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Chebani R, Lombart F, Chaby G, Dadban A, Debarbieux S, Viguier MA, Ingen-Housz-Oro S, Pham-Ledard A, Bedane CR, Picard-Dahan C, Berthin C, Dereure O, Konstantinou MP, Castel M, Jouen F, Joly P, Seta V, Duvert-Lehembre S, Le Roux C, Quereux G, Sassolas B, Brenaut E, Sin C, Richard MA, Bérard F, Giusti D, Belmondo T, Gille T, Caux F, Prost-Squarcioni C, Grootenboer-Mignot S, Alexandre M. Omalizumab in the treatment of bullous pemphigoid resistant to first-line therapy: a French national multicentre retrospective study of 100 patients. Br J Dermatol 2024; 190:258-265. [PMID: 37792727 DOI: 10.1093/bjd/ljad369] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Interest in the use of omalizumab to treat bullous pemphigoid (BP) in the event of resistance or contraindication to conventional therapies is currently based on limited evidence. OBJECTIVES To assess the effectiveness and safety of omalizumab in BP and to identify predictive factors in response to treatment. METHODS We conducted a French national multicentre retrospective study including patients with a confirmed diagnosis of BP treated with omalizumab after failure of one or several treatment lines. We excluded patients with clinically atypical BP, as per Vaillant's criteria. The criteria for clinical response to omalizumab were defined according to the 2012 international consensus conference. Anti-BP180-NC16A IgE enzyme-linked immunosorbent assay was performed on sera collected before initiating omalizumab, when available. RESULTS Between 2014 and 2021, 100 patients treated in 18 expert departments were included. Median age at diagnosis was 77 years (range 20-98). Complete remission (CR) was achieved in 77% of patients, and partial remission in an additional 9%. CR was maintained 'off therapy' in 11.7%, 'on minimal therapy' in 57.1%, and 'on non-minimal therapy' in 31.2%. Median time to CR was 3 months (range 2.2-24.5). Relapse rate was 14%, with a median follow-up time of 12 months (range 6-73). Adverse events occurred in four patients. CR was more frequently observed in patients with an increased serum baseline level of anti-BP180-NC16A IgE (75% vs. 41%; P = 0.011). Conversely, urticarial lesions, blood total IgE concentration or eosinophil count were not predictive of CR. Patients with an omalizumab dosage > 300 mg every 4 weeks showed a similar final outcome to those with a dosage ≤ 300 mg every 4 weeks, but control of disease activity [median 10 days (range 5-30) vs. 15 days (range 10-60); P < 0.001] and CR [median 2.4 months (range 2.2-8.2) vs. 3.9 months (range 2.3-24.5); P < 0.001] were achieved significantly faster. CONCLUSIONS We report the largest series to date of BP treated by omalizumab and confirm its effectiveness and safety in this indication. Serum baseline level of anti-BP180-NC16A IgE may predict response to treatment.
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Affiliation(s)
- Réda Chebani
- Department of Dermatology, Amiens University Hospital, Amiens, France
| | - Florian Lombart
- Department of Dermatology, Amiens University Hospital, Amiens, France
| | - Guillaume Chaby
- Department of Dermatology, Amiens University Hospital, Amiens, France
| | - Ali Dadban
- Department of Dermatology, Amiens University Hospital, Amiens, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Christelle Le Roux
- Department of Dermatology and Referral Centre for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | | | | | | | | | | | | | | | | | | | - Frédéric Caux
- Department of Dermatology and Referral Centre for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | - Catherine Prost-Squarcioni
- Department of Dermatology and Referral Centre for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | | | - Marina Alexandre
- Department of Dermatology and Referral Centre for Autoimmune Bullous Diseases (MALIBUL), Avicenne Hospital, Hôpitaux Universitaires de Paris Seine-Saint-Denis, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
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Ma X, Li J, Fan L, Jiang H, Shi G, Ge D, Shi X. Systemic lupus erythematosus combined with Castleman disease and secondary paraneoplastic pemphigus: a case report. Pediatr Rheumatol Online J 2023; 21:126. [PMID: 37858241 PMCID: PMC10588252 DOI: 10.1186/s12969-023-00871-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/30/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND The literature describes a case of systemic lupus erythematosus (SLE) complicated with Castleman's disease (CD) and secondary paraneoplastic pemphigus (PNP). CASE PRESENTATION A 12-year-old female presented with a neck mass, rash, arthralgia, and skin and mouth ulceration for 5 years were admitted. All blood cells were low. Multiple autoantibodies associated with SLE were positive. The pathology of the neck mass revealed the classical manifestations of CD. She was treated with prednisone, hydroxychloroquine, leflunomide, thalidomide, and dressings. Pathological examination of the skin revealed PNP. The neck mass was removed and continued to take antirheumatic drugs. At subsequent follow-up, the patient's disease status was stable and the skin mucosal lesion did not recur. CONCLUSION The case of simultaneous SLE, CD, and PNP in children was rarely reported, and the correct diagnosis of the disease will help to take timely treatment.
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Affiliation(s)
- Xin Ma
- Department of Rheumatology and Immunology, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, No,24 Jinghua Road, Luoyang, China
| | - Jiyuan Li
- Department of Thoracic Surgery, The First Affiliated Hospital, and College of Clinicalcal Medicine of Henan University of Science and Technology, No,24 Jinghua Road, Luoyang, China
| | - Linlin Fan
- Department of Rheumatology and Immunology, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, No,24 Jinghua Road, Luoyang, China
| | - Hongwei Jiang
- Henan Key Laboratory of Rare Diseases, Endocrinology and Metabolism Center, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, No,24 Jinghua Road, Luoyang, China
| | - Gaishao Shi
- Department of Rheumatology and Immunology, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, No,24 Jinghua Road, Luoyang, China
| | - Dongfeng Ge
- Department of Pathology, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, No,24 Jinghua Road, Luoyang, China
| | - Xiaofei Shi
- Department of Rheumatology and Immunology, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, No,24 Jinghua Road, Luoyang, China.
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Zeng FA, Wilson A, Sheriff T, Murrell DF. Side effects of steroid-sparing agents in patients with bullous pemphigoid and pemphigus: A systematic review. JAAD Int 2022; 9:33-43. [PMID: 36089938 PMCID: PMC9450124 DOI: 10.1016/j.jdin.2022.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 10/26/2022] Open
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Kianfar N, Dasdar S, Mahmoudi H, Daneshpazhooh M. Burden of pemphigus vulgaris with a particular focus on women: A review. Int J Womens Dermatol 2022; 8:e056. [PMID: 36204194 PMCID: PMC9529034 DOI: 10.1097/jw9.0000000000000056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 08/28/2022] [Indexed: 11/05/2022] Open
Abstract
Pemphigus vulgaris is a chronic autoimmune mucocutaneous blistering disorder. Apart from the disease itself, other aspects of patients' life, including psychological, social, and financial, can be affected. Women are particularly more disposed to the impact of the disease due to their physiological characteristics, the specific periods of pregnancy and lactation as well as their social and familial role. In this review, we summarized the burden of pemphigus vulgaris on various aspects of women's lives. It is essential to understand these problems and provide appropriate support for patients with such a burdensome disease.
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Affiliation(s)
- Nika Kianfar
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shayan Dasdar
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Mahmoudi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Epidermolysis bullosa acquisita. An Bras Dermatol 2022; 97:409-423. [PMID: 35701269 PMCID: PMC9263658 DOI: 10.1016/j.abd.2021.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/19/2021] [Accepted: 09/20/2021] [Indexed: 11/24/2022] Open
Abstract
Epidermolysis bullosa acquisita is a rare autoimmune disease, characterized by the synthesis of anti-collagen VII autoantibodies, the main component of hemidesmosome anchoring fibrils. The antigen-antibody binding elicits a complex inflammatory response, which culminates in the loss of dermo-epidermal adhesion of the skin and/or mucous membranes. Skin fragility with bullae, erosions, and milia in areas of trauma characterizes the mechanobullous form of the disease. In the inflammatory form of epidermolysis bullosa acquisita, urticarial inflammatory plaques with tense bullae, similar to bullous pemphigoid, or mucosal lesions can determine permanent scars and loss of functionality in the ocular, oral, esophageal, and urogenital regions. Due to the similarity of the clinical findings of epidermolysis bullosa acquisita with other diseases of the pemphigoid group and with porphyria cutanea tarda, the diagnosis is currently confirmed mainly based on the clinical correlation with histopathological findings (pauci-inflammatory subepidermal cleavage or with a neutrophilic infiltrate) and the demonstration of the presence of anti-collagen VII IgG in situ by direct immunofluorescence, or circulating anti-collagen VII IgG through indirect immunofluorescence and/or ELISA. There is no specific therapy for epidermolysis bullosa acquisita and the response to treatment is variable, usually with complete remission in children and a worse prognosis in adults with mucosal involvement. Systemic corticosteroids and immunomodulators (colchicine and dapsone) are alternatives for the treatment of mild forms of the disease, while severe forms require the use of corticosteroid therapy associated with immunosuppressants, intravenous immunoglobulin, and rituximab.
