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van Beek N, Eming R, Reuss A, Zillikens D, Sárdy M, Günther C, Kiritsi D, Benoit S, Beissert S, Gläser R, Gollnick H, Horváth ON, Pfeiffer C, Röcken M, Schauer F, Schreml S, Steinbrink K, Zink A, Schade-Brittinger C, Hertl M, Schmidt E. Efficacy and safety of adjuvant immunoadsorption in pemphigus vulgaris and pemphigus foliaceus (IA-Pem Study): a multicentre randomized controlled trial. Br J Dermatol 2024; 190:657-667. [PMID: 38133541 DOI: 10.1093/bjd/ljad489] [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: 08/31/2023] [Revised: 11/23/2023] [Accepted: 11/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are potentially life-threatening autoimmune blistering diseases. Treatment is based on long-term immunosuppression with high doses of glucocorticosteroids in combination with potentially corticosteroid-sparing agents and/or rituximab. Immunoadsorption (IA) has emerged as a fast-acting adjuvant treatment option. OBJECTIVES To assess the clinical efficacy of IA in addition to best medical treatment (BMT). METHODS We conducted a multicentre (26 centres from Germany and Austria) randomized controlled trial in 72 patients with newly diagnosed, relapsed or chronic active PV or PF (34 female patients and 38 male patients, aged 42-72 years) comparing BMT (prednisolone 1.0 mg kg-1 per day plus azathioprine or mycophenolate) with adjuvant IA (BMT + IA). Central 1 : 1 randomization was done at the coordinating centre for clinical trials (KKS Marburg). The primary endpoint was analysed using Kaplan-Meier and Cox regression methods. RESULTS The study was ended prematurely owing to safety concerns after random allocation of 72 patients to BMT + IA (n = 34) or BMT (n = 38). The primary endpoint, time to complete remission on therapy, was not significantly different for the two groups [hazard ratio (HR) 1.35, 95% confidence interval (CI) 0.68-2.69; P = 0.39]. The cumulative dose of prednisolone was significantly lower in the BMT + IA group compared with BMT alone (difference -1214, 95% CI -2225 to -70; P = 0.03). In a post hoc analysis, patients with more extensive PV/PF showed a tendency towards a shorter time to remission in the BMT + IA group compared with the BMT group (HR 1.87, P = 0.17 in patients with baseline Pemphigus Disease Area Index ≥ 15). While more adverse events were observed in patients in the BMT group (29 vs. 25), severe adverse events were more frequent in patients in the BMT + IA group (17 events in 10 patients vs. 11 events in 8 patients). CONCLUSIONS In this study, adjuvant IA did not demonstrate a shorter time to clinical remission, but a corticosteroid-sparing effect was observed. In patients with extensive PV/PF, post hoc analysis suggests that adjuvant IA may lead to earlier remission, but potential adverse events must be carefully weighed against the expected benefits.
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Affiliation(s)
- Nina van Beek
- Department of Dermatology, Allergology and Venereology
| | | | - Alexander Reuss
- Coordinating Center for Clinical Trials, Phillips University, Marburg, Germany
| | | | - Miklós Sárdy
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Claudia Günther
- Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Dimitra Kiritsi
- Department of Dermatology and Venereology, University Hospital Freiburg, Freiburg, Germany
| | - Sandrine Benoit
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Beissert
- Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Regine Gläser
- Department of Dermatology, Venereology and Allergology, Christian-Albrechts University, Kiel, Germany
| | - Harald Gollnick
- Department of Dermatology and Venereology, Otto-von-Guericke University, Magdeburg, Germany
| | - Orsolya N Horváth
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Christiane Pfeiffer
- Department of Dermatology and Allergology, University Hospital Ulm, Ulm, Germany
| | - Martin Röcken
- Department of Dermatology, Eberhard Karls University, Tübingen, Germany
| | - Franziska Schauer
- Department of Dermatology and Venereology, University Hospital Freiburg, Freiburg, Germany
| | - Stephan Schreml
- Department of Dermatology, University Medical Centre Regensburg, Regensburg, Germany
| | - Kerstin Steinbrink
- Department of Dermatology, Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Alexander Zink
- Department of Dermatology and Allergology, Technical University Munich, Munich, Germany
| | | | | | - Enno Schmidt
- Department of Dermatology, Allergology and Venereology
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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2
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Pemphigus for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2022. [DOI: 10.1007/s13671-022-00369-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Kunadia A, Sami N. Combination Therapy of Plasma Exchange and Rituximab to Treat Cicatricial Pemphigoid and Bullous Pemphigoid. Cureus 2021; 13:e19932. [PMID: 34984113 PMCID: PMC8713951 DOI: 10.7759/cureus.19932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/27/2021] [Indexed: 11/30/2022] Open
Abstract
The pemphigoid group of subepidermal autoimmune blistering diseases can affect both cutaneous and mucosal tissues. Therapy of this group of diseases, including cicatricial pemphigoid (CP) and bullous pemphigoid (BP), consists of systemic steroids and immunomodulatory agents. Recalcitrant cases have typically been treated with plasmapheresis or rituximab individually. This report describes two patients with severe, rapidly progressive CP and BP refractory to high-dosage systemic steroids and immunomodulatory agents. Both patients were treated with a combination of plasmapheresis and rituximab. In addition to these cases, one retrospective study showed the effectiveness of other immunosuppressants in combination with plasmapheresis in 17 patients with pemphigus refractory to corticosteroids and immunosuppressants alone. No major adverse events occurred in the study. Similar studies employing immunoadsorption and rituximab with various combinations of intravenous immune globulin (IVIg), corticosteroids, and other conventional immunosuppressants have shown promising results in other autoimmune blistering diseases. The successful response in the patients described here, as well as those described in the literature who underwent similar management, provides a possible combination treatment option for patients with severe, recalcitrant pemphigoid. A further trial with a larger group of pemphigoid patients is warranted.
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Abstract
Pemphigus vulgaris (PV) is a severe chronic autoimmune blistering disease that affects the skin and mucous membranes. It is characterized by suprabasal acantholysis due to disruption of desmosomal connections between keratinocytes. Autoantibodies against desmosomal cadherins, desmoglein 3 and 1, have been shown to induce disease. Certain human leukocyte antigen (HLA) types and non-HLA foci confer genetic susceptibility. Until the discovery of corticosteroids in the 1950s, PV was 75% fatal. Since then, multiple PV treatments, such as systemic corticosteroids and adjunctive therapy with immunosuppressive medications (mycophenolate mofetil, azathioprine, cyclophosphamide, cyclosporine, methotrexate, gold, and others) have been introduced; however, none have led to long-term remissions and many have undesired adverse effects. Our growing understanding of the pathophysiologic mechanisms in PV is leading to development of new targeted therapies, such as intravenous immunoglobulin, anti-CD20 monoclonal antibodies, inhibitors of Bruton tyrosine kinase and neonatal Fc receptors, and adoptive cellular transfer, that may result in lasting control of this life-threatening disease.
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MESH Headings
- Agammaglobulinaemia Tyrosine Kinase/antagonists & inhibitors
- Agammaglobulinaemia Tyrosine Kinase/metabolism
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal/therapeutic use
- Antigens, CD20/immunology
- Antigens, CD20/metabolism
- Autoantibodies/immunology
- Autoantibodies/metabolism
- Combined Modality Therapy/methods
- Drug Therapy, Combination/methods
- Genetic Predisposition to Disease
- HLA Antigens/genetics
- HLA Antigens/immunology
- Histocompatibility Antigens Class I/metabolism
- Humans
- Immunoglobulins, Intravenous/pharmacology
- Immunoglobulins, Intravenous/therapeutic use
- Immunosuppressive Agents/pharmacology
- Immunosuppressive Agents/therapeutic use
- Immunotherapy, Adoptive/methods
- Molecular Targeted Therapy/methods
- Pemphigus/genetics
- Pemphigus/immunology
- Pemphigus/therapy
- Plasmapheresis
- Receptors, Fc/antagonists & inhibitors
- Receptors, Fc/metabolism
- Remission Induction/methods
- Signal Transduction/drug effects
- Signal Transduction/immunology
- Treatment Outcome
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Affiliation(s)
- Emily M Altman
- Department of Dermatology, University of New Mexico, 1021 Medical Arts Avenue NE, Albuquerque, NM, 87102, USA.
