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Vafaeian A, Mahmoudi H, Daneshpazhooh M. What is novel in the clinical management of pemphigus vulgaris? Expert Rev Clin Pharmacol 2024; 17:489-503. [PMID: 38712540 DOI: 10.1080/17512433.2024.2350943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/30/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Pemphigus, an uncommon autoimmune blistering disorder affecting the skin and mucous membranes, currently with mortality primarily attributed to adverse reactions resulting from treatment protocols. Additionally, the existing treatments exhibit a notable recurrence rate. The high incidence of relapse and the considerable adverse effects associated with treatment underscore the imperative to explore safer and more effective therapeutic approaches. Numerous potential therapeutic targets have demonstrated promising outcomes in trials or preliminary research stages. These encompass anti-CD-20 agents, anti-CD-25 agents, TNF-α inhibition, FAS Ligand Inhibition, FcRn inhibition, BAFF inhibition, Bruton's tyrosine kinase (BTK) inhibition, CAAR T Cells, JAK inhibition, mTOR inhibition, abatacept, IL-4 inhibition, IL-17 inhibition, IL-6 inhibition, polyclonal Regulatory T Cells, and autologous hematopoietic stem cell transplantation. AREAS COVERED The most significant studies regarding the impact and efficacy of the mentioned treatments on pemphigus were meticulously curated through a comprehensive search conducted on the PubMed database. Moreover, the investigations of interest cited in these studies were also integrated. EXPERT OPINION The efficacy and safety profiles of the other treatments under discussion do not exhibit the same level of robustness as anti-CD20 therapy, which is anticipated to endure as a critical element in pemphigus treatment well into the foreseeable future.
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Affiliation(s)
- Ahmad Vafaeian
- Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Mahmoudi
- Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Starr H, Howerth EW, Leon R, Gogal RM, Banovic F. Microarray Gene Expression Analysis of Lesional Skin in Canine Pemphigus Foliaceus. Vet Sci 2024; 11:89. [PMID: 38393106 PMCID: PMC10893259 DOI: 10.3390/vetsci11020089] [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: 12/11/2023] [Revised: 02/02/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
Canine pemphigus foliaceus (PF) is considered the most common autoimmune skin disease in dogs; the mechanism of PF disease development is currently poorly understood. Therefore, this study aimed to characterize the molecular mechanisms and altered biological pathways in the skin lesions of canine PF patients. Using an RNA microarray on formalin-fixed, paraffin-embedded samples, we analyzed the transcriptome of canine PF lesional skin (n = 7) compared to healthy skin (n = 5). Of the 800 genes analyzed, 420 differentially expressed genes (DEGs) (p < 0.05) were found. Of those, 338 genes were significantly upregulated, including pro-inflammatory and Th17-related genes. Cell type profiling found enhancement of several cell types, such as neutrophils, T-cells, and macrophages, in PF skin compared to healthy skin. Enrichment analyses of the upregulated DEGs resulted in 78 statistically significant process networks (FDR < 0.05), including the Janus kinase signal transducer and activator of transcription (JAK-STAT) and mitogen-activated protein kinase (MAPK) signaling. In conclusion, canine PF lesional immune signature resembles previously published changes in human pemphigus skin lesions. Further studies with canine PF lesional skin using next-generation sequencing (e.g., RNA sequencing, spatial transcriptomics, etc.) and the development of canine keratinocyte/skin explant PF models are needed to elucidate the pathogenesis of this debilitating disease.
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Affiliation(s)
- Haley Starr
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA; (H.S.); (R.L.)
| | - Elizabeth W. Howerth
- Department of Pathology, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA;
| | - Renato Leon
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA; (H.S.); (R.L.)
| | - Robert M. Gogal
- Department of Biomedical Sciences, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA;
| | - Frane Banovic
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA; (H.S.); (R.L.)
