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van Beek N, Holtsche MM, Atefi I, Olbrich H, Schmitz MJ, Pruessmann J, Vorobyev A, Schmidt E. State-of-the-art diagnosis of autoimmune blistering diseases. Front Immunol 2024; 15:1363032. [PMID: 38903493 PMCID: PMC11187241 DOI: 10.3389/fimmu.2024.1363032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/15/2024] [Indexed: 06/22/2024] Open
Abstract
Autoimmune blistering disorders (AIBDs) are a heterogeneous group of approximately a dozen entities comprising pemphigus and pemphigoid disorders and dermatitis herpetiformis. The exact diagnosis of AIBDs is critical for both prognosis and treatment and is based on the clinical appearance combined with the detection of tissue-bound and circulating autoantibodies. While blisters and erosions on the skin and/or inspectable mucosal surfaces are typical, lesions may be highly variable with erythematous, urticarial, prurigo-like, or eczematous manifestations. While direct immunofluorescence microscopy (IFM) of a perilesional biopsy is still the diagnostic gold standard, the molecular identification of the major target antigens opened novel therapeutic avenues. At present, most AIBDs can be diagnosed by the detection of autoantigen-specific serum antibodies by enzyme-linked immunosorbent assay (ELISA) or indirect IFM when the clinical picture is known. This is achieved by easily available and highly specific and sensitive assays employing recombinant immunodominant fragments of the major target antigens, i.e., desmoglein 1 (for pemphigus foliaceus), desmoglein 3 (for pemphigus vulgaris), envoplakin (for paraneoplastic pemphigus), BP180/type XVII collagen (for bullous pemphigoid, pemphigoid gestationis, and mucous membrane pemphigoid), laminin 332 (for mucous membrane pemphigoid), laminin β4 (for anti-p200 pemphigoid), type VII collagen (for epidermolysis bullosa acquisita and mucous membrane pemphigoid), and transglutaminase 3 (for dermatitis herpetiformis). Indirect IFM on tissue substrates and in-house ELISA and immunoblot tests are required to detect autoantibodies in some AIBD patients including those with linear IgA disease. Here, a straightforward modern approach to diagnosing AIBDs is presented including diagnostic criteria according to national and international guidelines supplemented by long-term in-house expertise.
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Affiliation(s)
- Nina van Beek
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Maike M. Holtsche
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Ingeborg Atefi
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Henning Olbrich
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Marie J. Schmitz
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Jasper Pruessmann
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Artem Vorobyev
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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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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3
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Syal A, Lott DG, Karle WE. Radiation-Induced Laryngeal Mucous Membrane Pemphigoid. Ann Otol Rhinol Laryngol 2023; 132:1261-1264. [PMID: 36433793 DOI: 10.1177/00034894221139121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
OBJECTIVES Bullous pemphigoid has previously been linked to radiotherapy, but here we report the first case of MMP suspected to be a consequence of RT. METHODS The patient described is an 85-year-old male who underwent RT to treat squamous cell carcinoma of the palatine tonsil. Shortly after therapy, the patient developed blisters with worsening dyspnea and dysphonia. RESULTS This patient was successfully treated with a combination of oral immunosuppressants and surgical intervention. CONCLUSION This incident underscores that not all episodes of mucosal ulceration following radiation are a result of mucositis and MMP should be considered in the differential. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Amit Syal
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - David G Lott
- Department of Otolaryngology, Mayo Clinic in Arizona, Phoenix, AZ, USA
| | - William E Karle
- Department of Otolaryngology, Mayo Clinic in Arizona, Phoenix, AZ, USA
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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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6
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Kurzeja M, Olszewska M, Grzybowski A, Rudnicka L. Ocular involvement in autoimmune bullous diseases. Clin Dermatol 2023; 41:481-490. [PMID: 37586570 DOI: 10.1016/j.clindermatol.2023.08.007] [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: 08/18/2023]
Abstract
Autoimmune bullous diseases represent a heterogenous group of disorders caused by autoantibodies against adhesion molecules; the location of the target protein determines the level of cleft formation. The spectrum of ocular lesions in autoimmune bullous diseases can range from mild symptoms to severe involvement with sight impairment and even, in some cases, blindness. In pemphigus vulgaris, the prevalence of ocular involvement has been reported to be between 7% and 26%. The most common clinical sign of ocular pemphigus vulgaris is bilateral conjunctivitis with hyperemia. Ocular involvement also occurs in 41% to 70% of patients with paraneoplastic pemphigus. The main ocular manifestations are bilateral cicatrizing conjunctivitis with symblepharon formation, and shortening of the fornices. In mucous membrane pemphigoid, ocular involvement is seen in 61% to 70% of patients; the most frequent ocular finding is cicatricial conjunctivitis. Patients with autoimmune bullous diseases having common ocular involvement should be assessed by an ophthalmologist to avoid serious complications. Diagnostic procedures and treatment require multidisciplinary care based on the close cooperation between dermatologists and ophthalmologists.