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5
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Hübner F, Kasperkiewicz M, Knuth-Rehr D, Shimanovich I, Hübner J, Süfke S, Muck P, Zillikens D, Schmidt E. Adjuvant treatment of severe/refractory bullous pemphigoid with protein A immunoadsorption. J Dtsch Dermatol Ges 2019; 16:1109-1118. [PMID: 30179319 DOI: 10.1111/ddg.13642] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 02/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND While depletion of circulating autoantibodies using immunoadsorption (IA) is an established therapeutic approach in patients with pemphigus vulgaris, IA has only sporadically been used in other autoimmune bullous disorders. Although bullous pemphigoid (BP) usually responds well to topical and systemic corticosteroids, rapid depletion of serum autoantibodies may be an effective adjuvant treatment option in patients with severe and/or refractory disease. PATIENTS AND METHODS Case series of 20 patients (13 women, 7 men; mean age 78.6 years; range 56-94 years) with severe or refractory BP. In addition to oral prednisolone (0.25-0.5 mg/kg/day), dapsone (1.0-1.5 mg/kg/day), and clobetasol propionate 0.05 % ointment (lesional application, twice daily), treatment consisted of protein A IA (three sessions on consecutive days). The mean follow-up period was 33.6 months (1-84 months). RESULTS The majority of patients showed a rapid and sustained response. One month after treatment, eight patients (42 %; 19 patients were included in the follow-up) were in complete remission; at the last follow-up visit (after 1 to 84 months), that number was 13 (68 %). Not only was there an initial drop in anti-BP180 autoantibodies (by 92 %), the effect also continued after one and three months, with mean autoantibody levels at 26 % and 13 % of baseline, respectively (p < 0.001). Both previously treated and treatment-naive patients showed a significant reduction in anti-BP180NC16A antibody levels throughout the observation period. Adverse events occurred in 13 of the 20 patients (65 %). Three were severe of which two were likely or probably related to IA. CONCLUSION Immunoadsorption is an effective adjuvant treatment option for (the usually elderly) patients with severe and/or refractory BP.
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Affiliation(s)
- Franziska Hübner
- Department of Dermatology, Allergology and Venereology, University of Lübeck, Lübeck, Germany
| | - Michael Kasperkiewicz
- Department of Dermatology, Allergology and Venereology, University of Lübeck, Lübeck, Germany
| | - Diana Knuth-Rehr
- Department of Dermatology, Allergology and Venereology, University of Lübeck, Lübeck, Germany
| | - Iakov Shimanovich
- Department of Dermatology, Allergology and Venereology, University of Lübeck, Lübeck, Germany
| | - Joachim Hübner
- Institute of Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
| | - Sven Süfke
- Department of Internal Medicine, University of Lübeck, Lübeck, Germany
| | - Philip Muck
- Department of Internal Medicine, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, Allergology and Venereology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, Allergology and Venereology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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6
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Amber KT, Maglie R, Solimani F, Eming R, Hertl M. Targeted Therapies for Autoimmune Bullous Diseases: Current Status. Drugs 2019; 78:1527-1548. [PMID: 30238396 DOI: 10.1007/s40265-018-0976-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Autoimmune bullous skin disorders are rare but meaningful chronic inflammatory diseases, many of which had a poor or devastating prognosis prior to the advent of immunosuppressive drugs such as systemic corticosteroids, which down-regulate the immune pathogenesis in these disorders. Glucocorticoids and adjuvant immunosuppressive drugs have been of major benefit for the fast control of most of these disorders, but their long-term use is limited by major side effects such as blood cytopenia, osteoporosis, diabetes mellitus, hypertension, and gastrointestinal ulcers. In recent years, major efforts were made to identify key elements in the pathogenesis of autoimmune bullous disorders, leading to the identification of their autoantigens, which are mainly located in desmosomes (pemphigus) and the basement membrane zone (pemphigoids). In the majority of cases, immunoglobulin G, and to a lesser extent, immunoglobulin A autoantibodies directed against distinct cutaneous adhesion molecules are directly responsible for the loss of cell-cell and cell-basement membrane adhesion, which is clinically related to the formation of blisters and/or erosions of the skin and mucous membranes. We describe and discuss novel therapeutic strategies that directly interfere with the production and regulation of pathogenic autoantibodies (rituximab), their catabolism (intravenous immunoglobulins), and their presence in the circulation and extravascular tissues such as the skin (immunoadsorption), leading to a significant amelioration of disease. Moreover, we show that these novel therapies have pleiotropic effects on various proinflammatory cells and cytokines. Recent studies in bullous pemphigoid suggest that targeting of immunoglobulin E autoantibodies (omalizumab) may be also beneficial. In summary, the introduction of targeted therapies in pemphigus and pemphigoid holds major promise because of the high efficacy and fewer side effects compared with conventional global immunosuppressive therapy.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of Illinois at Chicago, 808 Wood St. Room 377, Chicago, IL, 60612, USA.
| | - Roberto Maglie
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany.,Department of Surgery and Translational Medicine, Section of Dermatology, University of Florence, Florence, Italy
| | - Farzan Solimani
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany
| | - Rüdiger Eming
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany.
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7
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Didona D, Maglie R, Eming R, Hertl M. Pemphigus: Current and Future Therapeutic Strategies. Front Immunol 2019; 10:1418. [PMID: 31293582 PMCID: PMC6603181 DOI: 10.3389/fimmu.2019.01418] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022] Open
Abstract
Pemphigus encompasses a heterogeneous group of autoimmune blistering diseases, which affect both mucous membranes and the skin. The disease usually runs a chronic-relapsing course, with a potentially devastating impact on the patients' quality of life. Pemphigus pathogenesis is related to IgG autoantibodies targeting various adhesion molecules in the epidermis, including desmoglein (Dsg) 1 and 3, major components of desmosomes. The pathogenic relevance of such autoantibodies has been largely demonstrated experimentally. IgG autoantibody binding to Dsg results in loss of epidermal keratinocyte adhesion, a phenomenon referred to as acantholysis. This in turn causes intra-epidermal blistering and the clinical appearance of flaccid blisters and erosions at involved sites. Since the advent of glucocorticoids, the overall prognosis of pemphigus has largely improved. However, mortality persists elevated, since long-term use of high dose corticosteroids and adjuvant steroid-sparing immunosuppressants portend a high risk of serious adverse events, especially infections. Recently, rituximab, a chimeric anti CD20 monoclonal antibody which induces B-cell depletion, has been shown to improve patients' survival, as early rituximab use results in higher disease remission rates, long term clinical response and faster prednisone tapering compared to conventional immunosuppressive therapies, leading to its approval as a first line therapy in pemphigus. Other anti B-cell therapies targeting B-cell receptor or downstream molecules are currently tried in clinical studies. More intriguingly, a preliminary study in a preclinical mouse model of pemphigus has shown promise regarding future therapeutic application of Chimeric Autoantibody Receptor T-cells engineered using Dsg domains to selectively target autoreactive B-cells. Conversely, previous studies from our group have demonstrated that B-cell depletion in pemphigus resulted in secondary impairment of T-cell function; this may account for the observed long-term remission following B-cell recovery in rituximab treated patients. Likewise, our data support the critical role of Dsg-specific T-cell clones in orchestrating the inflammatory response and B-cell activation in pemphigus. Monitoring autoreactive T-cells in patients may indeed provide further information on the role of these cells, and would be the starting point for designating therapies aimed at restoring the lost immune tolerance against Dsg. The present review focuses on current advances, unmet challenges and future perspectives of pemphigus management.