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Wang R, Wang M. A case of herpetiform pemphigus mimicking bullous pemphigoid after using secukinumab and successfully treated with sulfasalazine. J Dermatol 2023; 50:1625-1628. [PMID: 37641883 DOI: 10.1111/1346-8138.16936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/02/2023] [Accepted: 08/12/2023] [Indexed: 08/31/2023]
Abstract
Interleukin 17A (IL-17A) inhibitors, such as secukinumab, have been widely used as the mainstream treatment for chronic plaque psoriasis; however, cutaneous adverse events have been reported. Here, we report a 43-year-old Chinese man who developed herpetiform pemphigus (HP) during secukinumab treatment for his psoriasis. He presented with (1) clinical features of HP, which resembled bullous pemphigoid; histopathological features of intraepidermal blisters, eosinophilic/neutrophilic spongiosis, and liquefactive degeneration of the basal cell layer; (3) positive anti-desmoglein 1 antibody by enzyme-linked immunosorbent assay and cell surface IgG reactivity within the epidermis by indirect immunofluorescence assay; and (4) a satisfactory response to salicylazosulfapyridine (sulfasalazine). To the best of our knowledge, this is the first report of the development of HP after the use of secukinumab for psoriasis.
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Affiliation(s)
- Rui Wang
- Department of Dermatology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
- NMPA Key Laboratory for Quality Control and Evaluation of Cosmetics, Beijing, China
| | - Mingyue Wang
- Department of Dermatology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
- NMPA Key Laboratory for Quality Control and Evaluation of Cosmetics, Beijing, China
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Starr H, Howerth E, Gogal R, Barber J, Leon R, Blubaugh A, Banovic F. Characterization of the serum and skin inflammatory profile in canine pemphigus foliaceus using multiplex assay and quantitative real-time polymerase chain reaction (qRT-PCR). Vet Immunol Immunopathol 2023; 262:110631. [PMID: 37473673 DOI: 10.1016/j.vetimm.2023.110631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/11/2023] [Accepted: 07/14/2023] [Indexed: 07/22/2023]
Abstract
Canine pemphigus foliaceus (PF) is a common autoimmune skin disease characterized by autoantibodies binding to epithelial adhesion molecules resulting inflammatory response. The immune network of cytokine and chemokine abnormalities that characterize the immune response in canine PF are poorly explored. This study evaluated serum and lesional skin cytokine and chemokine profiles of dogs diagnosed with PF compared to healthy control dogs. Serum samples obtained from 11 PF dogs and 16 healthy control dogs were analyzed using commercially available canine multiplex assay for 13 biomarkers (Canine Milliplex assay). Eight lesional skin samples from seven PF dogs and five healthy site-matched samples from five healthy dogs were evaluated for 20 immune markers using quantitative real-time PCR. Immunomodulating medications were suspended for at least four weeks in all dogs before obtaining serum and skin samples. PF patients showed significantly higher serum concentrations of tumor necrosis factor-α, interleukin (IL)- 6, IL-8, IL-18, CCL2, KC-like, and granulocyte-macrophages colony-stimulating factor when compared to healthy controls (Mann-Whitney U test; p < 0.05 for all). Lesional PF skin exhibited significant expression and upregulation of pro-inflammatory/T helper (Th1) 1 markers IL-1β, MX1, GZMB, OAS1, and IFN-γ as well as Th2 cytokines IL-13, IL-33, TSLP, IL-31 and Th17/22 markers IL-17A and IL-22 (Mann-Whitney U test; p < 0.05 for all). Taken together, the findings from this study describe the role of numerous cytokines and chemokines associated with immune response in the skin and serum of canine PF patients. Further larger-sample proteomics and RNA-sequencing transcriptomics studies are needed to understand the immune pathogenesis of canine PF skin lesions.
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Affiliation(s)
- Haley Starr
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine University of Georgia, Athens, GA 30602, USA
| | - Elizabeth Howerth
- Department of Pathology, College of Veterinary Medicine University of Georgia, Athens, GA 30602, USA
| | - Robert Gogal
- Department of Biosciences and Diagnostic Imaging, University of Georgia, Athens, GA 30602, USA
| | - Jamie Barber
- Department of Infectious Disease, University of Georgia, Athens, GA 30602, USA
| | - Renato Leon
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine University of Georgia, Athens, GA 30602, USA
| | - Amanda Blubaugh
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine University of Georgia, Athens, GA 30602, USA
| | - Frane Banovic
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine University of Georgia, Athens, GA 30602, USA.