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Affiliation(s)
- Marta Kurzeja
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland.
| | | | - Andrzej Grzybowski
- Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland; Institute for Research in Ophthalmology, Poznań, Poland
| | - Lidia Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
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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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8
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Yaïci R, Roth M, Geerling G. [Initial results of the German ocular pemphigoid register]. DIE OPHTHALMOLOGIE 2023; 120:502-507. [PMID: 37115219 DOI: 10.1007/s00347-023-01859-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 04/29/2023]
Abstract
Mucous membrane pemphigoid (MMP) is a rare disease that presents clinicians with a diagnostic and therapeutic challenge. The aim of this article is to present the German ocular pemphigoid register, which is a retrospective data collection and a collaborative network to improve the care of these patients. It was founded in 2020 and currently comprises 17 eye clinics/cooperation partners. An initial evaluation of the results shows a known epidemiological profile and an expected high proportion of patients with negative diagnostics (48.6%) despite a clinically suspected diagnosis. In this register study predominantly recruiting from eye clinics, the proportion of patients with a strictly ocular involvement was 65.4%. Also of interest was the high number of patients with glaucoma (22.3%) as the most frequent comorbidity. Based on the working group formed, a prospective survey will be conducted in the future, which enables a follow-up.
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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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9
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Kern JS, Hofmann SC. [Management of bullous pemphigoid and mucous membrane pemphigoid]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2022; 74:927-936. [PMID: 37843581 DOI: 10.1007/s00105-023-05241-3] [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: 09/19/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common blistering autoimmune dermatosis and, as an age-associated disease, is also the bullous dermatosis with the highest increase in incidence in recent years due to demographic developments. Mucous membrane pemphigoid (MMP), which is less common, is a clinically and immunopathologically heterogeneous blistering autoimmune dermatosis characterized by blisters and erosions on mucous membranes. OBJECTIVE This work summarizes the manifold clinical characteristics of both diseases and provides an up-to-date overview of diagnostics and therapy of BP and SHP. MATERIALS AND METHODS A selective literature search was carried out. RESULTS While eczematous, urticarial, or bullous lesions on the integument are typical for BP, MMP is characterized by pronounced, erosive mucosal changes orally, ocularly, genitoanally, tracheally or esophageally and, at most, only minor skin involvement. For diagnosis, the combination of histology, direct immunofluorescence microscopy, and serological detection of autoantibodies against the hemidesmosomal proteins BP180 and BP230 and, in MMP, also against laminin 332 is important. New pathophysiological findings and therapeutics have recently significantly expanded the range of treatment options. CONCLUSION Due to the comorbidities of the usually elderly BP patients and the often multiple affected mucous membranes in MMP, with the risk of developing irreversible complications such as strictures and synechiae, interdisciplinary diagnosis and therapy is often required.
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Affiliation(s)
- Johannes S Kern
- Department of Dermatology, Alfred Hospital, Central Clinical School, Monash University, 55 Commercial Road, 3004, Melbourne Victoria, Australien.
| | - Silke C Hofmann
- Zentrum für Dermatologie, Allergologie und Dermatochirurgie, HELIOS Universitätsklinikum Wuppertal, Universität Witten/Herdecke, Heusnerstr. 40, 42283, Wuppertal, Deutschland.
