticosteroids are recommended as first-line regimens. Additional recommendations are given, tailored to treatment of single-site MMP such as oral, ocular, laryngeal, oesophageal and genital MMP, as well as the diagnosis of ocular MMP. Treatment recommendations are limited by the complete lack of high-quality randomized controlled trials.
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16
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A Case of Severe and Refractory Membranous Nephropathy Associated to Mucous Membrane Pemphigoid. Case Rep Nephrol 2021; 2021:9940293. [PMID: 34055432 PMCID: PMC8133855 DOI: 10.1155/2021/9940293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/07/2021] [Indexed: 11/25/2022] Open
Abstract
Primary membranous nephropathy (MN) and mucous membrane pemphigoid (MMP) are two autoimmune conditions with well-defined diagnostic and treatment guidelines. MN has been linked to bullous pemphigoid (BP) in certain case reports, though little is known regarding the association of MN and other bullous diseases. The association of MN and MMP has rarely been described, and very little data exist regarding the treatment of this association. We report a case of severe refractory membranous nephropathy secondary to mucous membrane pemphigoid successfully treated with rituximab. A 35-year-old woman with known MMP was referred to our clinic for new-onset generalized edema and proteinuria. MN was confirmed on renal biopsy. Despite therapy with high-dose systemic glucocorticoids, combined with mycophenolate mofetil, and later azathioprine, nephrotic-range proteinuria persisted even at a daily dose of prednisone of 40 mg. The patient was then started on rituximab infusions, which induced remission of both mucous membrane pemphigoid and membranous glomerulonephritis. This suggests that MN can be secondary to MMP, and rituximab may be useful induce remission in cases that are refractory to standard therapy.
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17
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Baniel A, Oestreicher-Kedem Y, Peled A, Bar-Ilan E, Geller S, Sprecher E, Baum S. Laryngeal mucous membrane pemphigoid serves as a prognostic factor for poor response to treatment with rituximab. Clin Exp Dermatol 2021; 46:915-919. [PMID: 33811681 DOI: 10.1111/ced.14662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/21/2021] [Accepted: 03/30/2021] [Indexed: 11/29/2022]
Abstract
Mucous membrane pemphigoid (MMP) is an autoimmune blistering, scarring and occasionally mutilating disease that may progress to blindness or airway obstruction. Over the past few years, rituximab (RTX) has emerged as a potential therapeutic solution for MMP; however, the literature regarding its efficacy in the treatment of severe MMP is sparse. We studied four patients with recalcitrant MMP who were treated with RTX. Three of these had recalcitrant laryngeal disease; two were unresponsive to RTX, while the third patient achieved complete remission (CR) but relapsed twice. The fourth patient, who had oral and ocular disease, also achieved CR. In addition, we reviewed 143 cases of MMP treated with RTX reported in the literature to date. Of these, 120 had late observation endpoints, of whom 81 (67.5%) achieved CR, 24 (20%) received partial remission and 15 (12.5%) had no remission. Based on this study, the presence of laryngeal MMP seems to predict refractoriness to RTX treatment. In conclusion, we found that RTX can ameliorate the MMP course and that laryngeal involvement, which is known to be a prognostic factor for severe MMP, may also predict poor response to RTX.
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Affiliation(s)
- A Baniel
- Division of Dermatology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Oestreicher-Kedem
- Department of Ear, Nose, Throat, Head and Neck Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Peled
- Division of Dermatology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - E Bar-Ilan
- Division of Dermatology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - S Geller
- Division of Dermatology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Sprecher
- Division of Dermatology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Baum
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Dermatology, Sheba Medical Centre, Ramat-Gan, Israel
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18
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Montagnon CM, Lehman JS, Murrell DF, Camilleri MJ, Tolkachjov SN. Subepithelial autoimmune bullous dermatoses disease activity assessment and therapy. J Am Acad Dermatol 2021; 85:18-27. [PMID: 33684494 DOI: 10.1016/j.jaad.2020.05.161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/17/2020] [Accepted: 05/21/2020] [Indexed: 12/18/2022]
Abstract
Subepidermal (subepithelial) autoimmune blistering dermatoses are a group of rare skin disorders characterized by the disruption of the dermal-epidermal junction through the action of autoantibodies. The fourth article in this continuing medical education series presents the current validated disease activity scoring systems, serologic parameters, treatments, and clinical trials for bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, bullous systemic lupus erythematosus, anti-p200 pemphigoid, linear IgA bullous dermatosis, and dermatitis herpetiformis.
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Affiliation(s)
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, Australia
| | - Michael J Camilleri
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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19
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Bevans SL, Parker J, Ivey JM, Pavlidakey P, Sami N. Rituximab as an Adjuvant Rescue Treatment for Ocular Cicatricial Pemphigoid. Cornea 2021; 40:1440-1444. [PMID: 33591038 DOI: 10.1097/ico.0000000000002683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/27/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Ocular cicatricial pemphigoid (OCP) can lead to devastating ocular complications without prompt treatment. A number of immunomodulatory agents have been attempted with varying success. The objective of this study was to evaluate the use of rituximab as an adjuvant to immunomodulatory treatments (IMTs) in refractory OCP. METHODS The clinical records of 14 patients with treatment refractory OCP treated with rituximab as monotherapy or in combination with IMTs were retrospectively reviewed, with a focus on demographics, treatments prerituximab and postrituximab, total number of rituximab infusions, response to treatment, and ocular outcomes including staging and best-corrected visual acuity. RESULTS Thirteen patients (92.9%) achieved a complete response with rituximab over a mean period of 4.3 months. The average sustained complete response time in those without relapse was 29.7 months. Five patients relapsed over a mean period of 15 months, 2 of whom were able to regain control over a mean of 2.5 months with additional rituximab treatments. At the final evaluation, rituximab-based therapy improved ocular outcomes in OCP by stabilizing Foster staging and preventing the deterioration of best-corrected visual acuity in 72% of eyes. In total, 90% of eyes with Foster stages 3 or less did not progress. All patients were able to decrease IMT dosage and/or transition to less potent adjuvant treatments. CONCLUSIONS The consideration of rituximab earlier in treatment of OCP as a rescue and/or maintenance therapy could result in an earlier arrest of disease progression, resulting in preservation of patients' vision, and enable tapering of adjuvant IMT.
