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Diagnosis and Management of Pathological Conditions. J Oral Maxillofac Surg 2023; 81:E221-E262. [PMID: 37833025 DOI: 10.1016/j.joms.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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2
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Montagnon CM, Lehman JS, Murrell DF, Camilleri MJ, Tolkachjov SN. Subepithelial autoimmune bullous dermatoses disease activity assessment and therapy. J Am Acad Dermatol 2021; 85:18-27. [PMID: 33684494 DOI: 10.1016/j.jaad.2020.05.161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/17/2020] [Accepted: 05/21/2020] [Indexed: 12/18/2022]
Abstract
Subepidermal (subepithelial) autoimmune blistering dermatoses are a group of rare skin disorders characterized by the disruption of the dermal-epidermal junction through the action of autoantibodies. The fourth article in this continuing medical education series presents the current validated disease activity scoring systems, serologic parameters, treatments, and clinical trials for bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, bullous systemic lupus erythematosus, anti-p200 pemphigoid, linear IgA bullous dermatosis, and dermatitis herpetiformis.
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Affiliation(s)
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, Australia
| | - Michael J Camilleri
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Cizenski JD, Michel P, Watson IT, Frieder J, Wilder EG, Wright JM, Menter MA. Spectrum of orocutaneous disease associations: Immune-mediated conditions. J Am Acad Dermatol 2017; 77:795-806. [PMID: 29029901 DOI: 10.1016/j.jaad.2017.02.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/01/2017] [Accepted: 02/03/2017] [Indexed: 02/07/2023]
Abstract
There are a number of diseases that manifest both on the skin and the oral mucosa, and therefore the importance for dermatologists in clinical practice to be aware of these associations is paramount. In the following continuing medical education series, we outline orocutaneous disease associations with both immunologic and inflammatory etiologies.
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Affiliation(s)
- Jeffrey D Cizenski
- Division of Dermatology, Baylor University Medical Center, Dallas, Texas
| | - Pablo Michel
- Division of Dermatology, Baylor University Medical Center, Dallas, Texas
| | - Ian T Watson
- Texas A&M Health Science Center College of Medicine, Bryan, Texas
| | - Jillian Frieder
- Division of Dermatology, Baylor University Medical Center, Dallas, Texas
| | - Elizabeth G Wilder
- Division of Dermatology, Baylor University Medical Center, Dallas, Texas
| | - John M Wright
- Department of Diagnostic Sciences, Texas A&M College of Dentistry, Dallas, Texas
| | - M Alan Menter
- Division of Dermatology, Baylor University Medical Center, Dallas, Texas.
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McCoy JM, Oreadi D. Diagnosis and Management of Pathological Conditions. J Oral Maxillofac Surg 2017; 75:e224-e263. [DOI: 10.1016/j.joms.2017.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Tejani S, Sultan A, Stojanov I, Woo SB. Candidal carriage predicts candidiasis during topical immunosuppressive therapy: a preliminary retrospective cohort study. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 122:448-54. [DOI: 10.1016/j.oooo.2016.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 06/05/2016] [Accepted: 06/11/2016] [Indexed: 12/14/2022]
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6
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Kalinska-Bienias A, Kalowska M, Kwiek B, Jakubowska B, Ishii N, Hashimoto T, Kowalewski C, Wozniak K. Efficacy and safety of perilesional/intralesional triamcinolone injections in oral mucous membrane pemphigoid. Br J Dermatol 2015. [DOI: 10.1111/bjd.14043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- A. Kalinska-Bienias
- Department of Dermatology and Immunodermatology; Medical University of Warsaw; Str. Koszykowa 82a 02-008 Warsaw Poland
| | - M. Kalowska
- Department of Dermatology and Immunodermatology; Medical University of Warsaw; Str. Koszykowa 82a 02-008 Warsaw Poland
| | - B. Kwiek
- Department of Dermatology and Immunodermatology; Medical University of Warsaw; Str. Koszykowa 82a 02-008 Warsaw Poland
| | - B. Jakubowska
- Department of Dermatology and Immunodermatology; Medical University of Warsaw; Str. Koszykowa 82a 02-008 Warsaw Poland
| | - N. Ishii
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Japan
| | - T. Hashimoto
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Japan
| | - C. Kowalewski
- Department of Dermatology and Immunodermatology; Medical University of Warsaw; Str. Koszykowa 82a 02-008 Warsaw Poland