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10
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Didona D, Hinterseher J, Eming R. [Bullous autoimmune dermatoses of the mucous membranes]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2022; 73:692-700. [PMID: 36006424 DOI: 10.1007/s00105-022-05036-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
Autoimmune bullous diseases (AIBD) comprise a group of organ-specific autoimmune diseases which are characterised by the production of autoantibodies against adhesion molecules and structural proteins of skin and mucosae. Depending on the target protein, AIBD are classified into intraepidermal (pemphigus group) and subepidermal (pemphigoid group, epidermolysis bullosa acquisita, dermatitis herpetiformis) blistering disorders. Depending on the clinical entity, patients can develop blisters, pustules, erosions, and erythema on the skin and mucosae.
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Affiliation(s)
- Dario Didona
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Marburg, Deutschland.
| | - Julia Hinterseher
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Marburg, Deutschland
| | - Rüdiger Eming
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Marburg, Deutschland
- Klinik III Dermatologie, Venerologie und Allergologie, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
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11
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Abstract
Since the beginning of the COVID-19 outbreak, attention has gradually moved from the respiratory manifestations of the disease toward its dermatologic aspects. The need for wearing personal protective measures and their cutaneous side effects, detection of related or specific COVID-19 skin eruptions, and the evaluation of certain risk groups of immunosuppressed dermatologic patients have initiated significant discussions about various therapeutic interventions and, in particular, about biologic therapy for psoriasis and for autoinflammatory, orphan, or malignant cutaneous disorders. Autoimmune bullous dermatoses have been of concern due to their chronic course, at times life-threatening prognosis, and the need for prolonged and often aggressive immunomodulatory therapy. We have summarized the current knowledge regarding the impact of COVID-19 infection on autoimmune bullous dermatoses, including recommendations for the main treatment strategies, available patient information, and the registries organized for documentation during the COVID-19 pandemic.
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Affiliation(s)
- Kossara Drenovska
- Department of Dermatology and Venereology, University Hospital "Alexandrovska," Medical University-Sofia, Sofia, Bulgaria.
| | - Snejina Vassileva
- Department of Dermatology and Venereology, University Hospital "Alexandrovska," Medical University-Sofia, Sofia, Bulgaria
| | - Ivan Tanev
- ZRENIE Private Eye Clinic, Sofia, Bulgaria
| | - Pascal Joly
- Department of Dermatology, Rouen University Hospital and INSERM U905, Centre de référence des maladies bulleuses autoimmunes, Normandie University, Rouen, France
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12
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Beek NV, Zillikens D, Schmidt E. Bullous Autoimmune Dermatoses. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:413-420. [PMID: 34369370 DOI: 10.3238/arztebl.m2021.0136] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 08/03/2020] [Accepted: 01/27/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Bullous autoimmune dermatoses are a clinically and immunopatho - logically heterogeneous group of diseases, characterized clinically by blisters or erosions of the skin and/or mucous membranes. In Germany, their prevalence is approximately 40 000 cases nationwide, and their incidence approximately 20 new cases per million people per year. METHODS This review is based on publications that were retrieved by a selective search of the literature focusing on the current German and European guidelines. RESULTS Recent years have seen the publication of guidelines, controlled prospective clinical trials, and multicenter diagnostic studies improving both diagnosis and therapy. Specific monovalent and multivariate serological test systems and pattern analysis of tissue-bound autoantibodies allow identification of the target antigens in 80-90% of patients. This enables the precise classification of disease entities, with implications for treatment selection and disease outcome. In 2019, the anti-CD20 antibody rituximab was approved by the European Medicines Agency for the treatment of moderate and severe pemphigus vulgaris, with an ensuing marked improvement in the care of the affected patients. To treat mild and moderate bullous pemphigoid, topical clobetasol proprionate is recommended, in severe disease, combined with systemic treatment, i.e. usually (a) prednisolone p.o. at an initial dose of 0.5mg/kg/d , (b) an immunomodulant, e.g. dapsone or doxycycline, or (c) prednisolone plus an immunomodulant. CONCLUSION The early recognition and precise diagnostic evaluation of bullous autoimmune dermatoses now enables improved, often interdisciplinary treatment, in accordance with the available guidelines. Current research projects are focused on new treatment approaches, an improved understanding of the underlying pathophysiology, and further refinements of diagnostic techniques.