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Current and Innovated Managements for Autoimmune Bullous Skin Disorders: An Overview. J Clin Med 2022; 11:jcm11123528. [PMID: 35743598 PMCID: PMC9224787 DOI: 10.3390/jcm11123528] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
Autoimmune bullous skin disorders are a group of disorders characterized by the formation of numerous blisters and erosions on the skin and/or the mucosal membrane, arising from autoantibodies against the intercellular adhesion molecules and the structural proteins. They can be classified into intraepithelial or subepithelial autoimmune bullous dermatoses based on the location of the targeted antigens. These dermatoses are extremely debilitating and fatal in certain cases, depending on the degree of cutaneous and mucosal involvement. Effective treatments should be implemented promptly. Glucocorticoids serve as the first-line approach due to their rapid onset of therapeutic effects and remission of the acute phase. Nonetheless, long-term applications may lead to major adverse effects that outweigh the benefits. Hence, other adjuvant therapies are mandatory to minimize the potential harm and ameliorate the quality of life. Herein, we summarize the current therapeutic strategies and introduce promising therapies for intractable autoimmune bullous diseases.
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7
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Kate A, Shanbhag S, Donthineni PR, Basu S. A case series of ocular involvement in bullous pemphigoid: clinical features, management, and outcomes. F1000Res 2022; 10:1201. [PMID: 35136583 PMCID: PMC8787558 DOI: 10.12688/f1000research.75120.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 12/02/2022] Open
Abstract
Ocular involvement in cases of bullous pemphigoid is rare and when present, the signs are usually subtle and in the form of fine tarsal scarring and dry eye disease. The current report aims to describe the clinical features and management protocols in a series of cases with aggressive ocular manifestations at presentation. All cases of bullous pemphigoid seen between 2017 and 2020 were included in this retrospective case series. Data regarding the clinical features, treatment administered, and outcomes was collected. Five cases (n=10 eyes) of bullous pemphigoid disease with ocular involvement were included. All eyes had significant cicatricial conjunctival changes in the form of symblephara, inferior forniceal shortening, and tarsal conjunctival scarring. Conjunctival granulomas were present in 3/10 eyes. Corneal involvement in the form of punctate keratitis was present in all eyes while 4/10 eyes had an epithelial defect as well. The management of these cases involved topical therapy with corticosteroids and lubricants (n=10 eyes) while pulse doses of intravenous methyl prednisolone were administered in 5/5 cases. Pulse intravenous cyclophosphamide was supplemented in 2/5 cases. Adequate control of the disease was noted in 3/5 cases while one case had a recalcitrant form of the disease and developed a dermalised ocular surface in both eyes. The last patient was lost to follow up during the course of therapy. Bullous pemphigoid can present with an aggressive form of cicatrizing conjunctivitis similar to other variants of autoimmune blistering disorders and must be considered as a differential in cases presenting with ocular cicatricial disease. Long-term intensive immunosuppression is required for the management of these cases to preserve the visual function and the integrity of the globe.
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Affiliation(s)
- Anahita Kate
- The Cornea Institute, L V Prasad Eye Institute, Vijaywada, Andhra Pradesh, India
| | - Swapna Shanbhag
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | | | - Sayan Basu
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
- Prof. Brien Holden Eye Research Centre, L V Prasad Eye Institute, Hyderabad, Telangana, India
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8
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Pratasava V, Sahni VN, Suresh A, Huang S, Are A, Hsu S, Motaparthi K. Bullous Pemphigoid and Other Pemphigoid Dermatoses. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57101061. [PMID: 34684098 PMCID: PMC8539012 DOI: 10.3390/medicina57101061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022]
Abstract
The pemphigoid family of dermatoses is characterized by autoimmune subepidermal blistering. The classic paradigm for pemphigoid, and the most common member, is bullous pemphigoid. Its variable clinical presentation, with or without frank bullae, is linked by significant pruritus afflicting the elderly. Mucous membrane pemphigoid is an umbrella term for a group of subepidermal blistering dermatoses that favor the mucosal membranes and can scar. Epidermolysis bullosa acquisita is a chronic blistering disorder characterized by skin fragility, sensitivity to trauma, and its treatment-refractory nature. Clinicians that encounter these pemphigoid disorders may benefit from an overview of their clinical presentation, diagnostic work-up, and therapeutic management, with an emphasis on the most frequently encountered pemphigoid disease, bullous pemphigoid.
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Affiliation(s)
- Valeryia Pratasava
- College of Medicine, Drexel University, Philadelphia, PA 19129, USA; (V.P.); (V.N.S.); (A.S.)
| | - Vikram N. Sahni
- College of Medicine, Drexel University, Philadelphia, PA 19129, USA; (V.P.); (V.N.S.); (A.S.)
| | - Aishwarya Suresh
- College of Medicine, Drexel University, Philadelphia, PA 19129, USA; (V.P.); (V.N.S.); (A.S.)
| | - Simo Huang
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (S.H.); (S.H.)
| | - Abhirup Are
- College of Medicine, University of Florida, Gainesville, FL 32606, USA;
| | - Sylvia Hsu
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (S.H.); (S.H.)
| | - Kiran Motaparthi
- Department of Dermatology, College of Medicine, University of Florida, Gainesville, FL 32606, USA
- Correspondence:
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Zeng FAP, Murrell DF. State-of-the-art review of human autoimmune blistering diseases (AIBD). Vet Dermatol 2021; 32:524-e145. [PMID: 34351020 DOI: 10.1111/vde.13008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
Autoimmune blistering diseases (AIBDs) are a heterogenous group of skin conditions, broadly classified into two categories depending on the location of blister formation: intraepidermal blistering in the pemphigus group and subepidermal blistering in the pemphigoid group. Although AIBDs occur in both humans and animals, the arsenal of data for human AIBDs far exceeds those of their animal counterpart. Therefore, the main purpose of this review is to highlight existing knowledge, and recent advances in the diagnosis and management of AIBDs in humans - to serve as a road map for veterinary dermatologists. AREAS COVERED: Recent findings include complement-independent pathways in the pathogenesis of bullous pemphigoid, as well as the role of desmoglein and desmocollin autoantibodies in inducing acantholysis. Systemic glucocorticoids are the mainstay of treatment for AIBDs in humans, yet their long-term use is associated with severe adverse effects and complications, thereby limiting their use. Therefore, researchers have been exploring new and safer alternative therapeutic options for human AIBDs such as anti-CD20 monoclonal antibodies (Rituximab), Bruton's tyrosine kinase inhibitors (BTKi) and neonatal Fc receptor (FcRn) blockers. EXPERT OPINION: Randomised controlled trial (RCT) level evidence show that Rituximab and short-course GC regimes are more effective and safer than traditional GC treatment for human AIBDs. FcRn blockers such as SYNT001 have shown positive results in preliminary phase 2 clinical trials for treatment of human pemphigus; further trials are required. Rilzabrutinib (PRN1008), an orally administered BTKi, has recently completed phase 2 trials in pemphigus and is in a phase 3 RCT in humans.