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Affiliation(s)
- Dario Didona
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Roberto Maglie
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany.,Surgery and Translational Medicine, Section of Dermatology, University of Florence, Florence, Italy.,Section of Dermatology, Departement of Health Sciences, University of Florence, Florence, Italy
| | - Rüdiger Eming
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
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8
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Porro AM, Hans Filho G, Santi CG. Consensus on the treatment of autoimmune bullous dermatoses: pemphigus vulgaris and pemphigus foliaceus - Brazilian Society of Dermatology. An Bras Dermatol 2019; 94:20-32. [PMID: 31166407 PMCID: PMC6544031 DOI: 10.1590/abd1806-4841.2019940206] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/30/2019] [Indexed: 02/08/2023] Open
Abstract
Pemphigus are intraepidermal autoimmune bullous dermatoses that occur with
lesions on the skin and / or mucous membranes. The most frequent types are
pemphigus vulgaris and pemphigus foliaceus (classic and endemic). This consensus
aims to present a complete and updated review of the treatment of these two more
frequent forms of pemphigus, based on the literature and the personal experience
of the authors. In moderate and severe cases of pemphigus vulgaris and
foliaceus, systemic corticosteroid therapy (prednisone or prednisolone) is the
treatment of choice. Adjuvant drugs, usually immunosuppressive drugs
(azathioprine, mycophenolate mofetil, methotrexate, cyclophosphamide) may be
prescribed as corticosteroid sparers in refractory cases or with
contraindications to corticosteroids to minimize side effects. In severe and
nonresponsive cases, corticosteroids in the form of intravenous pulse therapy,
immunoglobulin and plasmapheresis / immunoadsorption can be administered.
Immunobiological drugs, particularly rituximab, appear as a promising
alternative. For milder cases, smaller doses of oral corticosteroid, dapsone and
topical corticosteroids are options. At the end flowcharts are presented as
suggestions for a therapeutic approach for patients with pemphigus vulgaris and
pemphigus foliaceus.
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Affiliation(s)
- Adriana Maria Porro
- Department of Dermatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Günter Hans Filho
- Dermatology Service, Hospital Universitário Maria Aparecida Pedrossian, Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brazil
| | - Claudia Giuli Santi
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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9
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Leuci S, Ruoppo E, Adamo D, Calabria E, Mignogna MD. Oral autoimmune vesicobullous diseases: Classification, clinical presentations, molecular mechanisms, diagnostic algorithms, and management. Periodontol 2000 2019; 80:77-88. [DOI: 10.1111/prd.12263] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Stefania Leuci
- Oral Medicine Unit, Department of Neurosciences, Reproductive and Odontostomatological SciencesFederico II University of Naples Naples Italy
| | - Elvira Ruoppo
- Oral Medicine Unit, Department of Neurosciences, Reproductive and Odontostomatological SciencesFederico II University of Naples Naples Italy
| | - Daniela Adamo
- Oral Medicine Unit, Department of Neurosciences, Reproductive and Odontostomatological SciencesFederico II University of Naples Naples Italy
| | - Elena Calabria
- Oral Medicine Unit, Department of Neurosciences, Reproductive and Odontostomatological SciencesFederico II University of Naples Naples Italy
| | - Michele Davide Mignogna
- Oral Medicine Unit, Department of Neurosciences, Reproductive and Odontostomatological SciencesFederico II University of Naples Naples Italy
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Ohkubo A, Okado T, Sakurasawa T, Maeda T, Itagaki A, Yamamoto H, Miyamoto S, Seshima H, Kurashima N, Mori T, Iimori S, Sohara E, Rai T, Uchida S, Naito S. Removal Characteristics of Immunoadsorption with the Tryptophan-Immobilized Column Using Conventional and Selective Plasma Separators in the Treatment of Myasthenia Gravis. Ther Apher Dial 2019; 23:271-278. [PMID: 31025833 DOI: 10.1111/1744-9987.12820] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/25/2019] [Indexed: 11/30/2022]
Abstract
Autoimmune neurological diseases are often treated by immunoadsorption using a conventional plasma separator and tryptophan-immobilized column (IA). However, there is only one case report on treatment with immunoadsorption using a selective plasma separator and tryptophan-immobilized column (SeIA) in clinical practice. This study aimed to investigate the removal characteristics of antibodies against acetylcholine receptors (AChRAb), immunoglobulin G, fibrinogen, and factor XIII (FXIII) in IA and SeIA in four patients with myasthenia gravis. A total of 19 sessions of immunoadsorption were performed (five sessions of IA and 14 sessions of SeIA) when the processed plasma volume was 2 L. The corresponding reductions were 52.5% ± 6.2% for AChRAb, 58.8% ± 4.2% for fibrinogen, and 36.9% ± 5.5% for FXIII after one session of IA. The corresponding reductions were 45.2% ± 9.9% for AChRAb, 3.5% ± 6.9% for fibrinogen, and -4.6% ± 11.1% for FXIII after one session of SeIA. The removal rates for AChRAb, fibrinogen, and FXIII in IA were significantly higher than those in SeIA. IA could effectively remove AChRAb, and SeIA could retain fibrinogen and FXIII. IA can be combined with SeIA, resulting in both IgG autoantibodies removal by IA and retention of coagulation factors by SeIA.
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Affiliation(s)
- Atsushi Ohkubo
- Medical Engineering Center, Medical Hospital of Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomokazu Okado
- Department of Nephrology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takatoshi Sakurasawa
- Medical Engineering Center, Medical Hospital of Tokyo Medical and Dental University, Tokyo, Japan
| | - Takuma Maeda
- Medical Engineering Center, Medical Hospital of Tokyo Medical and Dental University, Tokyo, Japan
| | - Ayako Itagaki
- Medical Engineering Center, Medical Hospital of Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroko Yamamoto
- Medical Engineering Center, Medical Hospital of Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoko Miyamoto
- Medical Engineering Center, Medical Hospital of Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroshi Seshima
- Medical Engineering Center, Medical Hospital of Tokyo Medical and Dental University, Tokyo, Japan
| | - Naoki Kurashima
- Medical Engineering Center, Medical Hospital of Tokyo Medical and Dental University, Tokyo, Japan
| | - Takayasu Mori
- Department of Nephrology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Soichiro Iimori
- Department of Nephrology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eisei Sohara
- Department of Nephrology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatemitsu Rai
- Department of Nephrology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinichi Uchida
- Department of Nephrology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shotaro Naito
- Department of Nephrology, Tokyo Medical and Dental University, Tokyo, Japan
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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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12
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Abstract
BACKGROUND Pemphigus diseases are a heterogeneous group of potentially life-threatening autoimmune bullous disorders. Therefore, rapidly acting and effective therapeutic approaches are essential. OBJECTIVES In this review, current therapeutic options in line with available guidelines are presented and new therapeutic approaches are discussed. METHODS A literature search was performed using PubMed. RESULTS Treatment of pemphigus is based on systemic glucocorticosteroids, frequently combined with potentially corticosteroid-sparing immunosuppressants such as azathioprine and mycophenolate mofetil/mycophenolic acid. Recently, the impressive efficacy of the anti-CD20 antibody rituximab has been shown in a prospective randomized trial. In severe or treatment-refractory cases, immunoadsorption or high-dose intravenous immunoglobulins (IVIG) are recommended. Adjuvant immunoadsorption also seems to be useful within the first 8-12 weeks of therapy in patients with very high autoantibody levels. A variety of new therapeutic approaches is currently evaluated in phase IIa studies. CONCLUSION Therapy of pemphigus has been greatly improved by the employment of rituximab. The use of glucocorticosteroids, associated with a high number of adverse events and elevated mortality, could be reduced by the additional use of rituximab. After approval of rituximab for the treatment of pemphigus by the US Food and Drug Administration in 2018, licensing in Europe is expected in 2019.