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Affiliation(s)
- Nina van Beek
- Department of Dermatology, Venereology, and Allergology, University of Lübeck, Lübeck, Germany; Lubeck Institute of Experimental Dermatology (LIED), University of Lubeck, Lubeck, Germany
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13
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Abstract
Paraneoplastic skin manifestations associated with malignancies are extremely polymorphous. Clinicians should be familiar with paraneoplastic dermatoses to establish an early diagnosis of the underlying neoplasm. Lack of familiarity with cutaneous clues for internal malignancies may delay diagnosis and treatment of cancer. In this review, we describe several paraneoplastic autoimmune dermatoses, including paraneoplastic autoimmune multiorgan syndrome, paraneoplastic bullous pemphigoid, and paraneoplastic dermatomyositis.
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Affiliation(s)
- D Didona
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Baldingerstr., 35043, Marburg, Deutschland.
| | - M Hertl
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Baldingerstr., 35043, Marburg, Deutschland
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14
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Hofmann SC, Juratli HA, Eming R. Bullöse Autoimmundermatosen. J Dtsch Dermatol Ges 2019; 16:1339-1360. [PMID: 30395404 DOI: 10.1111/ddg.13688_g] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/16/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Silke C Hofmann
- Zentrum für Dermatologie, Allergologie und Dermatochirurgie, HELIOS Universitätsklinikum Wuppertal, Universität Witten/Herdecke
| | - Hazem A Juratli
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg
| | - Rüdiger Eming
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg
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15
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Hofmann SC, Juratli HA, Eming R. Bullous autoimmune dermatoses. J Dtsch Dermatol Ges 2019; 16:1339-1358. [PMID: 30395395 DOI: 10.1111/ddg.13688] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/16/2018] [Indexed: 12/12/2022]
Abstract
Pathophysiologically, bullous autoimmune dermatoses are caused by autoantibodies directed against adhesion molecules or structural proteins of the skin and mucous membranes, clinically resulting in blister formation. Depending on the respective target proteins of the autoimmune response and their location in the skin, a distinction is made between intraepidermal (pemphigus disorders), junctional (pemphigoid disorders), and subepidermal (epidermolysis bullosa acquisita, dermatitis herpetiformis) autoimmune blistering diseases. The most common bullous autoimmune dermatosis, bullous pemphigoid is characterized by marked clinical variability and intense pruritus. Predominantly affecting elderly individuals, there has been a significant increase in its incidence in recent years. While mucosal lesions occur in less than 30 % of bullous pemphigoid patients, the second most common bullous autoimmune dermatosis, pemphigus vulgaris, typically presents with oral erosions as the predominant and - frequently - initial symptom. Its onset is usually in the 4th to 6th decade of life. Scarring is typically found in subepidermal blistering disorders such as epidermolysis bullosa acquisita or mucous membrane pemphigoid. Diagnosis is based on clinical and histological findings as well as direct and indirect immunofluorescence and detection of circulating autoantibodies. Although a number of controlled clinical trials have been conducted in recent years, treatment of bullous autoimmune disorders is still primarily based on clinical experience. Therapeutic options include topical and systemic corticosteroids as well as adjuvant immunosuppressants. Recalcitrant cases may require treatment with immunoadsorption, intravenous immunoglobulins, or the monoclonal anti-CD20 antibody rituximab.