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Affiliation(s)
| | - Dedee F Murrell
- University of New South Wales, Sydney, Australia.,Department of Dermatology, St George Hospital, Sydney, Australia.,The George Institute for Global Health, Sydney, Australia
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10
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Bardazzi F, Loi C, Chessa Marco A, Di Altobrando A, Filippi F, Lacava R, Viviani F, Balestri R, Leuzzi M, Sacchelli L. Therapeutic approaches and targets for treatment of autoimmune bullous diseases. Dermatol Ther 2021; 34:e15032. [PMID: 34145701 DOI: 10.1111/dth.15032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/14/2021] [Indexed: 01/22/2023]
Abstract
Autoimmune bullous diseases are a heterogeneous group of diseases characterized by the development of cutaneous and mucosal vesicles, blisters, and finally erosions. The common pathogenetic mechanism is the presence of autoantibodies targeting structural proteins of the skin and mucous membranes (demosomes and hemidesmosomes): in the case of pemphigus, the antigens are intraepidermal, whereas in the case of pemphigoid, dermatitis herpetiformis, and epidermolysis bullosa acquisita they are subepidermal. Mucosal involvement typically affects the oral and ocular mucosa, but in some cases, the upper airways or the upper digestive tract are affected. The burden on patients' lives could be severe due to the impairment of normal feeding or breathing. In other cases, they may represent paraneoplastic syndromes. Since autoimmune bullous diseases may result in significant morbidity and mortality, depending on the grade of cutaneous and mucosal involvement, a prompt therapeutic approach is mandatory and, in recalcitrant cases, may be challenging. The first line therapy consists of corticosteroids, both topical and systemic. Once remission or control of the acute phase is obtained, adjuvant therapies need to be introduced in order to spare the corticosteroid load and minimize side effects such as iatrogenic diabetes or osteoporosis. Herein, we describe all current therapeutic approaches to autoimmune bullous diseases, also including emerging therapies.
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Affiliation(s)
- Federico Bardazzi
- Department of Specialized, Clinical and Experimental medicine, Division of Dermatology, University of Bologna, Italy
| | - Camilla Loi
- Department of Specialized, Clinical and Experimental medicine, Division of Dermatology, University of Bologna, Italy
| | - Adriano Chessa Marco
- Department of Specialized, Clinical and Experimental medicine, Division of Dermatology, University of Bologna, Italy
| | - Ambra Di Altobrando
- Department of Specialized, Clinical and Experimental medicine, Division of Dermatology, University of Bologna, Italy
| | - Federica Filippi
- Department of Specialized, Clinical and Experimental medicine, Division of Dermatology, University of Bologna, Italy
| | - Rossella Lacava
- Department of Specialized, Clinical and Experimental medicine, Division of Dermatology, University of Bologna, Italy
| | - Filippo Viviani
- Department of Specialized, Clinical and Experimental medicine, Division of Dermatology, University of Bologna, Italy
| | - Riccardo Balestri
- Division of Dermatology, Rare Disease Outpatient Service, Santa Chiara Hospital, Trento, Italy
| | - Miriam Leuzzi
- Department of Specialized, Clinical and Experimental medicine, Division of Dermatology, University of Bologna, Italy
| | - Lidia Sacchelli
- Department of Specialized, Clinical and Experimental medicine, Division of Dermatology, University of Bologna, Italy
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Kridin K, Ahmed AR. The evolving role of rituximab in the treatment of pemphigus vulgaris: a comprehensive state-of-the-art review. Expert Opin Biol Ther 2021; 21:443-454. [PMID: 33455475 DOI: 10.1080/14712598.2021.1874915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Pemphigus vulgaris (PV) is a life-threatening autoimmune mucocutaneous blistering disease. Systemic corticosteroids (CS), while life-saving, have several serious side effects. To improve treatment and prognosis, recently rituximab (RTX), a chimeric monoclonal antibody against CD20 molecule on B cells, has become popular. This Expert Opinion discusses clinical and scientifically relevant aspects of RTX treating PV. AREA COVERED This presentation describes the mechanism of action, clinical efficacy, safety, adverse events, protocols used, and clinical outcomes. Concerns for infection, reactivation of latent or previous infections, and high relapse rate are discussed. EXPERT OPINION Use of RTX in PV is still a work in progress. There are many unanswered questions. FDA did not provide a protocol or guidelines. Whenever RTX is used, systemic corticosteroids are simultaneously used, albeit for a shorter duration and lower dose. Used in these doses for these durations they can cause immunosuppression. Would it be more appropriate if instead of 'First Line Therapy' it would be more advisable to use the term 'First Adjunctive Immunosuppressive Agent'?
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
| | - A Razzaque Ahmed
- Department of Dermatology, Tufts University School of Medicine, and the Center for Blistering Diseases, USA
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Askari G, Ghavami A, Shahdadian F, Moravejolahkami AR. Effect of synbiotics and probiotics supplementation on autoimmune diseases: A systematic review and meta-analysis of clinical trials. Clin Nutr 2021; 40:3221-3234. [PMID: 33642142 DOI: 10.1016/j.clnu.2021.02.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 01/30/2021] [Accepted: 02/08/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND & AIMS Today synbiotics are considered as immunomodulatory agents. The current systematic review and meta-analysis investigated the effect of synbiotics and probiotics on inflammatory and oxidative stress markers in autoimmune disease. MATERIALS & METHODS The English literature search was performed using PubMed, Scopus, Web of Science, and the Central Cochrane Library through March 2020. Random effects models and generic inverse variance methods were used to synthesize quantitative data by STATA14. RESULTS From a total of 623 entries identified via searches, ten RCTs (n = 440; 216 as intervention, 224 as controls) were included. An additional eleven studies with same intervention and different markers were also explained systematically. The pooled effect size showed that Interleukin (IL)-6 (WMD = -7.79 pg/ml; 95% CI = -13.81, -1.77, P = 0.011), Tumor Necrosis Factor (TNF)-α (WMD = -1.05 pg/ml; 95% CI = -2.01, -0.10, P = 0.030), high sensitivity C-Reactive Protein (hs-CRP) (SMD = -0.58; 95% CI = -0.79, -0.37, P < 0.001), Malondialdehyde (MDA) (SMD = -0.36; 95% CI = -0.68, -0.04; P = 0.026), Homeostasis Model of Assessment-estimated Insulin Resistance (HOMA-IR) (WMD = -0.71; 95% CI = -1.05, -0.37, P < 0.001), and beta cell function (HOMA-β) (WMD = -15.18; 95% CI = -22.08, -8.28, P < 0.001) changed following probiotics (or synbiotics) supplementation. Also supplementation with doses more than 2 billion CFU could reduce IL-10 concentrations (WMD = -1.84; 95% CI = -2.23, 1.87; P < 0.001). Glutathione (GSH) and Total Antioxidant Capacity (TAC) levels did not influence by synbiotics and probiotics; insignificancy was remained after subgrouping for participants' age, study duration, and disease duration. CONCLUSION Our findings revealed that synbiotics and probiotics supplementation has significant effect on some inflammatory and oxidative stress markers; although, the number of trials was too small to powerful conclusion and further investigations may be needed.
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Affiliation(s)
- Gholamreza Askari
- Department of Community Nutrition, School of Nutrition & Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Abed Ghavami
- Student Research Committee, Department of Community Nutrition, School of Nutrition & Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Farnaz Shahdadian
- Student Research Committee, Department of Clinical Nutrition, School of Nutrition & Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Amir Reza Moravejolahkami
- Student Research Committee, Department of Clinical Nutrition, School of Nutrition & Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
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Chen SA, Wang LT, Chen ZH, Yang FP, Zhu QY, Chen HY, Luo XQ. Extensive cutaneous iatrogenic Kaposi's sarcoma after bullous pemphigoid treatment with oral methylprednisolone: a rare Chinese case report. J Int Med Res 2021; 49:300060520982829. [PMID: 33496629 PMCID: PMC7841242 DOI: 10.1177/0300060520982829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune disease that requires immunosuppressive
therapy. Systemic corticosteroids are considered the standard treatment for
moderate-to-severe BP. Kaposi’s sarcoma (KS) is a rare multifocal endothelial
tumour that affects the skin, mucosa and viscera. As an angioproliferative
disease of obscure aetiopathogenesis and histogenesis, KS is associated with
human herpesvirus 8 (HHV-8). This current case report describes a rare
occurrence of extensive cutaneous KS in a 60-year-old Chinese male patient after
oral methylprednisolone treatment for BP with an emphasis on its pathological
characterization. A total of more than 40 nodules were found on his trunk and
lower limbs covering more than 20% of his body surface area. Immunohistochemical
staining of biopsy samples from the lesion showed the patient was positive for
HHV-8, CD31, CD34, XIIIa, ERG and Ki-67. The Epstein–Barr virus test showed the
patient tested negative for immunoglobulin (Ig)A and IgM, but was positive for
IgG. Immunosuppression associated with the treatment for BP may activate a
latent HHV-8 infection and induce the development of KS.
