Autoimmune Blistering Diseases in the Elderly: Clinical Presentations and Management

Autoimmune blistering diseases treated with glucocorticoids: An international study of steroid-induced myopathy

BACKGROUND

Patients with autoimmune blistering diseases (AIBDs) are often exposed to chronic glucocorticoid (GC) treatment with many side effects. Glucocorticoid-induced myopathy (GIM) is a well-established side effect, which particularly affects the proximal muscles. The Glucocorticoid Toxicity Index (GTI) is a validated global assessment tool which quantifies GC toxicity over time.

OBJECTIVES

This study marks the first study which analyses GIM in patients with AIBDs. The objectives of this study were to utilize the GTI to investigate the nature and prevalence of GIM in AIBD patients and explore potential risk factors.

METHODS

This international cohort study was conducted in blistering disease clinics across Australia, China, Greece, Iran, Japan, the Philippines, Turkey and the United States of America between February 2019 and July 2023. The GTI tool was completed by a medical practitioner at each patient visit. Data related to glucocorticoid toxicity were entered into the Steritas GTI 2.0 to generate an aggregate improvement and cumulative worsening score at each visit.

RESULTS

The study included 139 patients. There were 132 episodes of myopathy, and 47.5% of patients developed muscle weakness at some point during the study period. Cumulative GC dose correlated positively with myopathy risk, while average dose and treatment duration were not significant. Older age, male gender and obesity more than doubled the likelihood of developing GIM.

CONCLUSIONS

GIM is a common side effect experienced by AIBD patients on GC treatment. Muscle weakness is less likely to occur if cumulative GC dose is less than 0.75 mg/kg/day. Studies of exercise programs to mitigate myopathy and newer alternative treatments to reduce cumulative GC dose should be considered.

Prevalence and burden of skin diseases among the elderly in Singapore: A 15-year clinical cohort study

BACKGROUND

Populations around the world are rapidly ageing. The profile of skin diseases in the elderly is likely to present unique demands on the healthcare system.

OBJECTIVES

To provide current data on the burden of skin diseases in Singaporean patients and identify differences in the pattern of skin diseases between elderly patients and the rest of the population.

METHODS

This was a retrospective cohort study of 858,117 patients who attended the National Skin Centre between 2004 to 2018. Prevalence was calculated by grouping International Classification of Diseases codes into different categories of skin conditions based on Global Burden of Disease and American Academy of Dermatology classifications. Years lost to disability (YLD) and disability-adjusted life years (DALY) were calculated to report the morbidity and mortality of skin diseases. Differences of each skin condition between age groups were compared.

RESULTS

The three most prevalent dermatoses across all age groups were dermatitis (33.3%), acne vulgaris (8.3%) and viral skin diseases (7.5%). The top three most common skin conditions among the elderly were dermatitis (37.7%), viral skin diseases (6.2%), and fungal skin diseases (4.3%). Decubitus ulcers, keratinocyte carcinomas and scabies represented a significant proportion of YLD per 100,000 in the elderly (p <0.001). Malignant melanomas, keratinocyte carcinomas, cellulitis, pyoderma, and decubitus ulcers contributed to high DALY in patients aged 70 - 80 years old.

CONCLUSION

Aligning health systems with specific healthcare needs will reduce the disproportionately high burden of skin disease observed in the elderly.

Immune checkpoint inhibitors: a promising anticancer therapy

Immune checkpoint inhibitors (ICIs) are revolutionizing the treatment of many cancers and have demonstrated their potential as 'cancer terminators'. However, ICI treatment also has constraints, such as its immune-related adverse events (irAEs) and therapeutic resistance. These drawbacks are gradually being overcome through better knowledge of the immune system, history of disease, duration of treatment, combinational drug regimes, adequate biomarkers, and effective patient response monitoring. In this review, we discuss the present ICI therapy landscape and its therapeutic outcomes for various diseases. We also highlight biomarkers related to the ICI response.

[Humoral immune diseases: Cutaneous vasculitis and auto-immune bullous dermatoses]

Humoral immunity is the cause of multiple diseases related to antibodies (IgA, IgG, IgM) produced by the patient. Two groups of diseases are identified. The first group is related to circulating antigen-antibody complexes. The antigens are various. They are often unknown. These immune complexes cause a vascular inflammation due to the complement fixation. Consequently, this group is dominated by inflammatory vasculitis. In the second group, the pathology is due to the fixation in situ of antibodies to a target antigen of the skin that is no more recognized by the patient. This group is represented by the auto-immune bullous dermatoses.

Blistering diseases in the mature patient

Autoimmune blistering diseases (AIBD) are a group of chronic diseases affecting the skin and mucous membranes, with different presentation, clinical course, histologic and immunopathologic findings, and different therapeutic approach. Blisters develop as a result of autoantibodies directed against distinct adhesion structures within desmosomes or within the basement membrane zone. The most common AIBD that develops in the elderly is bullous pemphigoid (previously also named "pemphigoid senilis"), but mature patients can also present with other AIBD as mucous membrane pemphigoid, epidermolysis bullosa acquisita, paraneoplastic pemphigus, pemphigus vulgaris, pemphigus foliaceus, linear IgA dermatosis, and dermatitis herpetiformis. There are no differences in treatment approach to mature patients with AIBD, but due to more common comorbidities, systemic therapy should be given with more caution and control, and due to distorted skin integrity in the aged skin, the safety concerns are increased with the long-term use of any topical medication.