| | - K. Wozniak
- Department of Dermatology and Immunodermatology; Medical University of Warsaw; Str. Koszykowa 82a 02-008 Warsaw Poland
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Carlson ER, Ghali GE, Herb-Brower KE. Diagnosis and management of pathological conditions. J Oral Maxillofac Surg 2012; 70:e232-71. [PMID: 23128003 DOI: 10.1016/j.joms.2012.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Woo SB. Diseases of the oral mucosa. MCKEE'S PATHOLOGY OF THE SKIN 2012:362-436. [DOI: 10.1016/b978-1-4160-5649-2.00011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Schifter M, Yeoh SC, Coleman H, Georgiou A. Oral mucosal diseases: the inflammatory dermatoses. Aust Dent J 2010; 55 Suppl 1:23-38. [PMID: 20553242 DOI: 10.1111/j.1834-7819.2010.01196.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The oral inflammatory dermatoses is a term used to describe a number of predominantly immune-mediated disorders: lichen planus (LP), erythema multiforme (EM), the vesiculobullous diseases pemphigoid (MMP), pemphigus (PV) and epidermolysis bullosa acquisita (EBA). These conditions are characterized by frequent involvement of the oral mucosa and often associated with extraoral manifestations, particularly of the skin, but can involve the eyes, both the conjunctiva and sclera, the nasal and pharyngeal mucosa, as well as the genitals. Given their frequent, and sometimes initial involvement of the oral mucosa, oral health professionals need to be both familiar with the clinical features and presentations of these conditions, and appreciate their critical role in management. This paper reviews the clinical features and presentation of the oral dermatoses, provides guidance as to the appropriate investigations needed to differentiate and correctly diagnose these conditions, details the aetio-pathology of these diseases and discusses their management.
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Affiliation(s)
- M Schifter
- Oral Medicine/Oral Pathology Unit, Westmead Centre for Oral Health, Westmead Hospital, Sydney.
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Abstract
Mucous membrane pemphigoid and pemphigus vulgaris are autoimmune blistering disorders in which many similar drugs and therapeutic strategies are utilized. In general, localized disease can be treated with topical agents. In contrast, patients with more severe and progressive disease usually require a combination of systemic corticosteroids and immunosuppressive medications. Oral corticosteroids, adjuvant immunosuppressive agents, antibiotics such as dapsone and immunomodulatory procedures like intravenous immunoglobulin are the main therapeutic agents used in treating these two disorders. Much of the morbidity and mortality associated with these disorders are related to the sites involved and to the drugs used for therapy. Treatment should be individualized based on severity, extent, and rate of progression of disease, comorbidities, and age of the patient. Serum levels of specific autoantibodies and indirect immunofluorescence titers, in certain cases, can be used to monitor response to therapy.
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Affiliation(s)
- Richelle M Knudson
- Department of Dermatology, Mayo Clinic/Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Scully C, Lo Muzio L. Oral mucosal diseases: Mucous membrane pemphigoid. Br J Oral Maxillofac Surg 2008; 46:358-66. [PMID: 17804127 DOI: 10.1016/j.bjoms.2007.07.200] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2007] [Indexed: 11/26/2022]
Abstract
Subepithelial vesiculobullous conditions are chronic autoimmune disorders that arise from reactions directed against components of the hemidesmosomes or basement membrane zones (BMZ) of stratified squamous epithelium to which the term immune-mediated subepithelial blistering diseases (IMSEBD) has been given. Mucous membrane pemphigoid (MMP) is the most common, but variants do exist. Non-immune disorders that involve these epithelial components typically have a genetic basis--the main example being epidermolysis bullosa. All subepithelial vesiculobullous disorders present as blisters and erosions, and diagnosis must be confirmed by biopsy examination with immunostaining, sometimes supplemented by other investigations. No single treatment reliably controls all subepithelial vesiculobullous disorders; the immunological differences within IMSEBD may account for differences in responses to treatment. Currently, as well as improving oral hygiene, immunomodulatory treatment is used to control the oral lesions of MMP, but it is not known if its specific subsets reliably respond to different agents.