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Affiliation(s)
- Sheng-An Chen
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Lan-Ting Wang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Zi-Hua Chen
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Fan-Ping Yang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qin-Yuan Zhu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hu-Yan Chen
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao-Qun Luo
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
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Madžgalj Š, Jakovljević D, Živanović D. Therapeutic modalities and course of the disease in patients with autoimune pemphigus (AP) treated at the Clinic of dermatovenerology in the period 2013-2018. MEDICINSKI PODMLADAK 2021. [DOI: 10.5937/mp72-33186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction: Autoimmune pemphigus (AP) is one of the most severe dermatologic diseases. AP belongs to the group of organ-specific autoimmune disorders, with autoantibodies directed against cellsurface antigens on keratinocytes, mostly desmogleins. Three main types of AP have been described, depending on the clinical and histopathological features and the different target antigens: Pemphigus vulgaris (PV), Pemphigus foliaceus (PF), each with its own subtypes and paraneoplastic pemphigus (PNP). The clinical course and prognosis of AP depend on its subtype, therapeutic modalities and their side effects. The main goal of the treatment is to achieve and maintain remission without any systemic therapy or with minimal therapeutic doses ("maintenance therapy"). Aim: A retrospective study of hospitalized patients with various forms of AP, analysis of clinical course and evaluation of therapeutic modalities employed. Material and methods: A total of 158 inpatients with diagnosed AP, admitted to the Clinic of Dermatovenereology, Clinical Centre of Serbia, from 2013 to 2018, with a subsequent followup of 6 to 12 months, were included in this study. Demographic and clinical data as well as treatment approaches were analyzed using descriptive and analytic statistics. Results: The most common subtype encountered was PV (72.15%); in the largest number of patients (46.84%) the disease occurred between ages 39-59. Conventional corticosteroid treatment was most frequently used (67.41%), along with azathioprine (66.86%) as the most common immunosuppressive drug. In 60.8% of patients no side effects or disease complications were recorded. During the follow-up, at the end of 2018, 48.1% of patients achieved remission. Conclusion: We have shown a high incidence of PV. Treatment approaches used in our patients were in accordance with the pemphigus subtype and course of the disease. A significant number of patients achieved clinical remission.
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Salman S, Awad M, Sarsik S, Ibrahim AM, Fathi M, Agha NY, Anis R, El Ashal G, Salem ML. Treatment options for autoimmune bullous dermatoses other than systemic steroids: A systematic review and network meta-analysis. Dermatol Ther 2020; 33:e13861. [PMID: 32558137 DOI: 10.1111/dth.13861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/09/2020] [Accepted: 06/05/2020] [Indexed: 02/05/2023]
Abstract
Autoimmune blistering diseases can eventually cause life-threatening complications if left untreated. Although there is no cure for these bullous diseases; their therapy is based on suppressing the immune system to cease the de novo formation of the generated antibodies. The current study aimed to assess the safety and efficacy of using standing alone alternative therapies beyond systemic steroids for management of autoimmune bullous diseases. We searched six literature databases for both randomized and quasi-randomized clinical trials that assessed the efficacy of drugs other than systemic steroids in autoimmune bullous diseases. Outcomes were calculated as odds ratios with 95% confidence-interval. We used the R software to perform conventional and network meta-analyses with a frequentist approach. The network ranking order for 629 bullous pemphigoid patients, from the best to the worst was, clobetasol propionate cream (40 mg; (P-score = .87), clobetasol propionate cream (10-30 mg; P-score = .77), nicotinamide plus tetracycline (P-score = .56), steroids (P-score = .29) and doxycycline (P-score = .01). Limitations of this study are the small sample of the included studies except for blister trial and lack of randomization in most trials. To conclude, Combined doxycycline and nicotinamides are safer and more effective option for extensive bullous pemphigoid patients than the usual use of systemic steroids. For limited disease, topical corticosteroid (40 mg/d) use provides a safer and better response modality than the other proposed treatments.
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Affiliation(s)
- Samar Salman
- Department of Dermatology and Venereology, Tanta University Hospital, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mina Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sameh Sarsik
- Department of Dermatology and Venereology, Tanta University Hospital, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Mohamed Fathi
- Kasr Al-Ainy Medical School, Cairo University, Cairo, Egypt
| | - Nadim Y Agha
- Kasr Al-Ainy Medical School, Cairo University, Cairo, Egypt
| | - Ruba Anis
- Kasr Al-Ainy Medical School, Cairo University, Cairo, Egypt
| | - Gehad El Ashal
- Kasr Al-Ainy Medical School, Cairo University, Cairo, Egypt
| | - Mohamed L Salem
- Immunology and Biotechnology Division, Zoology Department, Faculty of Science, Tanta University, Tanta, Egypt
- Center of Excellence in Cancer Research, Tanta University, Tanta, Egypt
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16
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Correlation of IgG autoantibodies against acetylcholine receptors and desmogleins in patients with pemphigus treated with steroid sparing agents or rituximab. PLoS One 2020; 15:e0233957. [PMID: 32555697 PMCID: PMC7302486 DOI: 10.1371/journal.pone.0233957] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 05/15/2020] [Indexed: 02/07/2023] Open
Abstract
Introduction Autoantibodies (autoAbs) against desmoglein-1 (DSG1) and desmoglein-3 (DSG3) have conventionally been studied and well accepted in the pathogenesis of pemphigus vulgaris (PV) and foliaceus (PF). Recent studies have suggested that non-DSG autoAbs may contribute to the pathogenesis of pemphigus, including autoAbs directed at acetylcholine receptors (AChR) and thyroid peroxidase (TPO). The purpose of this study is to retrospectively analyze PV and PF patient sera to better understand the relationship between anti-AChR and -TPO Abs to disease activity and DSG reactivity between patients treated with prednisone and steroid sparing agents (SSA; n = 22) or prednisone and rituximab (n = 21). Methods Patients were evaluated at 2 time points, T1 and T2, for disease activity using the Pemphigus Disease Area Index (PDAI), and sera were tested for the presence of TPO, DSG1, DSG3, muscarinic (M3) and nicotinic (n) AChR IgG autoAbs, as well as antibodies against Varicella Zoster Virus (VZV) by ELISA. Results Disease activity significantly decreased in patients from T1 to T2 (p < .0001). A significant difference was seen in IgG anti-DSG1 (p < .0001) and anti-DSG3 (p = .0049) levels when T1 was compared to T2 in both treatment groups. A significant increase was found between pemphigus patients and normal subjects with nAChR (p < .0001) at T1 but not with m3AChR, TPO or VZV Abs. No significant difference was seen between T1 and T2 values in patients with pemphigus for the non–desmoglein Abs TPO (p = .7559), M3AChR (p = .9003), nAChR (p = .5143) or VZV (p = .2454). These findings demonstrate that although an increase in IgG anti-nAChR autoAbs was found in PV and PF subjects, these Abs did not decrease with treatment. No other non-DSG Abs were increased or significantly changed over time in patients with pemphigus. This suggests that anti -AChR and -TPO Abs may not play a direct role in the pathogenesis of most patients with pemphigus, but does not rule out a role for non-DSG auto antibodies in distinct subsets of pemphigus patient.
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Post-rituximab immunoglobulin M (IgM) hypogammaglobulinemia. Autoimmun Rev 2020; 19:102466. [PMID: 31917267 DOI: 10.1016/j.autrev.2020.102466] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 12/19/2022]
Abstract
Rituximab is a B cell depleting monoclonal antibody that targets the B cell-specific cell surface antigen CD20 and is currently used to treat several autoimmune diseases. The elimination of mature CD20-positive B lymphocytes committed to differentiate into autoantibody-producing plasma cells is considered to be the major effect of rituximab, that makes it a beneficial biological agent in treating autoimmune diseases. Hypogammaglobulinemia has been reported after rituximab therapy in patients with lymphoma and rheumatoid arthritis. Similar data are scarce for other autoimmune diseases. Low immunoglobulin G (IgG) or hypogammaglobulinemia has attracted the most attention because of its significant role in protective immunity. However, the incidence and clinical implications of low immunoglobulin M (IgM) or hypogammaglobulinemia have not been studied in detail. This review will focus on the frequency and the clinical concerns of low IgM levels that result as a consequence of the administration of rituximab. The etiopathogenic mechanisms underlying post-rituximab IgM hypogammaglobulinemia and its implications are presented. The long-term consequences, if any, are not known or documented. Multiple factors may be involved in whether IgG or IgM decreases secondary to rituximab therapy. It is possible that the autoimmune disease itself may be one of the important factors. The dose, frequency and number of infusions appear to be important variables. Post-rituximab therapy immunoglobulin levels return to normal. During this process. IgM levels take a longer time to return to normal levels when compared to IgG or other immunoglobulins. IgM deficiency persists after B cell repopulation to normal levels has occurred. Laboratory animals and humans deficient in IgM can have multiple infections. Specific pharmacologic agents or biologic therapy that address and resolve IgM deficiency are currently unavailable. If the clinical situation so warrants, then prophylactic antibiotics may be indicated and perhaps helpful. Research in this iatrogenic phenomenon will provide a better understanding of not only the biology of IgM, but also the factor(s) that control its production and regulation, besides its influence if any, on rituximab therapy.