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Affiliation(s)
- Stephanie L Bevans
- University of Alabama at Birmingham Department of Dermatology, Birmingham, AL; University of Alabama at Birmingham Department of Ophthalmology, Birmingham, AL; University of Mississippi Medical Center Department of Dermatology, Jackson, MS; University of Alabama at Birmingham Department of Dermatology, Birmingham, AL; and University of Central Florida Department of Medicine, Orlando, FL
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20
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Watson N, Carrozzo M, Hampton P. A retrospective cohort study reporting rituximab treatment for 33 patients with immunobullous disease. J Oral Pathol Med 2020; 50:92-97. [PMID: 33184901 DOI: 10.1111/jop.13123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/22/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Autoimmune bullous disorders, encompassing pemphigus and pemphigoid diseases, are associated with significant morbidity and mortality. This is in part due to high cumulative doses of corticosteroids in combination with immunosuppressant agents used in traditional treatment regimes. Rituximab is an antiCD20 monoclonal antibody which can induce complete remission, but it is currently unlicensed in the UK and approved only after other treatments have failed. METHODS We report a retrospective cohort study of 33 patients with pemphigus and pemphigoid diseases treated with rituximab from a single tertiary centre from 2013 to 2019. RESULTS "Complete remission off therapy" was achieved by 27.3% (n = 9), and a further 27.3% (n = 9) had complete remission on minimal therapy. Twenty-one per cent (n = 7) had "partial remission on minimal therapy"; 9.1% (n = 3) patients were in the "consolidation phase," and 12.1% (n = 4) had a "relapse/flare." A steady reduction in prednisolone doses was observed post-Rituximab infusion. Pre-Rituximab the median dose of prednisolone was 20mg (range 10-35, IQR 25), 15mg (range 9.5-22.5, IQR 13) at 1 month, 9mg (range 5-10, IQR 5) at 6 months, 4mg (range 0-5mg, IQR 5) at 12 months and 0 (0-4.35, IQR 4.25) at 18 months. Twelve per cent (n = 4) of patients had documented infusion reaction symptoms. Twelve per cent (n = 4) had later infective complications. CONCLUSION This real clinic data adds to the evidence that Rituximab is a safe and effective treatment for both pemphigus and pemphigoid autoimmune blistering conditions. Significantly, we were able to demonstrate a substantial reduction in corticosteroid dosage in our cohort of patients following rituximab treatment.
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Affiliation(s)
- Nicola Watson
- Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Marco Carrozzo
- School of Dental Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Philip Hampton
- Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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21
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Hanaoka R, Haginoya T, Koike M. A case of rheumatoid arthritis complicated with mucous membrane pemphigoid. Mod Rheumatol Case Rep 2020; 5:191-194. [PMID: 33081597 DOI: 10.1080/24725625.2020.1839196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Rheumatoid arthritis (RA) is a disease of unknown aetiology that causes irreversible joint destruction and has been known to present with not only various extra-articular symptoms, but also various autoimmune disorders. Mucous membrane pemphigoid (MMP) is a chronic autoimmune disease characterised by inflamed and eroded mucosa. The prognosis of MMP can be poor, so early diagnosis and prompt initiation of therapy are necessary for optimal management. Here, we report a rare case of RA complicated with MMP involving a 68-year-old woman admitted to our hospital because of hoarseness and symmetrical narrowing of the eye fissures. She presented with bilateral coxalgia and had been diagnosed with RA 24 years earlier. Oral methotrexate was prescribed, but subsequently discontinued, and this was followed by treatment with tocilizumab 3 years earlier. Tocilizumab was discontinued because of financial distress 5 months earlier, after which her RA disease activity worsened. She presented to our hospital after further worsening of her eye-opening difficulty. Physical and laboratory examinations led to a diagnosis of MMP. Her sputum, cough, throat discomfort, conjunctival congestion, mucous erosion, and blistering promptly disappeared after treatment with rituximab (500 mg per week for 4 weeks). She subsequently recovered her vocalisation ability, and her hoarseness, dysphagia, and eye-opening difficulty gradually improved, but not completely. This case suggests that that RA and MMP share common immunological mechanisms. Therefore, MMP should be considered when encountering patients with RA who present with systemic membrane mucous disorders.
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Affiliation(s)
- Ryosuke Hanaoka
- Department of Rheumatology, Kamitsuga General Hospital, Kanuma, Tochigi, Japan
| | - Toshiko Haginoya
- Department of Rheumatology, Kamitsuga General Hospital, Kanuma, Tochigi, Japan
| | - Masami Koike
- Department of Dermatology, Koike-Clinic, Kanuma, Tochigi, Japan
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Amir Dastmalchi D, Moslemkhani S, Bayat M, Balighi K, Abedini R, Mahmoudi H, Daneshpazhooh M. The efficacy of rituximab in patients with mucous membrane pemphigoid. J DERMATOL TREAT 2020; 33:1084-1090. [PMID: 32723108 DOI: 10.1080/09546634.2020.1801974] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Mucous membrane pemphigoid (MMP) is an autoimmune blistering disorder with tendency to scarring. Long term immunosuppressive treatment may be required to minimize the consequences of the disease. METHODS In this retrospective study, we investigated the efficacy of rituximab (RTX) in MMP patients and compare the beneficial effects of early versus late administration of RTX. Medical records of 24 MMP patients who were treated with 500 mg RTX on day 1, then weekly for 4 consecutive weeks were reviewed. RESULTS Twenty-one patients (87.5%) reached disease control (DC) at the mean interval of 4.95 months (SD: 5.15; range: 1-24) after RTX. Complete remission (CR) with scarring was achieved in 45.8% (n = 11) and 33.3% (n = 8) attained CR without any residual scar (total CR with or without scar 79.1%). Two patients (8.3%) reached partial remission including persistent gingivitis. Only one patient progressed from non-cicatricial to cicatricial MMP despite receiving RTX. 47.6% (n = 10) of patients experienced relapse after achieving DC at a mean interval of 15.2 months (range: 6-30, SD: 7.0). Considerably, earlier the RTX was administered, sooner the DC was obtained (Pearson r = 0.742, p-value < .001). CONCLUSIONS These results suggest that RTX may prevent further scarring and progression in MMP patients especially if administered early.