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Affiliation(s)
- N van Beek
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - D Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - E Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.,Lübecker Institut für Experimentelle Dermatologie (LIED), Universität zu Lübeck, Lübeck, Deutschland
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13
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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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14
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Hübner F, Kasperkiewicz M, Knuth-Rehr D, Shimanovich I, Hübner J, Süfke S, Muck P, Zillikens D, Schmidt E. Adjuvante Behandlung des schweren/refraktären bullösen Pemphigoids mit Protein-A-Immunadsorption. J Dtsch Dermatol Ges 2018; 16:1109-1119. [PMID: 30179332 DOI: 10.1111/ddg.13642_g] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 02/27/2018] [Indexed: 11/28/2022]
Abstract
HINTERGRUND Mittels Immunadsorption (IA) können Immunglobuline und Immunkomplexe aus dem Plasma entfernt werden. Während dieses therapeutische Verfahren beim Pemphigus vulgaris bereits etabliert ist, wird es bei anderen blasenbildenden Autoimmundermatosen bislang nur sporadisch eingesetzt. Das bullöse Pemphigoid (BP) spricht zwar meist gut auf eine Therapie mit topischen und systemischen Kortikosteroiden an, jedoch könnte bei Patienten mit ausgedehnten Läsionen oder bei einem Rezidiv die rasche Reduktion der pathogenen Autoantikörper eine effektive adjuvante Therapie darstellen. PATIENTEN UND METHODIK Fallserie mit 20 Patienten (13 Frauen, 7 Männer; mittleres Alter 78,6 Jahre; 56-94 Jahre) mit schwerem oder refraktärem BP, die zusätzlich zur Basistherapie bestehend aus Prednisolon (0,25-0,5 mg/kg/d), Dapson (1,0-1,5 mg/kg/d) und Clobetasolpropionat 0,05 % Salbe (läsional 2 x/d) mit Protein-A-IA (3 IAs an aufeinander folgenden Tagen) behandelt wurden. Die durchschnittliche Nachbeobachtungszeit betrug 33,6 Monate (1-84 Monate). ERGEBNISSE Bei der Mehrzahl der Patienten zeigte sich ein rascher und langandauernder Therapieeffekt. Nach einem Monat befanden sich acht Patienten (von 19 nachbeobachteten, 42 %) und zum Zeitpunkt des letzten Kontakts (nach 1-84 Monaten) 13 Patienten (68 %) in kompletter Remission. Die Anti-BP180-Autoantikörper wurden nicht nur initial (um 92 %) gesenkt, sondern lagen auch nach ein und drei Monaten im Mittel bei 26 % und 13 % des Wertes vor Therapiebeginn (p < 0,001). Bei Differenzierung in vortherapierte bzw. therapienaive Patienten zeigten sich in beiden Subgruppen signifikante Absenkungen der Anti-BP180NC16A-Antikörper-Spiegel zu allen Zeitpunkten. Unerwünschte Ereignisse traten bei dreizehn (65 %) der 20 Patienten auf, Drei der Ereignisse waren schwer und zwei davon wahrscheinlich oder möglicherweise in Zusammenhang mit der IA. SCHLUSSFOLGERUNGEN Die IA ist eine effektive adjuvante Therapieoption bei den in aller Regel älteren Patienten mit einem schweren und/oder therapierefraktären BP.
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Affiliation(s)
- Franziska Hübner
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | | | - Diana Knuth-Rehr
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | - Iakov Shimanovich
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | - Joachim Hübner
- Institut für Sozialmedizin und Epidemiologie, Universität zu Lübeck
| | - Sven Süfke
- Medizinische Klinik I, Universität zu Lübeck
| | - Philip Muck
- Medizinische Klinik I, Universität zu Lübeck
| | - Detlef Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck
| | - Enno Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck.,Lübecker Institut für Experimentielle Dermatologie (LIED), Universität zu Lübeck
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15
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Hofrichter M, Dworschak J, Emtenani S, Langenhan J, Weiß F, Komorowski L, Zillikens D, Stöcker W, Probst C, Schmidt E, Goletz S. Immunoadsorption of Desmoglein-3-Specific IgG Abolishes the Blister-Inducing Capacity of Pemphigus Vulgaris IgG in Neonatal Mice. Front Immunol 2018; 9:1935. [PMID: 30233569 PMCID: PMC6130267 DOI: 10.3389/fimmu.2018.01935] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 08/06/2018] [Indexed: 12/11/2022] Open
Abstract
Pemphigus vulgaris (PV) is a potentially life-threatening autoimmune blistering disease which is associated with autoantibodies directed against two desmosomal proteins, desmoglein (Dsg) 3 and 1. Treatment of PV is rather challenging and relies on the long-term use of systemic corticosteroids and additional immunosuppressants. More recently, autoantibody-depleting therapies such as rituximab, high-dose intravenous immunoglobulins, and immunoadsorption were shown to be valuable treatment options in PV. Specific removal of pathogenic autoantibodies would further increase efficacy and usability of immunoadsorption. Here, we tested the capacity of our recently developed prototypic Dsg1- and Dsg3-specific adsorbers to remove circulating pathogenic autoantibodies from three different PV patients. The pathogenic potential of the Dsg3/1-depleted IgG fractions and the anti-Dsg3-specific IgG was explored in two different in vitro assays based on cultured human keratinocytes, the desmosome degradation assay and the dispase-based dissociation assay. In addition, the neonatal mouse model of PV was used. In both in vitro assays, no difference between the pathogenic effect of total PV IgG and anti-Dsg3-specific IgG was seen, while Dsg3/1-depleted and control IgG were not pathogenic. For the samples of all 3 PV patients, depletion of anti-Dsg3/1 IgG resulted in a complete loss of pathogenicity when injected into neonatal mice. In contrast, injection of anti-Dsg3-specific IgG, eluted from the column, induced gross blistering in the mice. Our data clearly show that anti-Dsg3-specific IgG alone is pathogenic in vitro and in vivo, whereas Dsg3/1-depletion results in a complete loss of pathogenicity. Furthermore, our data suggest that Dsg-specific adsorption may be a suitable therapeutic modality to efficiently reduce pathogenic autoantibodies in patients with severe PV.
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Affiliation(s)
- Maxi Hofrichter
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Jenny Dworschak
- Institute of Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Shirin Emtenani
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Jana Langenhan
- Institute of Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Fanny Weiß
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Lars Komorowski
- Institute of Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Winfried Stöcker
- Institute of Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Christian Probst
- Institute of Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Stephanie Goletz
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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16
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Hans-Filho G, Aoki V, Bittner NRH, Bittner GC. Fogo selvagem: endemic pemphigus foliaceus. An Bras Dermatol 2018; 93:638-650. [PMID: 30156612 PMCID: PMC6106655 DOI: 10.1590/abd1806-4841.20188235] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/07/2018] [Indexed: 11/22/2022] Open
Abstract
Fogo selvagem or endemic pemphigus foliaceus is an autoimmune acantholytic anti-cadherin bullous disease that primarily affects seborrheic areas, which might disseminate. Brazil has the world's largest number of patients, mainly in the Central-West region, but the disease has also been reported in other South American countries. It affects young people and adults who have been exposed to rural areas, with occurrence of familial cases. Anti-desmoglein-1 autoantibodies are directed against desmosomal structures, with loss of adhesion of the upper layers of the epidermis, causing superficial blisters. The etiology is multifactorial and includes genetic, immune, and environmental factors, highlighting hematophagous insect bites; drug-related factors are occasionally involved. Flaccid blisters readily rupture to yield erosive-crusty lesions that sometimes resemble seborrheic dermatitis, actinic keratosis, and chronic cutaneous lupus erythematosus. The clinical presentation varies from localized to disseminated lesions. Clinical suspicion should be confirmed with histopathological and immunofluorescence tests, among others. The progression is usually chronic, and therapy varies according to clinical presentation, but generally requires systemic corticosteroid therapy associated with adjuvant immunosuppressive treatment to decrease the adverse effects of corticosteroids. Once the disease is under control, many patients remain stable on low-dose medication, and a significant proportion achieve remission.