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Minai L, Takeichi T, Ogawa Y, Honobe-Tabuchi A, Okamoto T, Mitsui H, Shimada S, Akiyama M, Kawamura T. Development of pemphigus vegetans and exacerbation of pemphigus foliaceus after secukinumab loading in a patient with complicated generalized pustular psoriasis and pyoderma gangrenosum. J Dermatol 2023; 50:245-249. [PMID: 36052669 DOI: 10.1111/1346-8138.16563] [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: 06/03/2022] [Revised: 07/30/2022] [Accepted: 08/15/2022] [Indexed: 02/04/2023]
Abstract
In dermatology, biologics that block signaling pathways of TNF-α, IL-4/IL13, IL-17s, and IL-23 are widely used for the treatment of several inflammatory skin diseases, such as atopic dermatitis and psoriasis. They have shown excellent efficacy with an acceptable safety profile. However, these biologics targeting pathogenic cytokines and their receptors could modulate immunological balance, leading to the development of other inflammatory or autoimmune skin diseases in some cases. In this study, we present a patient who suffered pemphigus vegetans and showed an exacerbation of pemphigus foliaceus after secukinumab loading for the treatment of complicated generalized pustular psoriasis and pyoderma gangrenosum.
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Affiliation(s)
- Lisa Minai
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Takuya Takeichi
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Youichi Ogawa
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Akiko Honobe-Tabuchi
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Takashi Okamoto
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Hiroshi Mitsui
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Shinji Shimada
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Masashi Akiyama
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tatsuyoshi Kawamura
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
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Godsel LM, Roth-Carter QR, Koetsier JL, Tsoi LC, Huffine AL, Broussard JA, Fitz GN, Lloyd SM, Kweon J, Burks HE, Hegazy M, Amagai S, Harms PW, Xing X, Kirma J, Johnson JL, Urciuoli G, Doglio LT, Swindell WR, Awatramani R, Sprecher E, Bao X, Cohen-Barak E, Missero C, Gudjonsson JE, Green KJ. Translational implications of Th17-skewed inflammation due to genetic deficiency of a cadherin stress sensor. J Clin Invest 2021; 132:144363. [PMID: 34905516 PMCID: PMC8803337 DOI: 10.1172/jci144363] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/08/2021] [Indexed: 11/17/2022] Open
Abstract
Desmoglein 1 (Dsg1) is a cadherin restricted to stratified tissues of terrestrial vertebrates, which serve as essential physical and immune barriers. Dsg1 loss-of-function mutations in humans result in skin lesions, multiple allergies, and isolated patient keratinocytes exhibit increased pro-allergic cytokine expression. However, the mechanism by which genetic deficiency of Dsg1 causes chronic inflammation is unknown. To determine the systemic response to Dsg1 loss, we deleted the three tandem Dsg1 genes in mice. Whole transcriptome analysis of embryonic Dsg1-/- skin showed a delay in expression of adhesion/differentiation/keratinization genes at E17.5, a subset of which recovered or increased by E18.5. Comparing epidermal transcriptomes from Dsg1-deficient mice and humans revealed a shared IL-17-skewed inflammatory signature. Although the impaired intercellular adhesion observed in Dsg1-/- mice resembles that resulting from anti-Dsg1 pemphigus foliaceus antibodies, pemphigus skin lesions exhibit a weaker IL-17 signature. Consistent with the clinical importance of these findings, treatment of two Dsg1-deficient patients with an IL-12/IL-23 antagonist originally developed for psoriasis resulted in improvement of skin lesions. Thus, beyond impairing the physical barrier, loss of Dsg1 function through gene mutation results in a psoriatic-like inflammatory signature before birth and treatment with a targeted therapy markedly improved skin lesions in patients.