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Arash A, Shirin L. The management of oral mucous membrane pemphigoid with dapsone and topical corticosteroid. J Oral Pathol Med 2008; 37:341-4. [DOI: 10.1111/j.1600-0714.2008.00653.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Azizi A, Lawaf S. The management of oral pemphigus vulgaris with systemic corticosteroid and dapsone. J Dent Res Dent Clin Dent Prospects 2008; 2:33-7. [PMID: 23285328 PMCID: PMC3533636 DOI: 10.5681/joddd.2008.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 02/12/2008] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIMS Oral pemphigus vulgaris is a chronic autoimmune mucocutaneous intraepi-thelial disease that primarily affects patients over the age of fifty, resulting in mucosal ulceration and is a potentially life-threatening disease. The purpose of this study was to investigate the efficacy of dap-sone in combination with systemic corticosteroids to treat the oral lesions of oral pemphigus. MATERIALS AND METHODS Twenty patients diagnosed with oral pemphigus were selected. Oral mani-festations were graded according to the severity of disease from 1 to 3. All patients were treated initially with systemic corticosteroids. Each was assigned to one of 4 groups according to their response to ther-apy. Patients who responded less than 50% healing of lesions began a trial of dapsone. After 4 weeks, signs and symptoms were recorded, and if a patient was lesion-free, the dapsone dosage was gradually tapered. RESULTS Five patients with mild to moderate disease were treated with systemic corticosteroids alone. 15 patients with moderate to severe disease were treated with systemic corticosteroid and dapsone ther-apy. Of these, 10 patients had significant benefits, while 5 patients did not respond to dapsone adjuvant. Conclusions. The use of dapsone in combination with systemic corticosteroids is a useful method for treatment of oral pemphigus. CONCLUSIONS The use of dapsone in combination with systemic corticosteroids is a useful method for treatment of oral pemphigus.
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Affiliation(s)
- Arash Azizi
- Assistant Professor, Department of Oral Medicine, Faculty of Dentistry, Ahwaz Jondishapoor University of Medical Sciences, Iran
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Rinaggio J, Crossland DM, Zeid MY. A Determination of the Range of Oral Conditions Submitted for Microscopic and Direct Immunofluorescence Analysis. J Periodontol 2007; 78:1904-10. [DOI: 10.1902/jop.2007.070095] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ojha J, Bhattacharyya I, Stewart C, Katz J. Cicatricial pemphigoid with severe gingival and laryngeal involvement in an 18-year-old female. ACTA ACUST UNITED AC 2007; 104:363-7. [PMID: 17376714 DOI: 10.1016/j.tripleo.2006.11.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 11/20/2006] [Accepted: 11/21/2006] [Indexed: 11/22/2022]
Abstract
Cicatricial pemphigoid (CP), also known as mucous membrane pemphigoid, is an autoimmune vesiculobullous disease occurring mostly in elderly people and seldom occurring in individuals under the age of 20 years. It predominantly affects the mucosal surfaces, primarily the oral and conjunctival mucosa. Uncommonly, the upper aerodigestive tract is involved, which can lead to life-threatening complications. We present the case of an 18-year-old girl with desquamative gingivitis and severe laryngeal webbing and stenosis, caused by cicatricial pemphigoid. Airway management necessitated a tracheostomy and additional surgical procedure. The clinical, diagnostic, and therapeutic features of this disease are discussed, focusing on the oral and unique laryngeal manifestations.
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Affiliation(s)
- Junu Ojha
- Department of Oral and Maxillofacial Surgery and Dental Diagnostic Sciences, University of Florida, College of Dentistry, Gainesville, FL 32610, USA.
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Abstract
Mucous membrane pemphigoid (MMP) is a sub-epithelial vesiculobullous disorder. It is now quite evident that a number of sub-epithelial vesiculobullous disorders may produce similar clinical pictures, and also that a range of variants of MMP exist, with antibodies directed against various hemidesmosomal components or components of the epithelial basement membrane. The term immune-mediated sub-epithelial blistering diseases (IMSEBD) has therefore been used. Immunological differences may account for the significant differences in their clinical presentation and responses to therapy, but unfortunately data on this are few. The diagnosis and management of IMSEBD on clinical grounds alone is impossible and a full history, general, and oral examination, and biopsy with immunostaining are now invariably required, sometimes supplemented with other investigations. No single treatment regimen reliably controls all these disorders, and it is not known if the specific subsets of MMP will respond to different drugs. Currently, apart from improving oral hygiene, immunomodulatory-especially immunosuppressive-therapy is typically used to control oral lesions. The present paper reviews pemphigoid, describing the present understanding of this fascinating clinical phenotype, summarising the increasing number of subsets with sometimes-different natural histories and immunological features, and outlining current clinical practice.