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Affiliation(s)
- Günter Hans-Filho
- Department Dermatology, Faculdade de Medicina, Universidade Federal
de Mato Grosso do Sul, Campo Grande (MS), Brazil
- Dermatology Service, Hospital Maria Aparecida Pedrossian,
Universidade Federal de Mato Grosso do Sul, Campo Grande (MS), Brazil
| | - Valéria Aoki
- Department of Dermatology, Faculdade de Medicina, Universidade de
São Paulo, São Paulo (SP), Brazil
| | - Nelise Ritter Hans Bittner
- Dermatology Service, Hospital Maria Aparecida Pedrossian,
Universidade Federal de Mato Grosso do Sul, Campo Grande (MS), Brazil
| | - Guilherme Canho Bittner
- Dermatology Service, Hospital Maria Aparecida Pedrossian,
Universidade Federal de Mato Grosso do Sul, Campo Grande (MS), Brazil
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17
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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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18
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Hu J, Chen J, Ye L, Cai Z, Sun J, Ji K. Anti-IgE therapy for IgE-mediated allergic diseases: from neutralizing IgE antibodies to eliminating IgE + B cells. Clin Transl Allergy 2018; 8:27. [PMID: 30026908 PMCID: PMC6050685 DOI: 10.1186/s13601-018-0213-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 05/28/2018] [Indexed: 12/14/2022] Open
Abstract
Allergic diseases are inflammatory disorders that involve many types of cells and factors, including allergens, immunoglobulin (Ig)E, mast cells, basophils, cytokines and soluble mediators. Among them, IgE plays a vital role in the development of acute allergic reactions and chronic inflammatory allergic diseases, making its control particularly important in the treatment of IgE-mediated allergic diseases. This review provides an overview of the current state of IgE targeted therapy development, focusing on three areas of translational research: IgE neutralization in blood; IgE-effector cell elimination; and IgE+ B cell reduction. IgE-targeted medicines such as FDA approved drug Xolair (Omalizumab) represent a promising avenue for treating IgE-mediated allergic diseases given the pernicious role of IgE in disease progression. Additionally, targeted therapy for IgE-mediated allergic diseases may be advanced through cellular treatments, including the modification of effector cells.
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Affiliation(s)
- Jiayun Hu
- 1Department of Biochemistry and Molecular Biology, School of Medicine of Shenzhen University, Shenzhen, 518035 China.,2Department of Allergy, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Jiajie Chen
- 1Department of Biochemistry and Molecular Biology, School of Medicine of Shenzhen University, Shenzhen, 518035 China
| | - Lanlan Ye
- 1Department of Biochemistry and Molecular Biology, School of Medicine of Shenzhen University, Shenzhen, 518035 China
| | - Zelang Cai
- 1Department of Biochemistry and Molecular Biology, School of Medicine of Shenzhen University, Shenzhen, 518035 China
| | - Jinlu Sun
- 2Department of Allergy, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Kunmei Ji
- 1Department of Biochemistry and Molecular Biology, School of Medicine of Shenzhen University, Shenzhen, 518035 China
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19
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Abstract
Pemphigus vulgaris (PV) is a life-threatening disease belonging to the pemphigus group of autoimmune intra-epidermal bullous diseases of the skin and mucosae. The therapeutic management of PV remains challenging and, in some cases, conventional therapy is not adequate to induce clinical remission. The cornerstone of PV treatment remains systemic corticosteroids. Although very effective, long-term corticosteroid administration is characterized by substantial adverse effects. Corticosteroid-sparing adjuvant therapies have been employed in the treatment of PV, aiming to reduce the necessary cumulative dose of corticosteroids. Specifically, immunosuppressive agents such as azathioprine and mycophenolate mofetil are widely used in PV. More recently, high-dose intravenous immunoglobulins, immunoadsorption, and rituximab have been established as additional successful therapeutic options. This review covers both conventional and emerging therapies in PV. In addition, it sheds light on potential future treatment strategies for this disease.
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
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20
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Schmidt T, Hoch M, Lotfi Jad SS, Solimani F, Di Zenzo G, Marzano AV, Goebeler M, Cozzani E, Kern JS, Sitaru C, Lakoš Jukić I, Sárdy M, Uzun S, Jedlickova H, Gläser R, Kaneda M, Eming R, Göpel G, Ishii N, Greene B, Hashimoto T, Hertl M. Serological diagnostics in the detection of IgG autoantibodies against human collagen VII in epidermolysis bullosa acquisita: a multicentre analysis. Br J Dermatol 2017; 177:1683-1692. [PMID: 28703393 DOI: 10.1111/bjd.15800] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Epidermolysis bullosa acquisita (EBA) is a rare, potentially devastating autoimmune disease of the skin. IgG autoantibodies directed against type VII collagen (Col7), the major component of anchoring fibrils, induce skin fragility leading to cutaneous and mucocutaneous blister formation, which is mostly of a scarring phenotype. Thus, powerful and reproducible diagnostic assays are critical to establish the diagnosis of EBA early to avoid irreversible sequelae. OBJECTIVES The present international, retrospective multicentre study included a large cohort of patients with EBA and evaluated the diagnostic power of four different diagnostic assays for the detection of anti-Col7 IgG autoantibodies. METHODS Overall, 95 EBA sera and 200 control sera consisting of 100 bullous pemphigoid sera, 50 pemphigus vulgaris sera and 50 sera of healthy controls were tested for anti-Col7 IgG autoantibodies using indirect immunofluorescence (IIF), two commercial enzyme-linked immunosorbent assay (ELISA) systems and Western blot (WB) analysis. EBA sera were taken from patients with positive direct immunofluorescence and IgG reactivity in at least one of the immunoserological assays (IIF, ELISA, WB). RESULTS A Col7-NC1/NC2 ELISA (MBL, Nagoya, Japan) showed the highest sensitivity (97·9%), followed by a Col7-NC1 ELISA (Euroimmun, Lübeck, Germany) (89·5%), WB with Col7-NC1 (85·3%), and IIF on saline-split human skin (74·7%). The specificities of both ELISA systems were comparable (NC1 98·7%, NC1/NC2 99·3%). Furthermore, WB was more sensitive than IIF, which was more specific. CONCLUSIONS The two commercially available ELISA systems allow for a highly sensitive and specific diagnosis of EBA. The sensitivity of the Col7-NC1/NC2 ELISA is significantly higher compared with the ELISA based on the Col7-NC1 domain only.