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Affiliation(s)
- Delara Amir Dastmalchi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Solmaz Moslemkhani
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Bayat
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Balighi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Robabeh Abedini
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Mahmoudi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Barroil M, Girard C, Lerisson M, Negroni V, Bertrand AS, Pallure V, Bessis D, Guillot B, Dereure O. [Use of rituximab in maintenance treatment of pemphigus: A retrospective series]. Ann Dermatol Venereol 2020; 147:173-178. [PMID: 31955970 DOI: 10.1016/j.annder.2019.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/31/2019] [Accepted: 08/05/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Rituximab (RTX), currently recommended as first-line treatment in moderate to severe pemphigus vulgaris (PV) and superficial pemphigus (PS) along with initial systemic steroids, may also be used as second-line or subsequent treatment, and this therapeutic strategy was investigated in a real-life monocentre retrospective survey. MATERIAL AND METHODS All patients treated between January 2010 and March 2018 with RTX as second-line or subsequent treatment for moderate to severe PV or PS and followed for at least one year were included. The main objective was to evaluate rates and times of complete clinical remission (CCR) after a first course of RTX. The secondary objectives consisted mainly of treatment safety, and frequency and time to relapse after the initial CCR. RESULTS The 24 patients selected received on average 2 cycles of RTX (i.e. 24 initial cycles and 24 additional cycles in all) over a mean follow-up period of 45 months. 18/24 (75%) patients achieved initial CCR within a mean 7.7 months. Despite at least one relapse in 13/18 initially responding patients regardless of relapse time, 59% (14/24) and 33% (8/24) were either in CCR and off treatment, or in partial remission, whether treated or untreated, according to the latest patient news, with an overall response rate of 92%. Safety was fair in these fragile patients. DISCUSSION AND CONCLUSION This survey of the practical use of RTX confirms its interest in moderate to severe pemphigus as a second-line or subsequent treatment, a situation that probably remains relevant even if this molecule is increasingly used as first-line therapy.
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Affiliation(s)
- M Barroil
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - C Girard
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - M Lerisson
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - V Negroni
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - A-S Bertrand
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - V Pallure
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - D Bessis
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - B Guillot
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - O Dereure
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France.
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Post-rituximab immunoglobulin M (IgM) hypogammaglobulinemia. Autoimmun Rev 2020; 19:102466. [PMID: 31917267 DOI: 10.1016/j.autrev.2020.102466] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 12/19/2022]
Abstract
Rituximab is a B cell depleting monoclonal antibody that targets the B cell-specific cell surface antigen CD20 and is currently used to treat several autoimmune diseases. The elimination of mature CD20-positive B lymphocytes committed to differentiate into autoantibody-producing plasma cells is considered to be the major effect of rituximab, that makes it a beneficial biological agent in treating autoimmune diseases. Hypogammaglobulinemia has been reported after rituximab therapy in patients with lymphoma and rheumatoid arthritis. Similar data are scarce for other autoimmune diseases. Low immunoglobulin G (IgG) or hypogammaglobulinemia has attracted the most attention because of its significant role in protective immunity. However, the incidence and clinical implications of low immunoglobulin M (IgM) or hypogammaglobulinemia have not been studied in detail. This review will focus on the frequency and the clinical concerns of low IgM levels that result as a consequence of the administration of rituximab. The etiopathogenic mechanisms underlying post-rituximab IgM hypogammaglobulinemia and its implications are presented. The long-term consequences, if any, are not known or documented. Multiple factors may be involved in whether IgG or IgM decreases secondary to rituximab therapy. It is possible that the autoimmune disease itself may be one of the important factors. The dose, frequency and number of infusions appear to be important variables. Post-rituximab therapy immunoglobulin levels return to normal. During this process. IgM levels take a longer time to return to normal levels when compared to IgG or other immunoglobulins. IgM deficiency persists after B cell repopulation to normal levels has occurred. Laboratory animals and humans deficient in IgM can have multiple infections. Specific pharmacologic agents or biologic therapy that address and resolve IgM deficiency are currently unavailable. If the clinical situation so warrants, then prophylactic antibiotics may be indicated and perhaps helpful. Research in this iatrogenic phenomenon will provide a better understanding of not only the biology of IgM, but also the factor(s) that control its production and regulation, besides its influence if any, on rituximab therapy.
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Ujiie H, Iwata H, Yamagami J, Nakama T, Aoyama Y, Ikeda S, Ishii N, Iwatsuki K, Kurosawa M, Sawamura D, Tanikawa A, Tsuruta D, Nishie W, Fujimoto W, Amagai M, Shimizu H. Japanese guidelines for the management of pemphigoid (including epidermolysis bullosa acquisita). J Dermatol 2019; 46:1102-1135. [PMID: 31646663 DOI: 10.1111/1346-8138.15111] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/10/2019] [Indexed: 10/25/2022]
Abstract
The pemphigoid group is a category of autoimmune subepidermal blistering diseases in which autoantibodies deposit linearly at the epidermal basement membrane zone (BMZ). The main subtypes of pemphigoid mediated by immunoglobulin G autoantibodies are bullous pemphigoid (BP), mucous membrane pemphigoid (MMP) and epidermolysis bullosa acquisita (EBA). To establish the first guidelines approved by the Japanese Dermatological Association for the management of pemphigoid diseases, the Committee for Guidelines for the Management of Pemphigoid Diseases (Including EBA) was founded as part of the Study Group for Rare Intractable Skin Diseases under the Ministry of Health, Labor and Welfare Research Project on Overcoming Intractable Diseases. These guidelines aim to provide current information for the management of BP, MMP and EBA in Japan. Based on evidence, the guidelines summarize the clinical and immunological manifestations, pathophysiologies, diagnostic criteria, disease severity determination criteria, treatment algorithms and treatment recommendations. Because of the rarity of these diseases, there are few clinical studies with a high degree of evidence, so several parts of these guidelines were established based on the opinions of the Committee. To further optimize these guidelines, periodic revision in line with the new evidence is necessary.