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Affiliation(s)
- J Bagan
- University of Valencia, Spain
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Sánchez AR, Rogers RS, Kupp LI, Sheridan PJ. Desquamative Gingivitis Associated With IgG/IgA Pemphigoid Presents a Challenging Diagnosis and Treatment: A Case Report. J Periodontol 2004; 75:1714-9. [PMID: 15732876 DOI: 10.1902/jop.2004.75.12.1714] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Mucous membrane pemphigoid (MMP) is a heterogeneous group of autoimmune blistering disorders characterized by subepithelial separation and the deposition of immunoglobulins and complement along the basement membrane zone (BMZ). This disease is diagnosed with direct immunofluorescence testing showing a linear deposition of immunoglobulins and/or complement along the BMZ and indirect immunofluorescence testing showing circulating IgG (and sometimes IgA) autoantibodies along the BMZ. In this case report we describe desquamative gingivitis secondary to IgG/IgA pemphigoid and the management of this challenging variant of MMP. METHODS Routine histology, direct immunofluorescence testing, and indirect immunofluorescence testing were utilized and correlated to the clinical findings to diagnose this unusual immunobullous disease. RESULTS Direct and indirect immunofluorescence testing confirmed the clinical diagnosis of IgG/IgA pemphigoid as the cause of desquamative gingivitis and the other mucosal findings in this patient. A treatment program including dapsone and other drugs completely resolved the oral lesions after 14 months of therapy. CONCLUSIONS Desquamative gingivitis associated with IgG/IgA pemphigoid can be challenging to diagnose and treat. After 14 months of treatment, a combination therapy consisting of dapsone with cimetidine and vitamin E to enhance drug efficacy and frequent intramuscular administrations of triamcinolone achieved control of both the oral and genital elements of IgG/IgA pemphigoid in this patient.
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Affiliation(s)
- Andrés R Sánchez
- Division of Periodontics, Department of Dental Specialties, Mayo Clinic, Rochester, MN 55905, USA.
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Abstract
Many systemic diseases can mimic periodontitis or gingivitis. These include many immunologic, infectious, neoplastic and metabolic disorders. In comparison with periodontitis and gingivitis, these disorders are considerable less common. However, since their diagnosis and management differ, a high index of suspicion is frequently needed when confronted a patient presenting with gingival or periodontal disease. This chapter has reviewed a number of systemic conditions that may mimic clinically both gingivitis and chronic periodontitis and has focused on the features that may assist the clinician in making the diagnosis and providing specific therapies.
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Nelson BL, Thompson LD. Oral Cicatricial Pemphigoid. EAR, NOSE & THROAT JOURNAL 2004. [DOI: 10.1177/014556130408300110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Lester D.R. Thompson
- Department of Pathology, Woodland Hills Medical Center, Southern California Kaiser Permanente Group, Woodland Hills, Calif
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Thongprasom K, Luengvisut P, Wongwatanakij A, Boonjatturus C. Clinical evaluation in treatment of oral lichen planus with topical fluocinolone acetonide: a 2-year follow-up. J Oral Pathol Med 2003; 32:315-22. [PMID: 12787037 DOI: 10.1034/j.1600-0714.2003.00130.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Oral lichen planus (OLP) is a chronic inflammatory disease which is recalcitrant to medical treatment. The purpose of this study was to compare the effectiveness of various forms of the topical steroid fluocinolone acetonide applications in patients with OLP. METHODS Data of OLP patients were collected retrospectively from the chart record and the 97 OLP patients were divided into three groups. The first group (n = 28) was treated with a 0.1% solution of fluocinolone acetonide (FAS), the second group (n = 22) with 0.1% fluocinolone acetonide in orabase (FAO), and the third group (n = 47) with both FAS and FAO (FAS/FAO) throughout the study. Each group was clinically evaluated as complete remission (CR), partial remission (PR), or no response (NR), following the treatment. Also, the side-effect of oral candidiasis was recorded in each group. RESULTS Two years of treatment resulted in complete remission of 77.3, 21.4, and 17.0% of patients in the FAO, FAS, and FAS/FAO groups, respectively. There was a statistically significant difference in disease remission (P < 0.05), but not in oral candidiasis appearance (P > 0.05) among various forms of topical steroid application. CONCLUSION The study concluded that FAO or FAS can produce improved results in the management of OLP by long-term follow-up.
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Affiliation(s)
- K Thongprasom
- Faculty of Dentistry, Oral Medicine Department, Chulalongkorn University, Bangkok 10330, Thailand.