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Affiliation(s)
- Silke C Hofmann
- Department of Dermatology, Allergology and Dermatosurgery, HELIOS University Medical Center of Witten/Herdecke University, Wuppertal, Germany
| | - Hazem A Juratli
- Department of Dermatology and Allergology, Marburg University Medical Center, Marburg, Germany
| | - Rüdiger Eming
- Department of Dermatology and Allergology, Marburg University Medical Center, Marburg, Germany
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16
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Syring FM, Zillikens D, Schmidt E, Kasperkiewicz M. [Anti-laminin 332 mucous membrane pemphigoid with irreversible ocular and tracheobronchial involvement : Delayed diagnosis of a severe autoimmune bullous disease]. DER HAUTARZT 2019; 70:367-370. [PMID: 30963224 DOI: 10.1007/s00105-019-4402-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A 53-year-old man presented with a 37-year history of erosive and scarring mucosal lesions of several organs. An initial diagnosis of Stevens-Johnson syndrome was maintained for many years. Due to late correct diagnosis of an anti-laminin 332 mucous membrane pemphigoid and the fact that early, targeted, intensified immunosuppressive therapy was not initiated, the disease led to almost complete loss of vision and obstruction of airways.
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Affiliation(s)
- F M Syring
- Klinik für Dermatologie, Allergologie und Venerologie, Universität Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - D Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universität Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - E Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universität Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - M Kasperkiewicz
- Klinik für Dermatologie, Allergologie und Venerologie, Universität Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
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18
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Abstract
Autoimmmune bullous diseases are mediated by pathogenetically relevant autoantibodies against components of the epidermis and/or superficial mucous membranes (in pemphigus) and structural proteins of the dermal-epidermal junction (in pemphigoid diseases). Using immunoadsorption (IA), an already well-established procedure in cardiac and rheumatic disorders, antibodies can be removed from the plasma. At present, most data on the adjuvant use of IA in dermatology are derived from patients with severe and/or refractory pemphigus vulgaris or pemphigus foliaceus and also from patients with pemphigoid diseases. Additionally, in the last few years different protocols for IA in patients with severe atopic dermatitis and elevated total serum IgE levels have been published. While panimmunoglobulin adsorbers are mainly used in dermatology, an IgE-specific adsorber has been used in some patients with atopic dermatitis and in the future, antigen-specific adsorbers are to be expected that will enable the specific reduction of autoantibodies.
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Affiliation(s)
- Franziska Hübner
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - Michael Kasperkiewicz
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - Detlef Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - Enno Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland. .,Lübecker Institut für Experimentelle Dermatologie (LIED), Universität zu Lübeck, Lübeck, Deutschland.
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19
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Witte M, Zillikens D, Schmidt E. Diagnosis of Autoimmune Blistering Diseases. Front Med (Lausanne) 2018; 5:296. [PMID: 30450358 PMCID: PMC6224342 DOI: 10.3389/fmed.2018.00296] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/05/2018] [Indexed: 12/11/2022] Open
Abstract
Autoimmune skin blistering diseases (AIBD) are characterized by autoantibodies that are directed against structural proteins in the skin and adjacent mucous membranes. Some clinical signs are typical for a specific AIBD, however, correct diagnosis requires the detection of tissue-bound or circulating autoantibodies. The gold standard for diagnosis of AIBD is the detection of autoantibodies or complement component 3 by direct immunofluorescence (DIF) microscopy of a perilesional biopsy. Circulating antibodies can be detected via indirect immunofluorescence (IIF) microscopy of different tissue substrates including human skin, monkey esophagus, and more recently, recombinant forms of the different target antigens. Latter are also employed in various commercial ELISA systems and by immunoblotting in in-house assays available in specialized laboratories. ELISA systems are also particularly valuable for monitoring of the disease activity during the disease course which can be helpful for treatment decisions. Exact diagnosis is essential for both treatment and prognosis, since some AIBD are associated with malign tumors such as paraneoplastic pemphigus and anti-laminin 332 mucous membrane pemphigoid. This review presents clinical and immunopathological features of AIBD for the state-of the art diagnosis of these disorders.
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Affiliation(s)
- Mareike Witte
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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[85-year-old male with cutaneous blisters : Preparation for the medical specialist examination: Part 25]. Hautarzt 2018; 69:183-188. [PMID: 30374540 DOI: 10.1007/s00105-018-4291-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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