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Affiliation(s)
- Hideyuki Ujiie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Jun Yamagami
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Takekuni Nakama
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - Yumi Aoyama
- Department of Dermatology, Kawasaki Medical School, Kurashiki, Japan
| | - Shigaku Ikeda
- Department of Dermatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - Keiji Iwatsuki
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Michiko Kurosawa
- Department of Epidemiology and Environmental Health, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Daisuke Sawamura
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Akiko Tanikawa
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Tsuruta
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Wataru Fujimoto
- Department of Dermatology, Kawasaki Medical School, Kurashiki, Japan
| | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Shimizu
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Bertrand AS, Dereure O, Girard C, Bessis D, Guillot B. Place du rituximab dans le traitement de la pemphigoïde des muqueuses. Ann Dermatol Venereol 2019; 146:659-661. [DOI: 10.1016/j.annder.2019.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 03/01/2019] [Accepted: 07/05/2019] [Indexed: 11/27/2022]
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Clinical Characteristics and Outcomes of Ocular Cicatricial Pemphigoid: A Cohort Study and Literature Review. Cornea 2019; 38:1406-1411. [PMID: 31356420 DOI: 10.1097/ico.0000000000002080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Ocular cicatricial pemphigoid (OCP) is a rare systemic autoimmune disease and a potentially blinding subepithelial blistering disorder. The purpose of this study was to describe the clinical spectrum of the disease and to assess the efficacy and safety of immunosuppressive agents in a cohort of patients with OCP. METHODS We conducted a monocentric retrospective cross-sectional cohort study of all unselected consecutive patients diagnosed with progressive OCP. Ocular and extra ophthalmological involvement as well as histological findings were gathered. Other outcomes were exposures to immunosuppressive agents defined by the use of a particular treatment. For each exposure, success in controlling ocular inflammation was graded as a complete response, response, or failure. Relapses and adverse events (AE) were also recorded. RESULTS Seventeen patients (34 affected eyes), 35% of whom were women, were included, with an age at diagnosis of 75 ± 11 years. Corneal involvement was diagnosed in 30 of 34 eyes, and 22 of 34 eyes had progressive fibrosing conjunctival involvement. Sixty-two exposures to immunosuppressive agents or biologics were recorded: dapsone, n = 26; mycophenolate mofetil, n = 6; azathioprine, n = 4; cyclophosphamide, n = 10; rituximab, n = 14; and intravenous immunoglobulin, n = 2. Rates of response and of complete response achievement during the first 3 months were 84% and 45%, respectively. Response rates were 100%, 100%, 86%, 85%, and 80% for intravenous immunoglobulin, mycophenolate mofetil, rituximab, dapsone, and cyclophosphamide, respectively. Thirteen percent of those drugs were discontinued because of an adverse event in 4 patients. CONCLUSIONS This study describes the efficacy of immunosuppressants or biologics with an acceptable safety profile for OCP.
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Thomas RM, Colon A, Motaparthi K. Rituximab in autoimmune pemphigoid diseases: Indications, optimized regimens, and practice gaps. Clin Dermatol 2019; 38:384-396. [PMID: 32563354 DOI: 10.1016/j.clindermatol.2019.07.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Rituximab is a monoclonal antibody targeting CD20 on B cells with proven efficacy for pemphigus vulgaris, now an FDA-approved indication. Other autoimmune bullous diseases can be challenging to treat and have significant associated morbidity and mortality, but data supporting the use of rituximab in pemphigoid group diseases remain limited. Although rituximab demonstrates efficacy for clinical improvement and remission in pemphigoid, concern for adverse events may also limit the use of this medication. We review the current evidence fo rthe use of rituximab in pemphigoid diseases, pertinent dosing schedules and laboratory monitoring, and the associated common and rare adverse events. Review of the literature to date not only supports consideration of rituximab for treatment of refractory pemphigoid group diseases but also reflects tolerability and an acceptable safety profile.
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Affiliation(s)
- Renee M Thomas
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Alysha Colon
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA.
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29
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Santi CG, Gripp AC, Roselino AM, Mello DS, Gordilho JO, Marsillac PFD, Porro AM. Consensus on the treatment of autoimmune bullous dermatoses: bullous pemphigoid, mucous membrane pemphigoid and epidermolysis bullosa acquisita - Brazilian Society of Dermatology. An Bras Dermatol 2019; 94:33-47. [PMID: 31166405 PMCID: PMC6544032 DOI: 10.1590/abd1806-4841.2019940207] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/30/2019] [Indexed: 02/06/2023] Open
Abstract
Bullous pemphigoid, mucous membrane pemphigoid and epidermolysis bullosa
acquisita are subepidermal autoimmune blistering diseases whose antigenic target
is located at the basement membrane zone. Mucous membrane pemphigoid and
epidermolysis bullosa acquisita can evolve with cicatricial mucosal involvement,
leading to respiratory, ocular and/or digestive sequelae with important
morbidity. For each of these dermatoses, a literature review covering all
therapeutic options was performed. A flowchart, based on the experience and
joint discussion among the authors of this consensus, was constructed to provide
treatment orientation for these diseases in Brazil. In summary, in the
localized, low-risk or non-severe forms, drugs that have immunomodulatory action
such as dapsone, doxycycline among others may be a therapeutic option. Topical
treatment with corticosteroids or immunomodulators may also be used. Systemic
corticosteroid therapy continues to be the treatment of choice for severe forms,
especially those involving ocular, laryngeal-pharyngeal and/or esophageal
mucosal involvement, as may occur in mucous membrane pemphigoid and
epidermolysis bullosa acquisita. Several immunosuppressants are used as adjuvant
alternatives. In severe and recalcitrant cases, intravenous immunoglobulin is an
alternative that, while expensive, may be used. Immunobiological drugs such as
rituximab are promising drugs in this area. Omalizumab has been used in bullous
pemphigoid.