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Affiliation(s)
- Lisa M Godsel
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | - Quinn R Roth-Carter
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | - Jennifer L Koetsier
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | - Lam C Tsoi
- Department of Dermatology, University of Michigan, Ann Arbor, United States of America
| | - Amber L Huffine
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | - Joshua A Broussard
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | - Gillian N Fitz
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | - Sarah M Lloyd
- Department of Molecular Biosciences, Northwestern University, Chicago, United States of America
| | - Junghun Kweon
- Department of Molecular Biosciences, Northwestern University, Chicago, United States of America
| | - Hope E Burks
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | - Marihan Hegazy
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | - Saki Amagai
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | - Paul W Harms
- Department of Pathology, University of Michigan, Ann Arbor, United States of America
| | - Xianying Xing
- Department of Dermatology, University of Michigan, Ann Arbor, United States of America
| | - Joseph Kirma
- Department of Dermatology, University of Michigan, Ann Arbor, United States of America
| | - Jodi L Johnson
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | | | - Lynn T Doglio
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | - William R Swindell
- Department of Internal Medicine, The Jewish Hospital, Cincinnati, United States of America
| | - Rajeshwar Awatramani
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | - Eli Sprecher
- Department of Dermatology, Tel Aviv University, Tel Aviv, Israel
| | - Xiaomin Bao
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
| | | | | | - Johann E Gudjonsson
- Department of Dermatology, University of Michigan, Ann Arbor, United States of America
| | - Kathleen J Green
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, United States of America
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Schauer F, Meiss F, Thoma K, Kiritsi D. IL17 inhibition for psoriasis vulgaris and arthritis results in clinical and serological remission of coexistent pemphigus foliaceus. J Dermatol 2021; 48:e246-e247. [PMID: 33580898 DOI: 10.1111/1346-8138.15801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 01/25/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Franziska Schauer
- Department of Dermatology, Medical Center- University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Frank Meiss
- Department of Dermatology, Medical Center- University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kaethe Thoma
- Department of Dermatology, Medical Center- University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dimitra Kiritsi
- Department of Dermatology, Medical Center- University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Holstein J, Solimani F, Baum C, Meier K, Pollmann R, Didona D, Tekath T, Dugas M, Casadei N, Hudemann C, Polakova A, Matthes J, Schäfer I, Yazdi AS, Eming R, Hertl M, Pfützner W, Ghoreschi K, Möbs C. Immunophenotyping in pemphigus reveals a T H17/T FH17 cell-dominated immune response promoting desmoglein1/3-specific autoantibody production. J Allergy Clin Immunol 2020; 147:2358-2369. [PMID: 33221382 DOI: 10.1016/j.jaci.2020.11.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 10/19/2020] [Accepted: 11/13/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND TH2 cells were thought to be a pivotal factor for initiation of the autoimmune blistering disease pemphigus. However, the role of other T-cell subsets in pemphigus pathogenesis remained unclear. OBJECTIVE We aimed to characterize the exact phenotype of T cells responsible for the development of pemphigus. METHODS Whole transcriptome shotgun sequencing was performed to determine differential gene expression in pemphigus lesions and skin of healthy individuals. The cutaneous cytokine signature was further evaluated by real-time quantitative PCR. In peripheral blood, the distribution of TH cell and folliclular helper (TFH) cell subsets was analyzed by flow cytometry. Finally, the capacity of TH and TFH cell subsets to induce desmoglein (Dsg)-specific autoantibodies by memory B cells was evaluated in coculture experiments. RESULTS Transcriptome analysis of skin samples identified an IL-17A-dominated immune signature in patients with pemphigus, and Kyoto Encyclopedia of Genes and Genomes pathway analysis confirmed the dominance of the IL-17A signaling pathway. Increased expression of IL17A and associated cytokines was also detected by real-time quantitative PCR comparing lesional with perilesional or healthy skin. Interestingly, utilization of flow cytometry showed that patients with active pemphigus had elevated levels of circulating IL-17+, TH17, TFH17, and TFH17.1 cells. Notably, levels of TH17 and TFH17 cells correlated with levels of Dsg-specific CD19+CD27+ memory B cells, and patients with acute pemphigus showed higher levels of Dsg3-autoreactive TFH17 cells. Coculture experiments revealed TFH17 cells as primarily responsible for inducing Dsg-specific autoantibody production by B cells. CONCLUSION Our findings show that TFH17 cells are critically involved in the pathogenesis of pemphigus and offer novel targets for therapeutic intervention.
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Affiliation(s)
- Julia Holstein
- Department of Dermatology, University Medical Center, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Farzan Solimani
- Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Carolin Baum
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Katharina Meier
- Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Robert Pollmann
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Dario Didona
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Tobias Tekath
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Martin Dugas
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Nicolas Casadei
- Institute of Medical Genetics and Applied Genomics, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Christoph Hudemann
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Alexandra Polakova
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Jakob Matthes
- Institute of Medical Genetics and Applied Genomics, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Iris Schäfer
- Department of Dermatology, University Medical Center, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Amir S Yazdi
- Department of Dermatology and Allergology, Uniklinik RWTH Aachen, Aachen, Germany
| | - Rüdiger Eming
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Wolfgang Pfützner
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Kamran Ghoreschi
- Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
| | - Christian Möbs
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
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