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Kirtschig G, Murrell D, Wojnarowska F, Khumalo N. Interventions for mucous membrane pemphigoid and epidermolysis bullosa acquisita. Cochrane Database Syst Rev 2003; 2003:CD004056. [PMID: 12535507 PMCID: PMC8406492 DOI: 10.1002/14651858.cd004056] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Mucous membrane pemphigoid and epidermolysis bullosa acquisita are acquired autoimmune blistering diseases of the skin. Although they are rare, both can result in scarring of mucous membranes, which may lead to blindness and life threatening respiratory complications. OBJECTIVES To assess the effects of treatments for mucous membrane pemphigoid and epidermolysis bullosa acquisita. SEARCH STRATEGY Randomised Controlled Trials (RCTs) of patients with MMP or EBA were identified from MEDLINE and EMBASE from their inception to March 2000. The Cochrane Skin Group Specialised Register and the Cochrane Controlled Trials Register (CCTR) were last examined in February 2002. The bibliographies from identified studies were searched. The author who has conducted clinical trials in the field was contacted to identify unpublished trials. SELECTION CRITERIA RCTs involving participants of any ages, and with a diagnosis confirmed by immunofluorescence. Where no RCTs were located, studies with other designs were considered. DATA COLLECTION AND ANALYSIS Data were extracted from all included studies using a defined electronic data extraction protocol. Two reviewers evaluated the studies in terms of the inclusion criteria. The data from identified RCTs was extracted independently by three reviewers and subsequently checked for discrepancies. Any disagreements were resolved by discussion with each other and the fourth reviewer. Meta-analysis was not appropriate due to a lack of data. MAIN RESULTS We found two small RCTs of MMP, both conducted in patients with severe eye involvement. The same author conducted both trials. In the first trial cyclophosphamide was superior to prednisone after six months of treatment; all 12 patients responded well to cyclophosphamide versus a good response in only five of 12 patients treated with prednisone (relative risk 2.40, 95% confidence interval 1.23 to 4.69). In the second trial all 20 patients treated with cyclophosphamide responded well to it after three months of treatment, but only 14 of 20 patients responded to the treatment with dapsone (relative risk 1.4, 95% confidence interval 1.07 to 1.90). We were not able to identify a RCT of therapeutic interventions in EBA. Thirty reports of uncontrolled studies of treatment for MMP involving five or more patients and 11 reports of treatment for EBA involving two or more patients were found, but were difficult to interpret. REVIEWER'S CONCLUSIONS There is limited evidence (from two small trials) that severe ocular mucous membrane pemphigoid responds best to treatment with cyclophosphamide combined with corticosteroids, and that mild to moderate disease in most patients seems effectively suppressed by treatment with dapsone. It is difficult to make any treatment recommendations for EBA in the absence of reliable evidence sources.
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Affiliation(s)
- G Kirtschig
- Dermatology, Vrije Universiteit Medisch Centrum, PO Box 7057, Amsterdam, Netherlands, 1007 MB.
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Olivry T, Dunston SM, Zhang G, Ghohestani RF. Laminin-5 is targeted by autoantibodies in feline mucous membrane (cicatricial) pemphigoid. Vet Immunol Immunopathol 2002; 88:123-9. [PMID: 12127411 DOI: 10.1016/s0165-2427(02)00166-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In human and canine patients with mucous membrane (cicatricial) pemphigoid (MMP), circulating autoantibodies have been shown to target multiple epidermal basement membrane antigenic epitopes. These autoantigens include collagen XVII in humans and dogs, as well as laminin-5, laminin-6 or integrin alpha-6/beta-4 in human beings. The purpose of this study was to determine if autoantibodies targeted laminin-5 in a cat exhibiting clinical and microscopic lesions resembling those of MMP in humans. In this patient, an indirect immunofluorescence (IF) assay revealed circulating IgG and IgA autoantibodies that bound to the basement membrane zone on the dermal side of salt-split gingiva (titer 1:1000 for IgG and 1:50 for IgA). Immunoblotting, performed with affinity-purified human laminin-5, demonstrated that the autoantibodies bound the alpha-3 chain of this heterotrimer. These observations identify laminin-5 as one of the antigens recognized by circulating autoantibodies in this feline homologue of MMP in humans and dogs.
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Affiliation(s)
- Thierry Olivry
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, 4700 Hillsborough Street, Raleigh, NC, USA.