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Affiliation(s)
- Claudia Giuli Santi
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Carlos Gripp
- Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Ana Maria Roselino
- Department of Medical Clinics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Danielle Santana Mello
- Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Paula Figueiredo de Marsillac
- Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Adriana Maria Porro
- Department of Dermatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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30
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Kridin K, Ahn C, Huang WC, Ansari A, Sami N. Treatment Update of Autoimmune Blistering Diseases. Dermatol Clin 2019; 37:215-228. [DOI: 10.1016/j.det.2018.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
Mucous membrane pemphigoid (MMP) is a pemphigoid disease defined by the presence of autoantibodies against the dermal-epidermal junction and predominant involvement of mucous membranes. Diagnosis is made by the clinical presentation and linear deposits of IgG and/or IgA and/or C3 at the dermal-epidermal junction by direct immunofluorescence microscopy of a perilesional biopsy. Circulating autoantibodies can be detected in most patients by indirect immunofluorescence microscopy on salt-split human skin as well as ELISA and immunoblotting with recombinant and cell-derived target antigens. For systemic treatment of MMP, corticosteroids, dapsone, mycophenolates, and azathioprine are applied. In severe cases and in cases with rapid disease progression cyclophosphamide, rituximab, high-dose intravenous immunoglobulins, and immunoadsorption are used. For the successful management of MMP patients, close cooperation with dentists, ophthalmologists, ENT specialists, gynecologists, and gastroenterologists is essential.
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Georgoudis P, Sabatino F, Szentmary N, Palioura S, Fodor E, Hamada S, Scholl HPN, Gatzioufas Z. Ocular Mucous Membrane Pemphigoid: Current State of Pathophysiology, Diagnostics and Treatment. Ophthalmol Ther 2019; 8:5-17. [PMID: 30694513 PMCID: PMC6393250 DOI: 10.1007/s40123-019-0164-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Indexed: 12/11/2022] Open
Abstract
Mucous membrane pemphigoid (MMP) is a systemic cicatrizing autoimmune disease that primarily affects orificial mucous membranes, such as the conjunctiva, the nasal cavity, the oropharynx, and the genitalia. Ocular involvement occurs in about 70% of all MMP cases. Ocular MMP (OcMMP) also encompasses the conditions linear immunoglobulin A disease, mucosal dominated epidermolysis bullosa acquisita, and anti-laminin 332/anti-epiligrin/anti-laminin 5 pemphigoid. It is a complex clinical entity that may lead to ocular surface failure and result in inflammatory and infectious complications, as well as potentially devastating visual loss. Early diagnosis and appropriate treatment are of paramount importance and require a high level of expertise as this condition can be extremely challenging to diagnose and treat even for experienced clinicians. In this review we provide an up-to-date insight on the pathophysiology of OcMMP, with an emphasis on the current state of its diagnostics and therapeutics. Our the aim is to increase our understanding of OcMMP and highlight modern diagnostic and therapeutic options.
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Affiliation(s)
| | | | - Nora Szentmary
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | | | - Eszter Fodor
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - Samer Hamada
- Corneo-Plastic Unit, Queen Victoria Hospital, East Grinstead, UK
| | - Hendrik P N Scholl
- Department of Ophthalmology, Basel University Hospital, Basel, Switzerland
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland
| | - Zisis Gatzioufas
- Department of Ophthalmology, Basel University Hospital, Basel, Switzerland.
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33
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Bullous Diseases of the Skin and Mucous Membranes. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00063-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Casan JML, Wong J, Northcott MJ, Opat S. Anti-CD20 monoclonal antibodies: reviewing a revolution. Hum Vaccin Immunother 2018; 14:2820-2841. [PMID: 30096012 PMCID: PMC6343614 DOI: 10.1080/21645515.2018.1508624] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/14/2018] [Accepted: 08/02/2018] [Indexed: 12/23/2022] Open
Abstract
Since the inception of rituximab in the 1990s, anti-CD20 monoclonal antibodies have revolutionised the treatment of B cell hematological malignancies and have become a cornerstone of modern gold-standard practice. Additionally, the potent efficacy of these agents in depleting the B cell compartment has been used in the management of a broad array of autoimmune diseases. Multiple iterations of these agents have been investigated and are routinely used in clinical practice. In this review, we will discuss the physiology of CD20 and its attractiveness as a therapeutic target, as well as the pharmacology, pre-clinical and clinical data for the major anti-CD20 monoclonal antibodies: rituximab, obinutuzumab and ofatumumab.
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Affiliation(s)
- J. M. L. Casan
- Haematology Department, Monash Health, Melbourne Australia
| | - J. Wong
- Haematology Department, Monash Health, Melbourne Australia
| | - M. J. Northcott
- Rheumatology Department, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | - S. Opat
- Haematology Department, Monash Health, Melbourne Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
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Bernauer W, Schuler S, Borradori L. Rituximab and bilateral HSV epithelial keratitis in a patient with mucous membrane pemphigoid. J Ophthalmic Inflamm Infect 2018; 8:12. [PMID: 30141181 PMCID: PMC6107448 DOI: 10.1186/s12348-018-0153-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/04/2018] [Indexed: 01/07/2023] Open
Abstract
Background B cell depleting therapy is widely used for lymphoproliferative diseases and immune-mediated disorders, including mucous membrane pemphigoid. The latter is an autoimmune blistering disease affecting predominantly the mucosae potentially associated with devastating complications. Methods A 71-year-old patient with severe mucous membrane pemphigoid involving ocular, oral pharyngeal and laryngeal involvement is described. To control the disease, the patient was given rituximab therapy in combination with oral corticosteroids. He subsequently experienced an epithelial herpes simplex virus keratitis in one eye and 3 months later in his fellow eye. Topical treatment with ganciclovir resulted in prompt recovery. Results For the first time, a correlation between rituximab and bilateral epithelial herpes simplex virus keratitis is described. Conclusions Although rituximab is a promising biologic agent for the treatment of autoimmune diseases, it bears the risk of reactivation of viral infections, including the onset of herpes simplex virus keratitis.