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Affiliation(s)
- T Schmidt
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - M Hoch
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - S S Lotfi Jad
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - F Solimani
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - G Di Zenzo
- Istituto Dermopatico dell'Immacolata, Rome, Italy
| | - A V Marzano
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano - Unità Operativa di Dermatologia, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - M Goebeler
- Department of Dermatology, Venereology and Allergology, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - E Cozzani
- Dermatology, IRCCS AOU San Martino Di.S.Sal., Genoa, Italy
| | - J S Kern
- Department of Dermatology, Medical Center, University of Freiburg, Freiburg, Germany
| | - C Sitaru
- Department of Dermatology, Medical Center, University of Freiburg, Freiburg, Germany
| | - I Lakoš Jukić
- Department of Dermatovenerology, University of Zagreb, Zagreb, Croatia
| | - M Sárdy
- München, Department of Dermatology and Allergology, Ludwig Maximilians University Munich, Munich, Germany
| | - S Uzun
- Department of Dermatology and Venereology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - H Jedlickova
- Department of Dermatovenereology, St. Anna University Hospital, Masaryk University, Brno, Czech Republic
| | - R Gläser
- Department of Dermatology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - M Kaneda
- Medical and Biological Laboratories, Co. Ltd, Nagoya, Japan
| | - R Eming
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - G Göpel
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - N Ishii
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - B Greene
- Institute of Biometry and Statistics, Philipps-University Marburg, D-35043, Marburg, Germany
| | - T Hashimoto
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - M Hertl
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
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21
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Tavakolpour S. Current and future treatment options for pemphigus: Is it time to move towards more effective treatments? Int Immunopharmacol 2017; 53:133-142. [DOI: 10.1016/j.intimp.2017.10.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/18/2017] [Accepted: 10/20/2017] [Indexed: 02/07/2023]
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22
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Dietze J, Hohenstein B, Tselmin S, Julius U, Bornstein SR, Beissert S, Günther C. Successful and well-tolerated bi-weekly immunoadsorption regimen in pemphigus vulgaris. ATHEROSCLEROSIS SUPP 2017; 30:271-277. [DOI: 10.1016/j.atherosclerosissup.2017.05.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Heineke MH, van der Steen LPE, Korthouwer RM, Hage JJ, Langedijk JPM, Benschop JJ, Bakema JE, Slootstra JW, van Egmond M. Peptide mimetics of immunoglobulin A (IgA) and FcαRI block IgA-induced human neutrophil activation and migration. Eur J Immunol 2017; 47:1835-1845. [PMID: 28736835 PMCID: PMC5659136 DOI: 10.1002/eji.201646782] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 06/06/2017] [Accepted: 07/20/2017] [Indexed: 12/19/2022]
Abstract
The cross‐linking of the IgA Fc receptor (FcαRI) by IgA induces release of the chemoattractant LTB4, thereby recruiting neutrophils in a positive feedback loop. IgA autoantibodies of patients with autoimmune blistering skin diseases therefore induce massive recruitment of neutrophils, resulting in severe tissue damage. To interfere with neutrophil mobilization and reduce disease morbidity, we developed a panel of specific peptides mimicking either IgA or FcαRI sequences. CLIPS technology was used to stabilize three‐dimensional structures and to increase peptides’ half‐life. IgA and FcαRI peptides reduced phagocytosis of IgA‐coated beads, as well as IgA‐induced ROS production and neutrophil migration in in vitro and ex vivo (human skin) experiments. Since topical application would be the preferential route of administration, Cetomacrogol cream containing an IgA CLIPS peptide was developed. In the presence of a skin permeation enhancer, peptides in this cream were shown to penetrate the skin, while not diffusing systemically. Finally, epitope mapping was used to discover sequences important for binding between IgA and FcαRI. In conclusion, a cream containing IgA or FcαRI peptide mimetics, which block IgA‐induced neutrophil activation and migration in the skin may have therapeutic potential for patients with IgA‐mediated blistering skin diseases.
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Affiliation(s)
- Marieke H Heineke
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, Amsterdam, The Netherlands
| | - Lydia P E van der Steen
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, Amsterdam, The Netherlands
| | - Rianne M Korthouwer
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, Amsterdam, The Netherlands
| | - J Joris Hage
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Joris J Benschop
- Pepscan Therapeutics, Zuidersluisweg 2, Lelystad, The Netherlands
| | - Jantine E Bakema
- Department of Otolaryngology/Head-Neck Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Marjolein van Egmond
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, Amsterdam, The Netherlands.,Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
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25
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Miyamoto S, Ohkubo A, Seshima H, Komori S, Yamamoto M, Maeda T, Itagaki A, Yamamoto H, Nojima K, Iimori S, Naito S, Kurashima N, Sohara E, Rai T, Uchida S, Okado T. Selective Plasma Exchange for the Removal of Pemphigus Autoantibodies, Fibrinogen, and Factor XIII in Pemphigus Vulgaris. Ther Apher Dial 2017; 21:226-231. [DOI: 10.1111/1744-9987.12555] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Satoko Miyamoto
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Atsushi Ohkubo
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Hiroshi Seshima
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Shigeto Komori
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Motoki Yamamoto
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Takuma Maeda
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Ayako Itagaki
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Hiroko Yamamoto
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Kohei Nojima
- Department of Dermatology; Tokyo Medical and Dental University; Tokyo Japan
| | - Soichiro Iimori
- Department of Nephrology; Tokyo Medical and Dental University; Tokyo Japan
| | - Shotaro Naito
- Department of Nephrology; Tokyo Medical and Dental University; Tokyo Japan
| | - Naoki Kurashima
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Eisei Sohara
- Department of Nephrology; Tokyo Medical and Dental University; Tokyo Japan
| | - Tatemitsu Rai
- Department of Nephrology; Tokyo Medical and Dental University; Tokyo Japan
| | - Shinichi Uchida
- Department of Nephrology; Tokyo Medical and Dental University; Tokyo Japan
| | - Tomokazu Okado
- Department of Nephrology; Tokyo Medical and Dental University; Tokyo Japan
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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Abstract
Autoimmune bullous diseases are characterized by intraepidermal or subepidermal autoantibody deposition that leads to blisters and secondary erosion. Mucous membranes are frequently affected in pemphigus vulgaris and always involved in cicatricial and mucosal pemphigoid. Mucosal lesions are detected less frequently in patients with bullous pemphigoid or epidermolysis bullosa acquisita. The diagnosis of autoimmune bullous disorders is based on determination of the subtype of autoantibodies bound in the skin and the clinical picture. Treatment is based on immunosuppression related to the type of disease and severity of the mucosal symptoms. Ocular involvement in mucosal pemphigoid and pemphigus vulgaris requires systemic treatment.
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Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Mersmann M, Dworschak J, Ebermann K, Komorowski L, Schlumberger W, Stöcker W, Zillikens D, Probst C, Schmidt E. Immunoadsorber for specific apheresis of autoantibodies in the treatment of bullous pemphigoid. Arch Dermatol Res 2016; 308:31-8. [PMID: 26498290 DOI: 10.1007/s00403-015-1606-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 09/29/2015] [Accepted: 10/14/2015] [Indexed: 01/28/2023]
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering skin disease associated with autoantibodies against two hemidesmosomal proteins, BP180 (type XVII collagen) and BP230. As the pathogenic relevance of antibodies against the immunodominant NC16A domain of BP180 has been clearly demonstrated, specific removal of these antibodies should be a rational therapeutic approach. Here, we evaluated three recombinant forms of bacterially produced BP180 NC16A, a monomer, trimer, and tetramer, together with different matrices for their efficacy to specifically adsorb autoantibodies from BP plasma samples. An adsorber consisting of NC16A-trimer coupled to NHS-activated Sepharose 4 Fast Flow revealed satisfying adsorption rates and a high specificity. The NC16A-trimer adsorber was regenerable and autoclavable. It has the potential to be used for specific immunoadsorption to treat severe and refractory BP and other pemphigoid diseases associated with BP180 NC16A reactivity.
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Affiliation(s)
- Michael Mersmann
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany.
