Bullous pemphigoid. Therapy and management

Penfigoide de mucosas: manifestaciones clínicas y tratamiento con corticoides, dapsona y ciclofosfamida en cinco pacientes

INTRODUCTION

Cicatricial pemphigoid includes several processes which are characterized by the presence of subepidermal bullae, and which affect the mucous membranes and, more rarely, the skin. At present, the term mucous membrane pemphigoid (MMP) is more accepted than other names used in the past, as they do not clearly define the broad spectrum presented by this disease. MMP can cause significant dysfunctions, primarily in the mucous membranes. Therefore, it is necessary to diagnose the disease as soon as possible, in order to quickly initiate systemic immunosuppressive treatment.

MATERIAL AND METHODS

We present our experience with 5 patients with MMP. We analyze the clinical manifestations and the response to immunosuppressive treatment during the evolution of the disease.

RESULTS

The patients were aged 41 to 69 years. The most frequent location of the lesions was the oral mucosa (80 %) and the ocular mucosa (80 %), followed by the pharyngeal mucosa (60 %), laryngeal mucosa (40 %), skin, anal mucosa (20 %) and genital mucosa (20 %). Three patients received systemic corticosteroids, dapsone and cyclophosphamide, and several sessions of plasmapheresis were also associated in one patient. One patient was controlled with topical corticosteroids and dapsone.

CONCLUSIONS

Many patients with MMP can present with severe secondary complications. For this reason, the diagnosis must be confirmed quickly and the appropriate treatment started as soon as possible. The association of corticosteroids, dapsone and cyclophosphamide is a combination that gives very good results.

Oral pemphigoid. Subset of cicatricial pemphigoid?

OBJECTIVE

Cicatricial pemphigoid (CP) is an autoimmune blistering disease characterized by anti-basement membrane zone (BMZ) antibodies with a varied heterogeneous clinical spectrum. We sought to characterize a subset of patients with disease limited to the oral cavity.

STUDY DESIGN

Twenty-nine random patients with vesiculobullous disease limited to the oral cavity were studied. We identified patients by clinical criteria, the presence of subepidermal/subepithelial bullae on routine histopathologic study, and deposition of IgG, complement, or both on the BMZ of perilesional tissue by immunopathological studies. Treatment included local and systemic therapies. Patients were monitored for a mean period of 6.7 years (range, 3.5 to 11 years).

RESULTS

The female/male ratio was 4.8:1. Patients with limited or minimal disease received local therapy only. In patients with extensive or severe disease, the use of dapsone yielded significant clinical improvement. Long-term follow-up showed that patients with severe disease treated with dapsone followed a clinical course similar to that in patients with minimal disease.

CONCLUSIONS

Oral pemphigoid is a distinct clinical subset of CP. Overall it has a relatively benign course compared with that in patients with CP involving the oral cavity and other mucosae and the skin. Patients with minimal disease respond satisfactorily to topical therapy. Patients with severe and extensive disease benefit from dapsone therapy. In most patients the clinical course is prolonged and treatment is required for several months; in our study the mean treatment period was 42 months (range, 24 to 78 months). All the patients in this study went into clinical remission and remained in remission on cessation of therapy. No other mucosae or the skin were involved during the follow-up period.

Benefits and risks of intralesional corticosteroid injection in the treatment of dermatological diseases

Intralesional corticosteroid (CS) injections have been used to treat a variety of dermatological and non-dermatological diseases with variable results. The purpose of the injection is to attain a high concentration of the drug at the diseased site, with minimal systemic absorption. Several CS preparations are available for intralesional injection, although triamcinolone derivatives have gained the widest usage in dermatology. The dose and the interval between injections depend on the type, size and severity of the lesion as well as the response to the previous injections. The most critical issue in the efficacy and also in the development of complications of the injections, is the method of injection. Several local and systemic side-effects have been reported following intralesional injections, but most of them are rare or acceptable. Thus intralesional CS injection is an integral part of the clinical practice of dermatology. Since their introduction in 1951, intralesional CS injections have become an integral part of clinical practice in dermatology. They are used alone or in combination with other therapeutic modalities in the treatment of many skin diseases. The purpose of the injection is to attain a high local concentration of the CS at the diseased site, without significant systemic absorption, thus avoiding the numerous side-effects associated with systemic administration. Intralesional CS injection may be a valuable therapeutic modality in situations where topical CS are not suitable for use, either because of low potency and inefficient epidermal barrier penetration or in clinical conditions associated with epidermal atrophy.

Cicatricial pemphigoid

Cicatricial pemphigoid is a subepidermal blistering disease that involves the mucous membranes and the skin. The oral cavity and the eye are most frequently involved. The clinical course is of long duration, and often there is significant scarring that can have devastating sequelae. The majority of the patients are elderly. The disease is characterized by the in vivo deposition of an anti-basement membrane zone antibody. The anti-basement membrane zone antibody cannot be detected in the circulation by routine laboratory techniques. The pathogenesis is poorly understood, and the cause is not known. Cicatricial pemphigoid may remain localized to the oral cavity or the eye or the skin (Brunsting-Perry variety), or it may be generalized. It rarely occurs in children, and it may be drug induced. Efforts must be made to differentiate cicatricial pemphigoid from bullous pemphigoid, epidermolysis bullosa acquisita, linear IgA bullous disease, and other vesiculobullous disease. Early recognition and treatment can improve the prognosis and avoid surgical intervention. Topical therapy is beneficial and expedites healing. Intralesional corticosteroids are effective and can help reduce the dose of systemic steroids. Most patients require systemic corticosteroid therapy. Dapsone is also useful in treating cicatricial pemphigoid, especially in patients in whom systemic steroids are ineffective or in whom they have to be discontinued because of side effects. Immunosuppressive agents (azathioprine or cyclosphosphamide) are indicated in patients with progressive disease. Occasionally both drugs may be needed.