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Affiliation(s)
- W Bernauer
- ÓMMA Eye Clinic, Theaterstrasse 2, CH-8001, Zurich, Switzerland. .,University of Zürich, Zurich, Switzerland.
| | - S Schuler
- ÓMMA Eye Clinic, Theaterstrasse 2, CH-8001, Zurich, Switzerland
| | - L Borradori
- Department of Dermatology, University Hospital of Bern, Bern, Switzerland.,University of Bern, Bern, Switzerland
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36
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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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Wijaya C, Morgan L, Novakovic D, Riminton S. Laryngoceles with airway compromise complicating mucous membrane pemphigoid. BMJ Case Rep 2018; 2018:bcr-2018-225316. [PMID: 30021739 DOI: 10.1136/bcr-2018-225316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Mucous membrane pemphigoid (MMP) encompasses a group of autoantibody-mediated, subepithelial blistering diseases, which primarily affect mucosal surfaces including oral, ocular, skin, genital, nasopharyngeal and oesophageal sites. We present a first description of laryngoceles as a manifestation of mucous membrane pemphigoid resulting in dynamic airway closure. Mucosal injury at other sites had previously resulted in pathergy and localised cicatrisation. We discuss successful combined medical and transcutaneous surgical intervention designed to avoid tracheostomy and minimise iatrogenic laryngeal cicatrisation.
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Affiliation(s)
- Carolyn Wijaya
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Immunology Department, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Lucy Morgan
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Respiratory Department, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Daniel Novakovic
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sean Riminton
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Immunology Department, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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Pierpont TM, Limper CB, Richards KL. Past, Present, and Future of Rituximab-The World's First Oncology Monoclonal Antibody Therapy. Front Oncol 2018; 8:163. [PMID: 29915719 PMCID: PMC5994406 DOI: 10.3389/fonc.2018.00163] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/30/2018] [Indexed: 12/13/2022] Open
Abstract
Rituximab is a chimeric mouse/human monoclonal antibody (mAb) therapy with binding specificity to CD20. It was the first therapeutic antibody approved for oncology patients and was the top-selling oncology drug for nearly a decade with sales reaching $8.58 billion in 2016. Since its initial approval in 1997, it has improved outcomes in all B-cell malignancies, including diffuse large B-cell lymphoma, follicular lymphoma, and chronic lymphocytic leukemia. Despite widespread use, most mechanistic data have been gathered from in vitro studies while the roles of the various response mechanisms in humans are still largely undetermined. Polymorphisms in Fc gamma receptor and complement protein genes have been implicated as potential predictors of differential response to rituximab, but have not yet shown sufficient influence to impact clinical decisions. Unlike most targeted therapies developed today, no known biomarkers to indicate target engagement/tumor response have been identified, aside from reduced tumor burden. The lack of companion biomarkers beyond CD20 itself has made it difficult to predict which patients will respond to any given anti-CD20 antibody. In the past decade, two new anti-CD20 antibodies have been approved: ofatumumab, which binds a distinct epitope of CD20, and obinutuzumab, a mAb derived from rituximab with modifications to the Fc portion and to its glycosylation. Both are fully humanized and have biological activity that is distinct from that of rituximab. In addition to these new anti-CD20 antibodies, another imminent change in targeted lymphoma treatment is the multitude of biosimilars that are becoming available as rituximab's patent expires. While the widespread use of rituximab itself will likely continue, its biosimilars will increase global access to the therapy. This review discusses current research into mechanisms and potential biomarkers of rituximab response, as well as its biosimilars and the newer CD20 binding mAb therapies. Increased ability to assess the effectiveness of rituximab in an individual patient, along with the availability of alternative anti-CD20 antibodies will likely lead to dramatic changes in how we use CD20 antibodies going forward.
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Affiliation(s)
- Timothy M. Pierpont
- Richards Laboratory, Department of Biomedical Sciences, Cornell University, Ithaca, NY, United States
| | - Candice B. Limper
- Richards Laboratory, Department of Biomedical Sciences, Cornell University, Ithaca, NY, United States
| | - Kristy L. Richards
- Richards Laboratory, Department of Biomedical Sciences, Cornell University, Ithaca, NY, United States
- Department of Medicine, Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine, New York, NY, United States
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Gaudin O, Seta V, Alexandre M, Bohelay G, Aucouturier F, Mignot-Grootenboer S, Ingen-Housz-Oro S, Bernardeschi C, Schneider P, Mellottee B, Caux F, Prost-Squarcioni C. Gliptin Accountability in Mucous Membrane Pemphigoid Induction in 24 Out of 313 Patients. Front Immunol 2018; 9:1030. [PMID: 29881377 PMCID: PMC5976795 DOI: 10.3389/fimmu.2018.01030] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/24/2018] [Indexed: 01/27/2023] Open
Abstract
Mucous membrane pemphigoids (MMPs) and bullous pemphigoid (BP) are autoimmune bullous diseases that share physiopathological features: both can result from autoantibodies directed against BP180 or BP230 antigens. An association has been reported between BP and intake of gliptins, which are dipeptidyl peptidase-IV inhibitors used to treat type 2 diabetes mellitus. Clinical and immunological differences have been reported between gliptin-induced BPs and classical BPs: mucosal involvement, non-inflammatory lesions, and target BP180 epitopes other than the NC16A domain. Those findings accorded gliptins extrinsic accountability in triggering MMP onset. Therefore, we examined gliptin intrinsic accountability in a cohort of 313 MMP patients. To do so, we (1) identified MMP patients with gliptin-treated (challenge) diabetes; (2) selected those whose interval between starting gliptin and MMP onset was suggestive or compatible with gliptin-induced MMP; (3) compared the follow-ups of patients who did not stop (no dechallenge), stopped (dechallenge) or repeated gliptin intake (rechallenge); (4) compared the clinical and immunological characteristics of suggestive-or-compatible-challenge patients to 121 never-gliptin-treated MMP patients serving as controls; and (5) individually scored gliptin accountability as the trigger of each patient's MMP using the World Health Organization-Uppsala Monitoring Center, Naranjo- and Begaud-scoring systems. 17 out of 24 gliptin-treated diabetic MMP patients had suggestive (≤12 weeks) or compatible challenges. Complete remission at 1 year of follow-up was more frequent in the 11 dechallenged patients. One rechallenged patient's MMP relapsed. These 17 gliptin-treated diabetic MMP patients differed significantly from the MMP controls by more cutaneous, less buccal, and less severe involvements and no direct immunofluorescence IgA labeling of the basement membrane zone. Multiple autoantibody-target antigens/epitopes (BP180-NC16A, BP180 mid- and C-terminal parts, integrin α6β4) could be detected, but not laminin 332. Last, among the 24 gliptin-treated diabetic MMP patients, five had high (I4-I3), 12 had low (I2-I1) and 7 had I0 Begaud intrinsic accountability scores. These results strongly suggest that gliptins are probably responsible for some MMPs. Consequently, gliptins should immediately be discontinued for patients with a positive accountability score. Moreover, pharmacovigilance centers should be notified of these events.