| | - Jenny Dworschak
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Kristin Ebermann
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Lars Komorowski
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Wolfgang Schlumberger
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Winfried Stöcker
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Christian Probst
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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Nygaard U, Vestergaard C, Deleuran M. Systemic Treatment of Severe Atopic Dermatitis in Children and Adults. CURRENT TREATMENT OPTIONS IN ALLERGY 2014. [DOI: 10.1007/s40521-014-0032-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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31
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Recke A, Trog LM, Pas HH, Vorobyev A, Abadpour A, Jonkman MF, van Zandbergen G, Kauderer C, Zillikens D, Vidarsson G, Ludwig RJ. Recombinant Human IgA1 and IgA2 Autoantibodies to Type VII Collagen Induce Subepidermal Blistering Ex Vivo. THE JOURNAL OF IMMUNOLOGY 2014; 193:1600-8. [DOI: 10.4049/jimmunol.1400160] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Langenhan J, Dworschak J, Saschenbrecker S, Komorowski L, Schlumberger W, Stöcker W, Westermann J, Recke A, Zillikens D, Schmidt E, Probst C. Specific immunoadsorption of pathogenic autoantibodies in pemphigus requires the entire ectodomains of desmogleins. Exp Dermatol 2014; 23:253-9. [DOI: 10.1111/exd.12355] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2014] [Indexed: 02/05/2023]
Affiliation(s)
- Jana Langenhan
- Institute of Experimental Immunology; Euroimmun AG; Lübeck Germany
| | - Jenny Dworschak
- Department of Dermatology; University of Lübeck; Lübeck Germany
| | | | - Lars Komorowski
- Institute of Experimental Immunology; Euroimmun AG; Lübeck Germany
| | | | - Winfried Stöcker
- Institute of Experimental Immunology; Euroimmun AG; Lübeck Germany
| | | | - Andreas Recke
- Department of Dermatology; University of Lübeck; Lübeck Germany
| | | | - Enno Schmidt
- Department of Dermatology; University of Lübeck; Lübeck Germany
| | - Christian Probst
- Institute of Experimental Immunology; Euroimmun AG; Lübeck Germany
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Clinical presentation, pathogenesis, diagnosis, and treatment of epidermolysis bullosa acquisita. ISRN DERMATOLOGY 2013; 2013:812029. [PMID: 23956869 PMCID: PMC3727188 DOI: 10.1155/2013/812029] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 06/02/2013] [Indexed: 11/18/2022]
Abstract
Epidermolysis bullosa acquisita (EBA) is a chronic mucocutaneous autoimmune skin blistering disease. The pathogenic relevance of autoantibodies targeting type VII collagen (COL7) has been well-documented. Therefore, EBA is a prototypical autoimmune disease with a well-characterized pathogenic relevance of autoantibody binding to the target antigen. EBA is a rare disease with an incidence of 0.2 new cases per million and per year. The current treatment of EBA relies on general immunosuppressive therapy, which does not lead to remission in all cases. Therefore, there is a high, so far unmet medical need for the development of novel therapeutic options. During the last 10 years, several novel in vitro and in vivo models of EBA have been established. These models demonstrated a critical role of the genetic background, T cells, and cytokines for mediating the loss of tolerance towards COL7. Neutrophils, complement activation, Fc gamma receptor engagement, cytokines, several molecules involved in cell signaling, release of reactive oxygen species, and matrix metalloproteinases are crucial for autoantibody-induced tissue injury in EBA. Based on this growing understanding of the diseases' pathogenesis, several potential novel therapeutic targets have emerged. In this review, the clinical presentation, pathogenesis, diagnosis, and current treatment options for EBA are discussed in detail.
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Kolesnik M, Becker E, Reinhold D, Ambach A, Heim M, Gollnick H, Bonnekoh B. Treatment of severe autoimmune blistering skin diseases with combination of protein A immunoadsorption and rituximab: a protocol without initial high dose or pulse steroid medication. J Eur Acad Dermatol Venereol 2013; 28:771-80. [DOI: 10.1111/jdv.12175] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 04/02/2013] [Indexed: 12/19/2022]
Affiliation(s)
- M. Kolesnik
- Clinic for Dermatology and Venereology; Otto-von-Guericke-University Magdeburg; Magdeburg Germany
| | - E. Becker
- Institute for Transfusion Medicine; Otto-von-Guericke-University Magdeburg; Magdeburg Germany
| | - D. Reinhold
- Institute for Molecular and Clinical Immunology; Otto-von-Guericke-University Magdeburg; Magdeburg Germany
| | - A. Ambach
- Clinic for Dermatology and Venereology; Otto-von-Guericke-University Magdeburg; Magdeburg Germany
| | - M.U. Heim
- Institute for Transfusion Medicine; Otto-von-Guericke-University Magdeburg; Magdeburg Germany
| | - H. Gollnick
- Clinic for Dermatology and Venereology; Otto-von-Guericke-University Magdeburg; Magdeburg Germany
| | - B. Bonnekoh
- Clinic for Dermatology and Venereology; Otto-von-Guericke-University Magdeburg; Magdeburg Germany
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37
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Kim JH, Kim SC. Epidermolysis bullosa acquisita. J Eur Acad Dermatol Venereol 2013; 27:1204-13. [PMID: 23368767 DOI: 10.1111/jdv.12096] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 12/17/2012] [Indexed: 12/29/2022]
Abstract
Epidermolysis bullosa acquisita (EBA) is a chronic autoimmune subepidermal bullous disease with clinical features similar to the genetic form of dystrophic epidermolysis bullosa. EBA is characterized by the presence of autoantibodies against type VII collagen which is a major component of the anchoring fibrils at the dermal-epidermal junction. EBA can be divided into two main clinical types; mechanobullous and inflammatory EBA. Mechanobullous EBA, referred to as classic EBA, presents with skin fragility, blisters and dystrophic changes on trauma-prone areas. Inflammatory EBA resembles other autoimmune subepidermal bullous diseases. Compelling evidence from mouse models supports a pathogenic role of autoantibodies against type VII collagen in EBA. Treatment of EBA is often unsatisfactory. The most widely used systemic treatment is corticosteroids. Colchicine and dapsone have been reported to be good treatment modalities when combined with corticosteroids. Some intractable cases of EBA have successfully been treated with intravenous immunoglobulin or rituximab.
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Affiliation(s)
- J H Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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38
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Chams-Davatchi C, Mortazavizadeh A, Daneshpazhooh M, Davatchi F, Balighi K, Esmaili N, Akhyani M, Hallaji Z, Seirafi H, Mortazavi H. Randomized double blind trial of prednisolone and azathioprine, vs. prednisolone and placebo, in the treatment of pemphigus vulgaris. J Eur Acad Dermatol Venereol 2012; 27:1285-92. [PMID: 23062214 DOI: 10.1111/j.1468-3083.2012.04717.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The classic treatment for pemphigus vulgaris is prednisolone. Immunosuppressive drugs can be used in association. OBJECTIVE To compare the efficacy of Azathioprine in reducing the Disease Activity Index (DAI). PATIENTS AND METHODS A double blind randomized controlled study was conducted on 56 new patients, assigned to two therapeutic groups: (i) prednisolone plus placebo; (ii) prednisolone plus Azathioprine. Patients were checked regularly for 1 year. 'Complete remission' was defined as healing of all lesions after 12 months, and prednisolone <7.5 mg daily, (DAI ≤ 1). Analysis was done by 'Intention To Treat' (ITT) and 'Treatment Completed Analysis' (TCA). RESULTS Both groups were similar in age, gender, disease duration, and DAI. Primary endpoint: By ITT and TCA, the mean DAI improved in both groups with no significant difference between them. The difference became significant for the last trimester (3 months; ITT: P = 0.033, TCA: P = 0.045). Secondary endpoint: The total steroid dose decreased significantly in both groups, with no significant difference between them, except for the last trimester (ITT: P = 0.011, TCA: P = 0.035). The mean daily steroid dose decreased gradually in both groups becoming statistically significant in favour of azathioprine, in the last trimester, especially at 12th months (ITT: P = 0.002, TCA: P = 0.005). Complete remission was significant at 12 months only for TCA (AZA/Control: 53.6%/39.9%, P = 0.043). LIMITATIONS Sample size was rather small to demonstrate all differences. Other limitations include the choice of primary and secondary endpoints and the unavailability to measure thiopurine methyltransferase activity. CONCLUSION Azathioprine helps to reduce prednisolone dose in long-run.
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Affiliation(s)
- C Chams-Davatchi
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Tehran University for Medical Sciences, Razi Hospital Rheumatology Research Center, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
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Meyersburg D, Schmidt E, Kasperkiewicz M, Zillikens D. Immunoadsorption in Dermatology. Ther Apher Dial 2012; 16:311-20. [DOI: 10.1111/j.1744-9987.2012.01075.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Behzad M, Möbs C, Kneisel A, Möller M, Hoyer J, Hertl M, Eming R. Combined treatment with immunoadsorption and rituximab leads to fast and prolonged clinical remission in difficult-to-treat pemphigus vulgaris. Br J Dermatol 2012; 166:844-52. [DOI: 10.1111/j.1365-2133.2011.10732.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Westermann L, Hügel R, Meier M, Weichenthal M, Zillikens D, Gläser R, Schmidt E. Glucocorticosteroid-resistant pemphigoid gestationis: successful treatment with adjuvant immunoadsorption. J Dermatol 2012; 39:168-71. [PMID: 22379622 DOI: 10.1111/j.1346-8138.2011.01376.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 40-year old prima para presented with multiple urticaria-like plaques and severe pruritus 2 weeks prior to giving birth by cesarean section. Three days after birth, the disease flared up and tense blisters appeared on hands, lower arms and feet. Based on the clinical presentation, direct immunofluorescence microscopy, complement binding test and detection of high levels of circulating anti-BP180 antibodies, the diagnosis of pemphigoid gestationis was established. Despite treatment with class IV topical corticosteroid and prednisolone p.o. up to 60 mg/day, both skin lesions and severe pruritus progressed accompanied by increasing anti-BP180 antibody serum levels. In order to continue breast feeding, the prednisolone dose could not be further increased and 10 immunoadsorptions over 4 weeks were performed. During this period, skin lesions cleared rapidly, pruritus subsided and BP180-specific serum autoantibodies decreased by 99.5% allowing the reduction of prednisolone to 7.5 mg/day. We conclude that immunoadsorption is an effective and safe adjuvant therapeutic option for severe pemphigoid gestationis.