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18
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Porro AM, Seque CA, Ferreira MCC, Enokihara MMSES. Pemphigus vulgaris. An Bras Dermatol 2019; 94:264-278. [PMID: 31365654 PMCID: PMC6668932 DOI: 10.1590/abd1806-4841.20199011] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/02/2019] [Indexed: 12/11/2022] Open
Abstract
Pemphigus vulgaris is a chronic autoimmune bullous dermatosis that results from the production of autoantibodies against desmogleins 1 and 3. It is the most frequent and most severe form of pemphigus, occurring universally, usually between 40 and 60 years of age. It usually begins with blisters and erosions on the oral mucosa, followed by lesions on other mucous membranes and flaccid blisters on the skin, which can be disseminated. There is a clinical variant, pemphigus vegetans, which is characterized by the presence of vegetating lesions in the large folds of the skin. Clinical suspicion can be confirmed by cytological examination, histopathological examination, and direct and indirect immunofluorescence tests. The treatment is performed with systemic corticosteroids, and immunosuppressive drugs may be associated, among them azathioprine and mycophenolate mofetil. More severe cases may benefit from corticosteroids in the form of intravenous pulse therapy, and recent studies have shown a beneficial effect of rituximab, an anti-CD20 immunobiological drug. It is a chronic disease with mortality around 10%, and septicemia is the main cause of death. Patients need long-term and multidisciplinary follow-up.
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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
| | - Camila Arai Seque
- Department of Dermatology, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Santi CG, Gripp AC, Roselino AM, Mello DS, Gordilho JO, Marsillac PFD, Porro AM. Consensus on the treatment of autoimmune bullous dermatoses: bullous pemphigoid, mucous membrane pemphigoid and epidermolysis bullosa acquisita - Brazilian Society of Dermatology. An Bras Dermatol 2019; 94:33-47. [PMID: 31166405 PMCID: PMC6544032 DOI: 10.1590/abd1806-4841.2019940207] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/30/2019] [Indexed: 02/06/2023] Open
Abstract
Bullous pemphigoid, mucous membrane pemphigoid and epidermolysis bullosa
acquisita are subepidermal autoimmune blistering diseases whose antigenic target
is located at the basement membrane zone. Mucous membrane pemphigoid and
epidermolysis bullosa acquisita can evolve with cicatricial mucosal involvement,
leading to respiratory, ocular and/or digestive sequelae with important
morbidity. For each of these dermatoses, a literature review covering all
therapeutic options was performed. A flowchart, based on the experience and
joint discussion among the authors of this consensus, was constructed to provide
treatment orientation for these diseases in Brazil. In summary, in the
localized, low-risk or non-severe forms, drugs that have immunomodulatory action
such as dapsone, doxycycline among others may be a therapeutic option. Topical
treatment with corticosteroids or immunomodulators may also be used. Systemic
corticosteroid therapy continues to be the treatment of choice for severe forms,
especially those involving ocular, laryngeal-pharyngeal and/or esophageal
mucosal involvement, as may occur in mucous membrane pemphigoid and
epidermolysis bullosa acquisita. Several immunosuppressants are used as adjuvant
alternatives. In severe and recalcitrant cases, intravenous immunoglobulin is an
alternative that, while expensive, may be used. Immunobiological drugs such as
rituximab are promising drugs in this area. Omalizumab has been used in bullous
pemphigoid.
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Affiliation(s)
- Claudia Giuli Santi
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Carlos Gripp
- Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Ana Maria Roselino
- Department of Medical Clinics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Danielle Santana Mello
- Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Paula Figueiredo de Marsillac
- Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Adriana Maria Porro
- Department of Dermatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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20
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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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21
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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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22
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Suga H, Sato S. IL
‐10–producing regulatory B cells in skin diseases. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2019. [DOI: 10.1002/cia2.12059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Hiraku Suga
- Department of Dermatology Faculty of Medicine The University of Tokyo Tokyo Japan
| | - Shinichi Sato
- Department of Dermatology Faculty of Medicine The University of Tokyo Tokyo Japan
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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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24
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Abstract
Bullous pemphigoid is the most frequent autoimmune bullous disease and mainly affects elderly individuals. Increase in incidence rates in the past decades has been attributed to population aging, drug-induced cases and improvement in the diagnosis of the nonbullous presentations of the disease. A dysregulated T cell immune response and synthesis of IgG and IgE autoantibodies against hemidesmosomal proteins (BP180 and BP230) lead to neutrophil chemotaxis and degradation of the basement membrane zone. Bullous pemphigoid classically manifests with tense blisters over urticarial plaques on the trunk and extremities accompanied by intense pruritus. Mucosal involvement is rarely reported. Diagnosis relies on (1) the histopathological evaluation demonstrating eosinophilic spongiosis or a subepidermal detachment with eosinophils; (2) the detection of IgG and/or C3 deposition at the basement membrane zone using direct or indirect immunofluorescence assays; and (3) quantification of circulating autoantibodies against BP180 and/or BP230 using ELISA. Bullous pemphigoid is often associated with multiple comorbidities in elderly individuals, especially neurological disorders and increased thrombotic risk, reaching a 1-year mortality rate of 23%. Treatment has to be tailored according to the patient's clinical conditions and disease severity. High potency topical steroids and systemic steroids are the current mainstay of therapy. Recent randomized controlled studies have demonstrated the benefit and safety of adjuvant treatment with doxycycline, dapsone and immunosuppressants aiming a reduction in the cumulative steroid dose and mortality.
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Affiliation(s)
- Denise Miyamoto
- Division of Dermatology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP),
Brazil
| | - Claudia Giuli Santi
- Division of Dermatology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP),
Brazil
| | - Valéria Aoki
- Department of Dermatology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo (SP), Brazil
| | - Celina Wakisaka Maruta
- Department of Dermatology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo (SP), Brazil
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25
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Alvarado SA, Muñoz-Mendoza D, Bahna SL. High-risk drug rashes. Ann Allergy Asthma Immunol 2018; 121:552-560. [PMID: 29803714 DOI: 10.1016/j.anai.2018.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/14/2018] [Accepted: 05/17/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To provide a brief overview of the clinical presentation, common offending agents, management, prognosis, and mortality of 6 selected high-risk drug rashes, namely, Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, multiple drug hypersensitivity (MDH) syndrome, acute generalized exanthematous pustulosis (AGEP), and drug-induced bullous pemphigoid (DIBP). DATA SOURCES A review of the published literature was performed with PubMed and supplemented with our clinical experience. STUDY SELECTIONS The most recent clinically relevant studies and older seminal works were selected. RESULTS Most of the published data on these uncommon rashes were based on small observational series or case reports. SJS and TEN have specific genotypes association with certain drugs, have high morbidity and mortality, and require aggressive management by a team of multiple specialists. DRESS syndrome is a severe, prolonged multiorgan reaction, yet it has a better prognosis than TEN. MDH is a syndrome of repeated reactions to unrelated drugs that often imposes diagnostic and management difficulties. AGEP consists of generalized sterile small pustules, usually mistaken for infection with subsequent inappropriate treatment. Bullous pemphigoid presents with tense pruritic bullae and characteristic linear basement membrane deposition of IgG and C3. DIBP has much better prognosis than the autoimmune variety. CONCLUSION In such high-risk drug rashes, early recognition, immediate withdrawal of the suspected drug(s), prompt individualized management, and monitoring of vital organs function are mandatory for reducing morbidity and mortality. The lack of reliable tests for identification of the causative agent imposes difficulty, particularly in patients receiving multiple medications.
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Affiliation(s)
- Sasha A Alvarado
- Allergy and Immunology Section, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Diana Muñoz-Mendoza
- Allergy and Immunology Section, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Sami L Bahna
- Allergy and Immunology Section, Louisiana State University Health Sciences Center, Shreveport, Louisiana.