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Affiliation(s)
- Olivier Gaudin
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - Vannina Seta
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Cochin Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Marina Alexandre
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - Gérôme Bohelay
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - Françoise Aucouturier
- Department of Immunology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Saint-Louis Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris, France
| | - Sabine Mignot-Grootenboer
- Department of Immunology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Bichat Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris, France
| | - Saskia Ingen-Housz-Oro
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Henri-Mondor Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Créteil, France
| | - Céline Bernardeschi
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Cochin Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Pierre Schneider
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Saint-Louis Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris, France
| | - Benoît Mellottee
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - Frédéric Caux
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
| | - Catherine Prost-Squarcioni
- Department of Dermatology, Referral Center for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
- Department of Histology, UFR Léonard de Vinci, Paris 13 University, Bobigny, France
- Department of Pathology, Avicenne Hospital, Assistance Publique Hôpitaux De Paris (AP-HP), Paris 13 University, Bobigny, France
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Maderal AD, Lee Salisbury P, Jorizzo JL. Desquamative gingivitis. J Am Acad Dermatol 2018; 78:851-861. [DOI: 10.1016/j.jaad.2017.04.1140] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/30/2017] [Indexed: 10/17/2022]
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Witte M, Zillikens D, Shimanovich I. Intravenous immunoglobulins for rituximab-resistant mucous membrane pemphigoid. J Eur Acad Dermatol Venereol 2018; 32:e321-e324. [PMID: 29443427 DOI: 10.1111/jdv.14873] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- M Witte
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - I Shimanovich
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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42
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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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Zehou O, Raynaud JJ, Le Roux-Villet C, Alexandre M, Airinei G, Pascal F, Heller M, Lièvre N, Laroche L, Caux F, Benamouzig R, Prost-Squarcioni C. Oesophageal involvement in 26 consecutive patients with mucous membrane pemphigoid. Br J Dermatol 2017; 177:1074-1085. [PMID: 28417469 DOI: 10.1111/bjd.15592] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Oesophageal involvement of mucous membrane pemphigoid (MMP) has not yet been thoroughly described. OBJECTIVES To characterize systematically the endoscopic lesions of a series of patients with oesophageal symptoms seen at a referral centre for autoimmune bullous diseases. METHODS Clinical, endoscopic and immunological findings of consecutively referred patients with MMP with oesophageal involvement, systemic and endoscopic treatments, and follow-up are described. RESULTS Of 477 consecutive patients with MMP consulting between 2002 and 2012, 26 (5·4%) had symptomatic oesophageal involvement. Dysphagia, observed in 23 (88%) patients, was the most frequent symptom. Oesophageal symptoms could be the first sign of MMP. Patients with oesophageal involvement had a mean of three other involved sites. At initial oesophageal endoscopy, 17 of 26 patients had active lesions (intact bullae, erosions and/or erythema), 15 had stricture(s) and 12 had other cicatricial lesions. Systemic therapy alone achieved oesophageal symptom relief for five patients. Dilatation was combined with systemic therapy for 12 patients and was successful in nine; one perforation occurred. CONCLUSIONS Symptomatic oesophageal involvement affected 5·4% of patients with MMP. Dermatologists and gastroenterologists should be aware of these mucocutaneous diseases and their oesophageal involvement, as it could lead to earlier diagnosis and better care. Oesophageal dilatation could be a therapeutic option for symptomatic stricture not relieved by optimized systemic therapy alone.
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Affiliation(s)
- O Zehou
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases, Avicenne Hospital, APHP, University Paris 13, 93009, Bobigny, France
| | - J-J Raynaud
- Department of Gastroenterology, Avicenne Hospital, APHP, University Paris 13, 93009, Bobigny, France
| | - C Le Roux-Villet
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases, Avicenne Hospital, APHP, University Paris 13, 93009, Bobigny, France
| | - M Alexandre
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases, Avicenne Hospital, APHP, University Paris 13, 93009, Bobigny, France
| | - G Airinei
- Department of Gastroenterology, Avicenne Hospital, APHP, University Paris 13, 93009, Bobigny, France
| | - F Pascal
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases, Avicenne Hospital, APHP, University Paris 13, 93009, Bobigny, France
| | - M Heller
- Department of Histology and Referral Center for Auto-Immune Bullous Diseases, UFR Léonard de Vinci, University Paris 13, 93017, Bobigny, France
| | - N Lièvre
- Department of Histology and Referral Center for Auto-Immune Bullous Diseases, UFR Léonard de Vinci, University Paris 13, 93017, Bobigny, France
| | - L Laroche
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases, Avicenne Hospital, APHP, University Paris 13, 93009, Bobigny, France
| | - F Caux
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases, Avicenne Hospital, APHP, University Paris 13, 93009, Bobigny, France
| | - R Benamouzig
- Department of Gastroenterology, Avicenne Hospital, APHP, University Paris 13, 93009, Bobigny, France
| | - C Prost-Squarcioni
- Department of Dermatology and Referral Center for Auto-Immune Bullous Diseases, Avicenne Hospital, APHP, University Paris 13, 93009, Bobigny, France.,Department of Histology and Referral Center for Auto-Immune Bullous Diseases, UFR Léonard de Vinci, University Paris 13, 93017, Bobigny, France.,Department of Pathology, Avicenne Hospital, APHP, University Paris 13, 93009, Bobigny, France
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Abstract
PURPOSE OF REVIEW Significant advances have been made in oncology and rheumatology with the introduction of molecularly targeted agents (MTAs). MTAs consist of monoclonal antibodies and small molecule inhibitors. The purpose of this manuscript is to review the recent applications of MTAs to orbital, lacrimal, and eyelid disease. RECENT FINDINGS The use of monoclonal antibodies has been described in the treatment of orbital vascular lesions, lymphoma, and squamous cell carcinoma. Inflammatory conditions treated with monoclonal antibodies include thyroid eye disease, IgG4 disease, and granulomatosis with polyangiitis. Immunotherapy with checkpoint inhibitors has also found applications to orbital disease. Use of small molecule inhibitors has been described in the treatment of basal cell carcinoma, squamous cell carcinoma, and Erdheim-Chester disease. There are many orbital, lacrimal, and eyelid side effects of MTAs with which the oculoplastic surgeon should be familiar, including hypertrichosis, edema, and orbital and eyelid inflammation. SUMMARY MTAs represent the future of treatment of oncologic and inflammatory conditions. Application of these agents to orbital, lacrimal, and eyelid disease will continue to expand. Elucidating the molecular mechanisms of oculoplastic disorders will facilitate additional potential pathways that could be targeted for therapy.