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Affiliation(s)
- Lilia Westermann
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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Recke A, Shimanovich I, Steven P, Westermann L, Zillikens D, Schmidt E. [Treatment-refractory anti-laminin 332 mucous membrane pemphigoid. Remission following adjuvant immunoadsorption and rituximab]. DER HAUTARZT 2011; 62:852-8. [PMID: 21706211 DOI: 10.1007/s00105-011-2189-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Mucous membrane pemphigoid (MMP) is clinically characterized by predominant involvement of mucous membranes which in case of conjunctival lesions can lead to blindness. In MMP, autoantibodies are directed against different proteins of the dermal-epidermal junction; in 25% of cases, laminin 332 is the target. Anti-laminin 332 MMP with ocular involvement is particularly difficult to treat. A 46-year-old Caucasian man with anti-laminin 332 pemphigoid and extensive oral and nasal erosions as well as severe conjunctival involvement did not respond to intravenous dexamethasone-cyclophosphamide pulses combined with oral cyclophosphamide. After initiation of a therapeutic regimen originally established for the treatment of pemphigus, including immunoapheresis and rituximab in combination with intravenous dexamethasone-cyclophosphamide pulses and oral mycophenolate mofetil, lesions cleared within 4 months and circulating autoantibody levels became undetectable 3 months later. This is the first report of the successful use of adjuvant immunoapheresis and rituximab in previously treatment-refractory anti-laminin 332 MMP.
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Affiliation(s)
- A Recke
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck, Lübeck
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Kasperkiewicz M, Shimanovich I, Meier M, Schumacher N, Westermann L, Kramer J, Zillikens D, Schmidt E. Treatment of severe pemphigus with a combination of immunoadsorption, rituximab, pulsed dexamethasone and azathioprine/mycophenolate mofetil: a pilot study of 23 patients. Br J Dermatol 2011; 166:154-60. [DOI: 10.1111/j.1365-2133.2011.10585.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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45
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Daniel BS, Borradori L, Hall RP, Murrell DF. Evidence-Based Management of Bullous Pemphigoid. Dermatol Clin 2011; 29:613-20. [DOI: 10.1016/j.det.2011.06.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Kasperkiewicz M, Zillikens D, Schmidt E. Pemphigoid diseases: Pathogenesis, diagnosis, and treatment. Autoimmunity 2011; 45:55-70. [DOI: 10.3109/08916934.2011.606447] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
In Germany, more than 2000 new patients per year have been calculated to be diagnosed with autoimmune blistering diseases. In a recent survey, the most frequently applied treatment regimens for bullous pemphigoid were class IV topical corticosteroids and oral prednisolone 0.5 mg or 1.0 mg/kg/d plus dapsone or azathioprine. For pemphigus, two-thirds of the clinics applied oral prednisolone at doses of 1.0 mg or 1.5 mg/kg/d and in more than 80% of departments, azathioprine was chosen as concomitant immunosuppressant. High-dose intravenous immunoglobulin, rituximab, and immunoadsorption are increasingly used for refractory patients. Treatment and diagnostic costs are covered by the health insurances when applied according to published expert recommendations.
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Schmidt E, Zillikens D. The diagnosis and treatment of autoimmune blistering skin diseases. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:399-405, I-III. [PMID: 21712975 DOI: 10.3238/arztebl.2011.0399] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 07/23/2010] [Indexed: 12/24/2022]
Abstract
BACKGROUND Autoimmune blistering skin diseases are a heterogeneous group of disorders associated with autoantibodies that are directed against desmosomal structural proteins (in pemphigus diseases) or hemidesmosomal ones (in pemphigoid diseases and epidermolysis bullosa acquisita), or else against epidermal/ tissue transglutaminases (in dermatitis herpetiformis). Knowledge of the clinical presentation of these disorders and of the relevant diagnostic procedures is important not just for dermatologists, but also for general practitioners, ophthalmologists, ENT specialists, dentists, gynecologists, and pediatricians. METHODS The literature on the subject was selectively reviewed. There are no existing guidelines available in Germany. RESULTS The recently developed sensitive and specific assays for circulating autoantibodies in these diseases now enable a serological diagnosis in about 90% of cases. The incidence of autoimmune blistering skin diseases in Germany has doubled in the last 10 years, to a current figure of about 25 new cases per million persons per year, because of improved diagnostic techniques as well as the aging of the population. Accurate and specific diagnosis is the prerequisite for reliable prognostication and appropriate treatment. For severe and intractable cases, more effective treatments have recently become available, including immunoadsorption, high-dose intravenous immunoglobulin, the anti-CD20 antibody rituximab, and combinations of the above. CONCLUSION The diagnostic assessment of autoimmune blistering skin diseases can be expected to improve in the near future as new serological testing systems are developed that employ recombinant forms of the target antigens. The treatments currently in use still need to be validated by prospective, controlled trials.
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Affiliation(s)
- Enno Schmidt
- Exzellenzzentrum für Entzündungsmedizin, Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck.
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Kasperkiewicz M, Schmidt E, Frambach Y, Rose C, Meier M, Nitschke M, Falk TM, Reich K, Ludwig RJ, Zillikens D. Improvement of treatment-refractory atopic dermatitis by immunoadsorption: a pilot study. J Allergy Clin Immunol 2010; 127:267-70, 270.e1-6. [PMID: 20970174 DOI: 10.1016/j.jaci.2010.07.042] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2010] [Revised: 07/28/2010] [Accepted: 07/29/2010] [Indexed: 10/18/2022]
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Marker M, Derfler K, Monshi B, Rappersberger K. Successful immunoapheresis of bullous autoimmune diseases: pemphigus vulgaris and pemphigoid gestationis. J Dtsch Dermatol Ges 2010; 9:27-31. [PMID: 20812992 DOI: 10.1111/j.1610-0387.2010.07500.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Immunoapheresis/immunoadsorption is a specific tool to remove immunoglobulins and immune complexes from the circulation. Immunoapheresis is successfully used in various autoantibody-mediated diseases (such as autoimmune renal disease and others). In dermatology immunoapheresis is increasingly applied as an adjuvant treatment for severe autoimmune bullous diseases. CASE REPORT We successfully employed adjuvant immunoapheresis to treat a 57-year-old man with life-threatening pemphigus vulgaris and a 30-year-old pregnant woman with severe pemphigoid gestationis. Immunoapheresis induced a rapid improvement and almost complete clearance of clinical symptoms without notable side effects. The clinical improvement was paralleled by a decline of the pathologic circulating autoantibodies. Following stabilization of his disease with immunoapheresis, the pemphigus vulgaris patient was continued on rituximab and remained almost free of symptoms for the next 12 months. The patient with pemphigoid gestationis was subsequently treated with systemic corticosteroids until the symptoms of her self-limited disease ceased. CONCLUSION Immunoapheresis might represent an excellent therapy for certain patients with severe pemphigus vulgaris or pemphigoid gestationis, unresponsive to conventional treatment regimens. We observed rapid improvement of clinical symptoms and no notable side effects.
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Affiliation(s)
- Michael Marker
- Department of Dermatology, Krankenanstalt Rudolfstiftung, Vienna, Austria.
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