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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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27
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Shephard MK, Nova CV, Thakrar P, Hodgson T. Checklists for safe prescribing in oral medicine clinics. Br Dent J 2017; 223:693-698. [DOI: 10.1038/sj.bdj.2017.887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2017] [Indexed: 11/09/2022]
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28
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Yang B, Chen G, Yang Q, Yan X, Zhang Z, Murrell DF, Zhang F. Reliability and validity of the Chinese version of the autoimmune bullous disease quality of life (ABQOL) questionnaire. Health Qual Life Outcomes 2017; 15:31. [PMID: 28153023 PMCID: PMC5290597 DOI: 10.1186/s12955-017-0594-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The autoimmune bullous diseases quality of life (ABQOL) questionnaire was recently developed by an Australian group and has been validated in Australian and North American patient cohorts. It is a 17-item, multidimensional, self-administered English questionnaire. The study aimed to validate the Chinese version of the ABQOL questionnaire and evaluate the reliability in Chinese patients. METHODS The Chinese version of the ABQOL questionnaire was produced by forward-backward translation and cross-cultural adaptation of the original English version. The ABQOL questionnaire was then distributed to a total of 101 patients with autoimmune bullous diseases (AIBDs) together with the Dermatology Life Quality Index (DLQI) and the 36-item Short Form Health Survey (SF-36). Validity was analyzed across a range of indices and reliability was assessed using internal consistency and test-retest methods. RESULTS The Chinese version of the ABQOL questionnaire has a high internal consistency (Cronbach's alpha coefficient, 0.88) and test-retest reliability (the intraclass correlation coefficient, 0.87). Face and content validity were satisfactory. Convergent validity testing showed that the correlation coefficients for the ABQOL and DLQI was 0.77 and for the ABQOL and SF-36 was -0.62. In terms of discriminant validity, there was no significant difference between the proportions of insensitive items in ABQOL and DLQI (p = 0.236). There was no significant difference between the proportions of insensitive items in ABQOL and SF-36 (p = 0.823). CONCLUSIONS The Chinese version of the ABQOL questionnaire has adequate validity and reliability. It may constitute a useful instrument to measure disease burden in Chinese patients with AIBDs.
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Affiliation(s)
- Baoqi Yang
- Institute of Dermatology and Department of Dermatology, The First Affiliated Hospital, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, 230032, China.,Department of Dermatology, Shandong Provincial Institute of Dermatology and Venereology, Shandong Provincial Academy of Medical Science, 27397 Jingshi Road, Jinan, Shandong, 250022, China.,Department of Dermatology, Shandong Provincial Hospital for Skin Diseases, 27397 Jingshi Road, Jinan, Shandong, 250022, China
| | - Guo Chen
- Department of Dermatology, Shandong Provincial Institute of Dermatology and Venereology, Shandong Provincial Academy of Medical Science, 27397 Jingshi Road, Jinan, Shandong, 250022, China.,Department of Dermatology, Laiwu Institute of Dermatology, 76 South Huayuan Road, Laiwu, Shandong, 271100, China
| | - Qing Yang
- Department of Dermatology, Shandong Provincial Institute of Dermatology and Venereology, Shandong Provincial Academy of Medical Science, 27397 Jingshi Road, Jinan, Shandong, 250022, China.,Department of Dermatology, Shandong Provincial Hospital for Skin Diseases, 27397 Jingshi Road, Jinan, Shandong, 250022, China
| | - Xiaoxiao Yan
- Department of Dermatology, Shandong Provincial Institute of Dermatology and Venereology, Shandong Provincial Academy of Medical Science, 27397 Jingshi Road, Jinan, Shandong, 250022, China.,Department of Dermatology, Shandong Provincial Hospital for Skin Diseases, 27397 Jingshi Road, Jinan, Shandong, 250022, China
| | - Zhaoxia Zhang
- Department of Dermatology, Shandong Provincial Institute of Dermatology and Venereology, Shandong Provincial Academy of Medical Science, 27397 Jingshi Road, Jinan, Shandong, 250022, China.,Department of Dermatology, Shandong Provincial Hospital for Skin Diseases, 27397 Jingshi Road, Jinan, Shandong, 250022, China
| | - Dédée F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Gray Street, Kogarah, Sydney, NSW, 2217, Australia
| | - Furen Zhang
- Institute of Dermatology and Department of Dermatology, The First Affiliated Hospital, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, 230032, China. .,Department of Dermatology, Shandong Provincial Institute of Dermatology and Venereology, Shandong Provincial Academy of Medical Science, 27397 Jingshi Road, Jinan, Shandong, 250022, China. .,Department of Dermatology, Shandong Provincial Hospital for Skin Diseases, 27397 Jingshi Road, Jinan, Shandong, 250022, China.
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29
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Hansen MS, Klefter ON, Julian HO, Lynge Pedersen AM, Heegaard S. Management of patients with ocular manifestations in vesiculobullous disorders affecting the mouth. Oral Dis 2016; 23:849-853. [PMID: 27717107 DOI: 10.1111/odi.12590] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/04/2016] [Indexed: 12/19/2022]
Abstract
Pemphigoid and pemphigus diseases as well as Stevens-Johnson syndrome present as vesiculobullous disorders of the skin and may additionally involve both the oral cavity and the ocular surface. Ocular involvement ranges from mild irritation and dry eye disease to chronic conjunctivitis, symblepharon, eyelid malposition, ocular surface scarring and severe visual loss. In addition to diagnostic assessments, ophthalmologists must treat the dry eye and meibomian gland dysfunction components of these diseases using a stepladder approach, including eyelid hygiene and lubricants. Topical anti-inflammatory therapy is used to treat acute inflammatory exacerbations of the ocular surface, but it cannot prevent scarring alone. Intralesional antimetabolite therapy can cause regression of conjunctival pathology in selected cases. Hence, patients with vesiculobullous disorders should be managed by a multidisciplinary team representing ophthalmology, dermatology, otolaryngology, oral medicine and pathology, internal medicine and intensive care. Systemic treatments including corticosteroids, azathioprine, cyclophosphamide, cyclosporine and mycophenolate mofetil help control inflammation. Intravenous immunoglobulins, plasmapheresis and targeted antibody therapy can be used in selected, severe and treatment-resistant cases. Local surgical management may include debridement of pseudomembranes, lysis of symblepharon, amniotic and mucous membrane grafting as well as reconstructive procedures. Prospective, multicentre, international studies are recommended to further support evidence-based practice.
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Affiliation(s)
- M S Hansen
- Department of Ophthalmology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - O N Klefter
- Department of Ophthalmology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - H O Julian
- Eye Clinic, Mølholm Hospital, Vejle, Denmark
| | - A M Lynge Pedersen
- Section of Oral Pathology and Oral Medicine, Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - S Heegaard
- Department of Ophthalmology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark.,Department of Pathology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
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Abstract
INTRODUCTION Pemphigus vulgaris (PV) is a chronic, autoimmune, vesiculobullous disease. As a result of the relative rarity of PV, published randomized controlled trials (RCTs) are limited, which makes it difficult to evaluate the efficacy of different treatment regimens in this disease. This also precludes conduct of a meta-analysis. METHODS English-language publications describing treatment outcomes of patients with PV were identified by searches of electronic databases through May 2015, and additionally by review of the bibliography of these publications. A total of 89 papers, which included 21 case reports, 47 case series, 8 RCTs, and 13 observational studies, were identified. The findings from these publications, including information on disease course and prognosis, medications used, treatment responses, and side effects, are summarized in the tables and text of this review. RESULTS Prior to availability of corticosteroid therapy, PV had a high fatality rate. Early publications from the 1970s reported high-dose, prolonged corticosteroid use and significant associated side effects. Later reports described use of corticosteroids along with steroid-sparing adjuvants, which allows a reduction in the total dose of corticosteroids and a reduction in observed mortality and morbidity. For the majority of patients in these reports, a long-term course on medications lasting about 5-10 years was observed; however, subgroups of patients requiring shorter courses or needing longer-term therapy have also been described. Early diagnosis of PV and early initiation of treatment were prognostic factors. In recent publications, commonly used initial regimens include corticosteroids in combination with mycophenolate or azathioprine; whereas, for patients with inadequate response to these regimens, adjuvants such as intravenous immunoglobulin (IVIg) or rituximab are used. CONCLUSION The review findings emphasize the importance of early diagnosis, early initiation of treatment, and use of steroid-sparing adjuvants to allow a reduced total dose and duration on corticosteroids. Also highlighted is the need for more RCTs.