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45
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De A, Ansari A, Sharma N, Sarda A. Shifting Focus in the Therapeutics of Immunobullous Disease. Indian J Dermatol 2017; 62:282-290. [PMID: 28584371 PMCID: PMC5448263 DOI: 10.4103/ijd.ijd_199_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Therapeutics of autoimmune bullous disease has seen a major shift of focus from more global immunosuppression to targeted immunotherapy. Anti CD 20 monoclonal antibody Rituximab revolutionized the therapeutics of autoimmune bullous disease particularly pemphigus. Though it is still being practiced off-label, evidences in the form of RCT and meta analysis are now available. Other novel anti CD 20 monoclonal antibodies like ofatumumab, veltuzumab, and ocrelizumab, tositumomab or obinutuzumab/GA101 may add to the therapeutic options in coming days. Beyond anti CD 20 monoclonal antibodies other options that show promise at least in select scenario are omalizumab, TNF inhibitors plasmapheresis and intravenous immunoglobulin. The present article will discuss the role of rituximab and other newer therapeutics in the treatment of autoimmune blistering disease, especially pemphigus and suggests their positions in the therapeutic ladder.
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Affiliation(s)
- Abhishek De
- Associate Professor, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Asad Ansari
- Senior Resident, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Nidhi Sharma
- Senior Resident, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Aarti Sarda
- Senior Resident, KPC Medical College, Kolkata, West Bengal, India
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You C, Lamba N, Lasave AF, Ma L, Diaz MH, Foster CS. Rituximab in the treatment of ocular cicatricial pemphigoid: a retrospective cohort study. Graefes Arch Clin Exp Ophthalmol 2017; 255:1221-1228. [DOI: 10.1007/s00417-017-3603-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/05/2017] [Accepted: 01/23/2017] [Indexed: 10/20/2022] Open
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Dart JK. The 2016 Bowman Lecture Conjunctival curses: scarring conjunctivitis 30 years on. Eye (Lond) 2017; 31:301-332. [PMID: 28106896 DOI: 10.1038/eye.2016.284] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 11/07/2016] [Indexed: 12/22/2022] Open
Abstract
This review is in two sections. The first section summarises 35 conditions, both common and infrequent, causing cicatrising conjunctivitis. Guidelines for making a diagnosis are given together with the use of diagnostic tests, including direct and indirect immunofluorescence, and their interpretation. The second section evaluates our knowledge of ocular mucous membrane pemphigoid, which is the commonest cause of cicatrizing conjunctivitis in most developed countries. The clinical characteristics, demographics, and clinical signs of the disease are described. This is followed by a review and re-evaluation of the pathogenesis of conjunctival inflammation in mucous membrane pemphigoid (MMP), resulting in a revised hypothesis of the autoimmune mechanisms causing inflammation in ocular MMP. The relationship between inflammation and scarring in MMP conjunctiva is described. Recent research, describing the role of aldehyde dehydrogenase (ALDH) and retinoic acid (RA) in both the initiation and perpetuation of profibrotic activity in MMP conjunctival fibroblasts is summarised and the potential for antifibrotic therapy, using ALDH inhibition, is discussed. The importance of the management of the ocular surface in MMP is briefly summarised. This is followed with the rationale for the use of systemic immunomodulatory therapy, currently the standard of care for patients with active ocular MMP. The evidence for the use of these drugs is summarised and guidelines given for their use. Finally, the areas for research and innovation in the next decade are reviewed including the need for better diagnostics, markers of disease activity, and the potential for biological and topical therapies for both inflammation and scarring.
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Affiliation(s)
- J K Dart
- Ocular Biology and Therapeutics, UCL Institute of Ophthalmology, London, UK.,National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and The UCL Institute of Ophthalmology, London, UK.,Corneal and External Disease Service, Moorfields Eye Hospital, London, UK
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Combined Use of Rituximab and Intravenous Immunoglobulin for Severe Autoimmune Cicatricial Conjunctivitis—An Interventional Case Series. Cornea 2016; 35:1611-1614. [DOI: 10.1097/ico.0000000000001024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kim M, Borradori L, Murrell DF. Autoimmune Blistering Diseases in the Elderly: Clinical Presentations and Management. Drugs Aging 2016; 33:711-723. [DOI: 10.1007/s40266-016-0402-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Rituximab is a monoclonal antibody that depletes B cells from the circulation. It was originally used to treat lymphoma but is increasingly used for the treatment of autoimmune diseases. Rituximab was found to be effective in randomised controlled trials for rheumatoid arthritis, granulomatosis with polyangiitis and other antineutrophil cytoplasmic antibody-associated vasculitides. However, evidence of efficacy is very limited for many other autoimmune conditions. Before starting rituximab, it is important to check the patient's baseline immunoglobulins and immunisation status. Patients should also be screened for latent infections and other contraindications.
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