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Musa NJ, Kumar V, Humphreys L, Aguirre A, Neiders ME. Oral pemphigoid masquerading as necrotizing ulcerative gingivitis in a child. J Periodontol 2002; 73:657-63. [PMID: 12083540 DOI: 10.1902/jop.2002.73.6.657] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Cicatricial pemphigoid (benign mucous membrane pemphigoid) is an autoimmune vesiculobullous disease that affects mucosal tissues of adults and rarely presents in children. Only 9 cases in the English literature have reported cicatricial pemphigoid in children, primarily as oral mucosal lesions. This paper presents a case of childhood cicatricial pemphigoid that clinically manifested as necrotizing ulcerative gingivitis (NUG). METHODS A 9-year-old girl presented with gingival bleeding and discomfort for 2 weeks. NUG was suspected and the patient was treated with antibiotics and an oral hygiene regimen. When the condition did not improve after repeated treatment trials, routine hematoxylin and eosin (H&E) and direct immunofluorescence examinations were performed. RESULTS Microscopic examination of H&E stained sections showed a non-specific ulceration with chronic inflammation. Direct immunofluorescence studies of peri-lesional tissue showed linear deposition of C3 at the basement membrane zone that was consistent with a diagnosis of cicatricial pemphigoid. CONCLUSION Cicatricial pemphigoid is an autoimmune ulcerative condition that is rarely seen in children. Immunofluorescence studies are essential to differentiate this condition from other ulcerative oral lesions.
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Affiliation(s)
- Nour J Musa
- Department of Oral Diagnostic Sciences, School of Dental Medicine, University at Buffalo, NY 14214, USA.
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Abstract
Cicatricial pemphigoid is an autoimmune bullous disease that has a predilection for mucous membranes and often results in scarring. We describe a case of cicatricial pemphigoid with severe involvement of the glans penis, which, despite systemic therapy, led to phimosis.
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Affiliation(s)
- John C Fueston
- Department of Dermatology, University of Cincinnati, College of Medicine, Cincinnati, OH 45267, USA
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Affiliation(s)
- F Wojnarowska
- Department of Dermatology, Oxford Radcliffe Hospital, Oxford, England, United Kingdom
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Affiliation(s)
- J Casiglia
- Bringham Dental Group, Brigham and Women's Hospital, Harvard University School of Medicine, Boston, Massachusetts 02115, USA
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Olivry T, Dunston SM, Schachter M, Xu L, Nguyen N, Marinkovich MP, Chan LS. A spontaneous canine model of mucous membrane (cicatricial) pemphigoid, an autoimmune blistering disease affecting mucosae and mucocutaneous junctions. J Autoimmun 2001; 16:411-21. [PMID: 11437489 DOI: 10.1006/jaut.2001.0510] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Mucous membrane pemphigoid (MMP) is a rare autoimmune blistering dermatosis of humans that was previously known as cicatricial pemphigoid. It is characterized by vesicles, ulcers and scarring that affect predominantly mucosae and mucocutaneous junctions. Circulating autoantibodies recognize epitopes on basement membrane proteins such as collagen XVII or laminin-5/6. Herein, we describe the clinico-pathological and immunological characteristics of 17 dogs afflicted with a dermatosis homologous to MMP of humans. Patients exhibited vesicles and erosions predominantly on mucous membranes or mucocutaneous junctions of the mouth, nose, eyes, genitalia or anus. Histopathology revealed subepithelial vesicles with variable dermal inflammation. Direct immunofluorescence demonstrated IgG or complement at the dermoepithelial junction. Indirect immunofluorescence using salt-split epithelia permitted the detection of circulating basement membrane-specific IgG autoantibodies in 15 cases. In 11 patients, autoantibodies recognized the NC16A segment of collagen XVII, as determined by salt-split indirect immunofluorescence, immunoblotting using canine keratinocytes and ELISA with synthetic canine peptides. In one dog, autoantiodies bound to the dermal side of salt-split epithelia and recognized epitopes within the 30 kDa carboxy-terminal segment of human collagen XVII. Canine MMP, like its human counterpart, exhibits distinctive clinical signs and histopathological lesions, yet circulating autoantibodies target different antigenic epitopes. This spontaneous canine model of MMP could prove useful for studies on the pathogenesis or therapy of this human disease.
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Affiliation(s)
- T Olivry
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina 27606, USA.
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Kurihara M, Nishimura F, Hashimoto T, Komai A, Ueda H, Kokeguchi S, Takashiba S, Murayama Y. Immunopathological diagnosis of cicatricial pemphigoid with desquamative gingivitis. A case report. J Periodontol 2001; 72:243-9. [PMID: 11288799 DOI: 10.1902/jop.2001.72.2.243] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cicatricial pemphigoid (CP) is a chronic subepidermal bullous dermatosis which primarily involves the mucous membranes. The oral cavity and the eye are most frequently involved. Since extension of the lesion into the pharynx and esophagus causes sore throat and dysphagia and progressive ocular lesions may cause blindness, early and valid diagnosis is very important. Here we present a case of cicatricial pemphigoid with onset at age 45 in a patient who manifested severe periodontal disease and showed the lesion on the mucous membranes of the mouth (desquamative gingivitis), skin, and eyes. Since definite diagnosis is very important, we describe how we made a differential diagnosis from other diseases which also accompany desquamative gingivitis. We examined the clinical manifestations, blood test results, HLA-genotype, histopathologic findings of the affected tissue, and immunological findings in relation to autoimmunity. Since many of the CP cases are first referred to periodontists or dentists, we believe that the diagnostic strategy described in the present study will be quite informative for making rapid and definite diagnoses of similar cases.