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31
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Kim J, Chan JJ. Cyclophosphamide in dermatology. Australas J Dermatol 2016; 58:5-17. [PMID: 26806212 DOI: 10.1111/ajd.12406] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 09/02/2015] [Indexed: 01/19/2023]
Abstract
Cyclophosphamide is a chemotherapeutic agent which was first discovered in experimental tumours in rats, and it has since been widely used to treat malignancies and severe manifestations of various auto-immune diseases. High-dose chemotherapy and continuous daily oral regimens are associated with significant toxicity profiles, but i.v. pulsed regimens have lowered the rates of adverse effects in rheumatological studies. Cyclophosphamide has been shown to be useful in the treatment of severe autoimmune conditions due to its powerful immunosuppressive ability; however, it remains a relatively underused modality in dermatology. This article reviews the current literature on cyclophosphamide and its clinical applications in dermatology.
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Affiliation(s)
- Janet Kim
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jonathan J Chan
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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32
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A Case of Bullous Skin Disease Presenting with Odynophagia: A Diagnostic Challenge. Case Rep Dermatol Med 2016; 2016:2839104. [PMID: 27066279 PMCID: PMC4808691 DOI: 10.1155/2016/2839104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 02/11/2016] [Indexed: 11/23/2022] Open
Abstract
We report a case of Epidermolysis Bullosa Acquisita (EBA) that presented as a diagnostic challenge. A 60-year-old Qatari lady presented with odynophagia, oral ulceration, and weight loss. Multiple physicians investigated her for over 6 months with a multitude of tests and serial gastroscopies, all of which failed to reach a conclusive diagnosis. Only after referral to a dermatologist and full body examination was diagnosis finally achieved. After reviewing the literature, we provide a summary of EBA and highlight the importance of comprehensive clinical reviews in order to avoid unnecessary morbidity.
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33
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Sung JY, Roh MR, Kim SC. Quality of Life Assessment in Korean Patients with Pemphigus. Ann Dermatol 2015; 27:492-8. [PMID: 26512162 PMCID: PMC4622882 DOI: 10.5021/ad.2015.27.5.492] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 12/10/2014] [Accepted: 01/06/2015] [Indexed: 11/08/2022] Open
Abstract
Background Measuring the quality of life (QOL) is important in the evaluation of nonclinical aspects of diseases, for the discovery of functional and psychological limitations, and in choosing treatment in the initial phase of the disease. Pemphigus is a potentially fatal autoimmune bullous disease caused by autoantibodies against desmogleins (cadherin family proteins in desmosomes). Thus far, there has been no published study on QOL in Korean patients with pemphigus. Objective To study the impact of pemphigus on the QOL in a large number of Korean patients. Methods Sixty-six patients enrolled at the Gangnam Severance Hospital from March 2012 to March 2013 were assessed for QOL by using the Dermatology Life Quality Index (DLQI), and for anxiety and depression by using the General Health Questionnaire (GHQ). Spearman's rank-order correlation, t-test, and ANOVA were used to identify the relations between the DLQI score and other clinical variables. Results Pemphigus vulgaris and pemphigus foliaceus significantly reduced the QOL of patients. The average DLQI score for all patients was 10.18. The mean DLQI score was 13.45 in patients in the active state and 5.15 in the patients in the remission state. The DLQI score highly correlated with disease severity, titer of anti-desmoglein 1 in enzyme-linked immunosorbent assay, and the corticosteroid dose. However, the QOL was not affected by sex, age, subtype of pemphigus, duration of disease, or comorbidities. Forty-two percent of the patients showed a positive result in the GHQ, reflecting probable minor psychiatric nonpsychotic conditions, and the GHQ score positively correlated to the DLQI score. Conclusion Pemphigus significantly impairs the QOL of patients. The QOL of Korean pemphigus patients significantly correlates with clinical severity. Therefore, considerable attention should be paid to the patients' QOL and psychological states as well as clinical status.
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Affiliation(s)
- Jae Yong Sung
- Department of Dermatology and Cutaneous Biology Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mi Ryung Roh
- Department of Dermatology and Cutaneous Biology Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soo-Chan Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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34
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Sami N. Mycophenolate mofetil (MMF) in the treatment of epidermolysis bullosa acquisita (EBA) long-term follow-up. JAAD Case Rep 2015; 1:321-3. [PMID: 27051767 PMCID: PMC4809265 DOI: 10.1016/j.jdcr.2015.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Naveed Sami
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama
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35
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World Workshop on Oral Medicine VI: a systematic review of the treatment of mucocutaneous pemphigus vulgaris. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 120:132-42.e61. [DOI: 10.1016/j.oooo.2015.01.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/01/2015] [Indexed: 11/20/2022]
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36
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Abstract
Rituximab is a chimeric monoclonal antibody that selectively binds to the CD20 molecule on B cells, resulting in their lysis. In autoimmune blistering diseases, the auto-antibody-producing B cells are destroyed and auto-antibody levels are reduced or eliminated. In the majority of patients, rituximab produces rapid clinical response and early resolution. In part, this accounts for the increased use of rituximab. Rituximab does not distinguish normal from pathologic B cells. Hence, shortly after its use, B-cell levels are zero and remain so for several months. In most patients, the use of systemic corticosteroids and immunosuppressive agents are continued after rituximab therapy, while their dosages are significantly decreased. In the majority of patients rituximab is used according to the protocol used in treating lymphoma patients or patients with rheumatoid arthritis. Approximately 50% of patients experience a relapse, requiring additional therapy. Serious adverse events and fatal outcomes have been reported, although their incidence is less than that observed with conventional therapy. Nonetheless, the causes, i.e. infections and septicemia, are similar. Several gaps exist in our understanding of how to optimally benefit from the use of this valuable biological agent. Future studies need to be targeted in designing and implanting protocols that maximize the benefit of rituximab and result in producing sustained prolonged remissions with minimal adverse events and a high quality of life.
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37
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Ahmed AR, Shetty S. A comprehensive analysis of treatment outcomes in patients with pemphigus vulgaris treated with rituximab. Autoimmun Rev 2015; 14:323-31. [DOI: 10.1016/j.autrev.2014.12.002] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 12/03/2014] [Indexed: 02/05/2023]
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38
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Aguilar-Duran S, Deroide F, Mee J, Rustin M. Pemphigus vulgaris presenting as erythema annulare centrifugum. Clin Exp Dermatol 2015; 40:466-7. [PMID: 25649763 DOI: 10.1111/ced.12581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2014] [Indexed: 12/01/2022]
Affiliation(s)
| | - F Deroide
- Department of Pathology, Royal Free Hospital, London, UK
| | - J Mee
- Immunodermatology Laboratory, St Thomas Hospital, London, UK
| | - M Rustin
- Department of Dermatology , Royal Free Hospital, London, UK
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39
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Serrano M, Martínez-Flores JA, Castro MJ, García F, Lora D, Pérez D, Gonzalez E, Paz-Artal E, Morales JM, Serrano A. Renal transplantation dramatically reduces IgA anti-beta-2-glycoprotein I antibodies in patients with endstage renal disease. J Immunol Res 2014; 2014:641962. [PMID: 24818167 PMCID: PMC4003762 DOI: 10.1155/2014/641962] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 03/10/2014] [Accepted: 03/10/2014] [Indexed: 02/04/2023] Open
Abstract
IgA anti-beta-2-glycoprotein I (aB2GPI) antibodies have been related to vascular pathology in the general population and mainly in hemodialyzed patients (prevalence 33%) in whom an elevated incidence of thrombosis and mortality is found. In this paper we have studied the presence of IgA aB2GPI antibodies at pretransplant and their evolution after transplantation with a cross-sectional-based follow-up study of a cohort of 288 endstage renal disease (ESRD) patients treated with kidney transplantation. Pretransplant IgA aB2GPI levels were elevated 31.7 ± 4.2 U/mL without differences in age or type of dialysis. Patients with different etiologies of ESRD showed higher levels of IgA aB2GPI than blood donors, except the groups of non-IgA glomerular disease and systemic erythematosus lupus, whose nonsignificant differences were observed. IgA aB2GPI antibodies dropped immediately after transplantation (10.7 ± 1.0 U/mL, P < 0.0001), coinciding with a high degree of immunosuppression, and remained significantly lower than that observed in pretransplant status. Prevalence of patients with elevated antibodies was also less in transplanted patients (8.9% versus 30.4%, P < 0.0001). Among, positivity for IgA aB2GPI was higher than in patients who had received their first transplant that those were retransplanted. This finding could have important clinical implications and can suggest new therapeutic strategies in patients with IgA aB2GPI antibodies.