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Affiliation(s)
- M Kurihara
- Department of Periodontology and Endodontology, Okayama University Dental School, Japan
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Abstract
It is obvious from the review of the literature that most treatments for oral diseases such as lichen planus, pemphigoid, and pemphigus are based on case reports, anecdotes, and small uncontrolled studies. Efforts must be made to perform more controlled studies to evaluate the efficacy of new treatments. Small numbers of patients at each site and multiple-drug therapy make this task difficult. Dermatologists should familiarize themselves with the newer immunosuppressive agents available. Use of these drugs requires knowledge of their pharmacokinetics and potential side effects, so that they may be used effectively and safely. Relatively low doses of azathioprine, cyclophosphamide, and cyclosporine should then be added to the dermatologist's armamentarium for the treatment of severe or recalcitrant diseases. Old drugs are resurfacing with new (but often off-label) uses as the underlying mechanisms of disease become understood. Thalidomide and mycophenolate mofetil are two examples of promising drugs for the future of dermatology.
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Affiliation(s)
- J L Popovsky
- Department of Dermatology, Cleveland Clinic Foundation, Ohio, USA
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Bohn J, Jonsson S, Holst R. Successful treatment of recalcitrant cicatricial pemphigoid with a combination of plasma exchange and cyclophosphamide. Br J Dermatol 1999; 141:536-40. [PMID: 10583063 DOI: 10.1046/j.1365-2133.1999.03054.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We describe two patients with severe oral cicatricial pemphigoid, one of whom also had severe pharyngeal involvement. Both patients were resistant to treatment with corticosteroids and other standard immunosuppressive therapies. Plasma exchange alone proved to be only temporarily effective, but the combination of plasma exchange with subsequent cyclophosphamide resulted in a remission in both patients. Both patients experienced mild side-effects during the plasma exchange treatment (urticaria and mild hypotension). At present, at follow-up of 6 and 9 years, respectively, the patients have no symptoms of active disease and have not required any further immunosuppressive treatment.
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Affiliation(s)
- J Bohn
- Departments of Dermatology and Haemoimmunotherapy, Vascular and Renal Diseases, Malmö University Hospital, S-205 02 Malmö, Sweden.
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Ciarrocca KN, Greenberg MS. A retrospective study of the management of oral mucous membrane pemphigoid with dapsone. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 1999; 88:159-63. [PMID: 10468458 DOI: 10.1016/s1079-2104(99)70110-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this retrospective study was to investigate the efficacy of dapsone therapy in the management of mucous membrane pemphigoid. STUDY DESIGN The charts of 29 patients who had been diagnosed with mucous membrane pemphigoid by means of routine histologic analysis and direct immunofluorescence were reviewed. The oral features were graded according to severity of disease from 1 to 3. Each patient was assigned to one of 4 groups according to his or her response to therapy. RESULTS Nine patients were treated successfully with topical corticosteroids alone. Eleven patients with moderate to severe disease who were treated initially with topical steroids showed minimal improvement; after dapsone was added, 7 of the 11 had total resolution of their lesions and 4 had greater than 75% improvement. Two patients had to discontinue dapsone because of side effects. CONCLUSIONS In this group of 20 patients with moderate to severe mucous membrane pemphigoid, the use of dapsone in combination with topical corticosteroids caused greater than 75% resolution of oral lesions in all patients studied.
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Affiliation(s)
- K N Ciarrocca
- Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, Philadelphia 19104, USA
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Scully C, Carrozzo M, Gandolfo S, Puiatti P, Monteil R. Update on mucous membrane pemphigoid: a heterogeneous immune-mediated subepithelial blistering entity. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 1999; 88:56-68. [PMID: 10442946 DOI: 10.1016/s1079-2104(99)70194-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Most oral involvement in the skin diseases (dermatoses) is related to mucous membrane pemphigoid or lichen planus. Mucous membrane pemphigoid was the subject of a European Symposium held in Turin, Italy, in June 1997. This review is based on that symposium. Mucous membrane pemphigoid is a subepithelial vesiculobullous disorder mainly of late middle age; it has a slight predilection for women. Whereas mucous membrane pemphigoid was formerly considered a single entity, it is now quite evident that a number of subepithelial vesiculobullous disorders may produce similar clinical pictures and also that a range of variants of mucous membrane pemphigoid exists, with antibodies directed against various hemidesmosomal components or components of the epithelial basement membrane. The term immune-mediated subepithelial blistering diseases has therefore been used. Diagnosis and management of immune-mediated subepithelial blistering diseases on clinical grounds alone are impossible; a full history, general and oral examinations, and biopsy with immunostaining are now invariably required, sometimes supplemented with other investigations. Most patients with mucous membrane pemphigoid affecting the mouth manifest desquamative gingivitis, a fairly common complaint typically seen in women who are middle-aged or older. Oral vesicles and erosions may also occur, and there can be a positive Nikolsky sign. Some patients have lesions of other stratified squamous epithelia, presenting as conjunctival, nasal, oesophageal, laryngeal, vulval, penile, or anal involvement. Apart from improving oral hygiene, immunomodulatory-in particular, immunosuppressive-therapy is typically required to control oral lesions in mucous membrane pemphigoid. No single treatment regimen reliably controls all these disorders.
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Affiliation(s)
- C Scully
- Eastman Dental Institute for Oral Health Care Science and International Centre for Excellence in Dentistry, United Kingdom.
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Dabelsteen E. Molecular biological aspects of acquired bullous diseases. CRITICAL REVIEWS IN ORAL BIOLOGY AND MEDICINE : AN OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION OF ORAL BIOLOGISTS 1998; 9:162-78. [PMID: 9603234 DOI: 10.1177/10454411980090020201] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Bullous diseases of the oral mucosa and skin were originally classified on the basis of clinical and histological criteria. The discovery of autoantibodies in some of these patients and the introduction of molecular biology have resulted in a new understanding of the pathological mechanisms of many of the bullous lesions. In this article, updated topics of the immune-mediated bullous lesions which involve oral mucosa and skin are reviewed. Pemphigus antigens, which are desmosomal-associated proteins and belong to the cadherin superfamily of cell adhesion proteins, have been isolated, and their genes have been cloned. The antigens which react with autoantibodies from patients with bullous pemphigoid, cicatricial pemphigoid, acquired epidermolysis bullosa, and linear IgA disease are all proteins of the hemidesmosome basement membrane complex. Interestingly, most of the antigens also appear to be the target for mutations seen in patients with the inherited type of epidermolysis bullosa in which bullous lesions are a prominent clinical feature.
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Affiliation(s)
- E Dabelsteen
- Department of Oral Diagnostics, School of Dentistry, Faculty of Health Sciences, University of Copenhagen, Denmark
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Differential Diagnosis and Treatment of Ulcerative, Erosive, and Vesiculobullous Lesions of the Oral Mucosa. Oral Maxillofac Surg Clin North Am 1998. [DOI: 10.1016/s1042-3699(20)30930-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
A 14-year-old girl presented with painful, erythematous gingivae, which occasionally developed blisters. There were no other mucosal or skin lesions. Clinical, histopathological and immunofluorescence studies suggested a diagnosis of benign mucous membrane (cicatricial) pemphigoid, presenting as desquamative gingivitis. Benign mucous membrane pemphigoid in childhood is rare and only a few cases with exclusive oral mucosal involvement have been reported in the literature. The desquamative gingivitis responded well to a topical steroid regimen.
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Affiliation(s)
- C Roche
- Department of Clinical Dental Sciences, University of Liverpool, England
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Affiliation(s)
- R J Nisengard
- School of Dental Medicine, State University of New York, Buffalo, USA
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Abstract
This article reviews the clinical features of vesiculobullous diseases with oral manifestations. Oral vesiculobullous diseases may be viral, immunologically mediated, drug induced, hereditary, or traumatic in origin. A general approach to the diagnosis is outlined, including immunofluorescent testing of suspected vesiculobullous disease. Recommendations for treatment of oral vesiculobullous diseases are included.
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Affiliation(s)
- S L Zunt
- Department of Oral Surgery, Medicine, and Pathology, Indiana University School of Dentistry, Indianapolis, USA
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Affiliation(s)
- J D Fine
- Department of Dermatology, University of North Carolina at Chapel Hill 27599, USA
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CLINICAL MANAGEMENT OF IDIOPATHIC AND AUTOIMMUNE DISEASE INVOLVING ORAL MUCOUS MEMBRANE. Oral Maxillofac Surg Clin North Am 1994. [DOI: 10.1016/s1042-3699(20)30766-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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