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Affiliation(s)
- Manuel Serrano
- Servicio de Nefrología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Jose Angel Martínez-Flores
- Servicio de Inmunología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Maria José Castro
- Servicio de Inmunología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Florencio García
- Servicio de Nefrología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - David Lora
- Servicio de Epidemiología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Dolores Pérez
- Servicio de Inmunología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Esther Gonzalez
- Servicio de Nefrología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Estela Paz-Artal
- Servicio de Inmunología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
- Sección de Inmunología, Universidad San Pablo-CEU, Campus de Monteprincipe, 28668 Madrid, Spain
- Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
| | - Jose M. Morales
- Servicio de Nefrología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
- Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
| | - Antonio Serrano
- Servicio de Inmunología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
- Sección de Inmunología, Universidad San Pablo-CEU, Campus de Monteprincipe, 28668 Madrid, Spain
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Correlation of thiopurine methyltransferase and inosine triphosphate pyrophosphatase polymorphisms and adverse effects induced by azathioprine treatment in Taiwanese dermatology patients. DERMATOL SIN 2014. [DOI: 10.1016/j.dsi.2013.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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41
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Dastgheib L, Sadati MS, Baghernejhad M. Assessment of the adjuvant effect of tacrolimus in the management of pemphigus vulgaris: A randomized controlled trial. J DERMATOL TREAT 2014; 26:90-3. [DOI: 10.3109/09546634.2013.873763] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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42
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Ruocco E, Wolf R, Ruocco V, Brunetti G, Romano F, Lo Schiavo A. Pemphigus: associations and management guidelines: facts and controversies. Clin Dermatol 2013; 31:382-390. [PMID: 23806155 DOI: 10.1016/j.clindermatol.2013.01.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Pemphigus, a prototypical organ-specific human autoimmune disease, may be associated with other immunity-related disorders, viral infections, and different types of tumors. Coexistence with immune diseases is fairly frequent and, for some of them (eg, myasthenia gravis, Basedow's disease, rheumatoid arthritis, or lupus erythematosus), common pathogenic mechanisms can be considered. The association with viral infections (mainly herpesvirus infections) raises the question of whether the virus triggers the outbreak of the disease or simply complicates its clinical course. Neoplastic proliferations coexisting with pemphigus have a different histogenesis and the pathogenic link may vary according to the associated tumor (thymoma, lymphoma, carcinoma, or sarcoma). A subset of pemphigus-neoplasia association is represented by Anhalt's paraneoplastic pemphigus, with peculiar clinical, histologic, and immunologic features characterizing it. Coexistence of pemphigus with Kaposi's sarcoma, albeit not frequent, offers an intriguing speculative interest. The cornerstone of management in pemphigus is the combination of systemic corticosteroids and immunosuppressants. The conventional treatment used in most cases is based on oral administration of deflazacort and azathioprine. In selected cases, mycophenolate mofetil is preferred to azathioprine. Severe forms of pemphigus require intravenous pulse therapy with dexamethasone (or methylprednisolone) and cyclophosphamide. In the recent years, the use of high-dose intravenous immunoglobulin therapy has gained several consents. Rituximab, a monoclonal anti-CD 20 antibody, which affects both the humoral and cell-mediated responses, has proved to give a good clinical response, often paralleled by decrease of pathogenic autoantibodies. The combination with intravenous immunoglobulin offers the double advantage of better clinical results and a reduced incidence of infection. Interventional treatments, such as plasmapheresis and extracorporeal immunoadsorption, are aimed at patients with life-threatening forms of pemphigus and high levels of circulating autoantibodies, a circumstance where the medical therapy alone risks failing. Second-line treatments include gold salts (which we do not favor because of the acantholytic potential inherent in thiol structure) and the association of oral tetracyclines with nicotinamide, which is rather safe. Local treatments, supplementary to the systemic therapy, are aimed at preventing infections and stimulating reepithelialization of eroded areas. Innovative topical treatments are epidermal growth factor, nicotinamide gel, pimecrolimus, and a proteomics-derived desmoglein peptide. Pemphigus patients should be warned against over-indulging in unnecessary drug intake, prolonged exposure to ultraviolet rays, intense emotional stress, and too spiced or too hot foods. Cigarette smoking is not contraindicated in pemphigus patients because of the nicotine anti-acantholytic properties.
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Affiliation(s)
- Eleonora Ruocco
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy
| | - Ronni Wolf
- Dermatology Unit, Kaplan Medical Center, Rehovot 76100 Israel; The School of Medicine, Hebrew University and Hadassah Medical Center, Jerusalem, Israel
| | - Vincenzo Ruocco
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy.
| | - Giampiero Brunetti
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy
| | - Francesca Romano
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy
| | - Ada Lo Schiavo
- Department of Dermatology, Second University of Naples, via S. Pansini, 5 - 80131 Naples, Italy
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Abstract
Background: Lymphomatoid papulosis is a rare CD30+ lymphoproliferative T-cell disorder with limited effective treatments. Objective: We describe the case of a 50-year-old woman diagnosed with lymphomatoid papulosis who was unable to access phototherapy and who failed to clear while on systemic treatment with methotrexate. Methods: The patient was initiated on mycophenolate mofetil (MMF), a prodrug of mycophenolic acid, at a dose of 2 g divided twice daily. Results: MMF produced a rapid response with complete clearing within 8 weeks, and the patient has been successfully maintained for 2 years at the same dose with no noted side effects. Other patients in our clinic have had similar success. Conclusions: Mycophenolic acid is a safe and well-tolerated therapy for lymphomatoid papulosis.
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Affiliation(s)
- Trevor Champagne
- From the Division of Dermatology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Scott Walsh
- From the Division of Dermatology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
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Ruocco E, Wolf R, Caccavale S, Brancaccio G, Ruocco V, Lo Schiavo A. RETRACTED: Bullous pemphigoid: Associations and management guidelines. Clin Dermatol 2013; 31:400-412. [DOI: 10.1016/j.clindermatol.2013.01.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Gual A, Iranzo P, Mascaró JM. Treatment of bullous pemphigoid with low-dose oral cyclophosphamide: a case series of 20 patients. J Eur Acad Dermatol Venereol 2013; 28:814-8. [PMID: 23581830 DOI: 10.1111/jdv.12155] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 03/14/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cyclophosphamide has been commonly used for the treatment of pemphigus vulgaris and mucous membrane pemphigoid with satisfactory results. Published data of this therapeutic approach for bullous pemphigoid are scant and showed significant morbidity and mortality. OBJECTIVE To assess the clinical efficacy and safety of low-dose oral cyclophosphamide (CFM) (50-100 mg/day) in patients with refractory bullous pemphigoid. METHODS We conducted a retrospective study including patients with bullous pemphigoid treated with CFM in the department of Dermatology in the Hospital Clínic of Barcelona, Spain. RESULTS Complete response was observed in 11 (58%) over 19 evaluable patients. Cyclophosphamide at 50 mg/day was enough to achieve clinical remission in eight of these patients. Partial response was observed in four (21%) more patients. Bone marrow suppression appeared in 12 (60%) patients, but treatment discontinuation was only required in three (15%) cases. Gastrointestinal intolerance occurred in one (5%) patient. One patient died during therapy from heart failure (not attributed to CFM) and another patient developed acute myeloid leukaemia 1.5 years after CFM therapy. CONCLUSIONS In our series, CFM had a marked therapeutic effect in bullous pemphigoid. These results of efficacy are similar to those described in other autoimmune blistering skin diseases. Only a few patients had to discontinue their treatment due to adverse effects. Therefore, we consider that low-dose oral CFM can be valuable therapeutic alternative in elderly patients with moderate-to-severe bullous pemphigoid.
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Affiliation(s)
- A Gual
- Department of Dermatology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic. Universitat de Barcelona, Barcelona, Spain
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Colliou N, Picard D, Caillot F, Calbo S, Le Corre S, Lim A, Lemercier B, Le Mauff B, Maho-Vaillant M, Jacquot S, Bedane C, Bernard P, Caux F, Prost C, Delaporte E, Doutre MS, Dreno B, Franck N, Ingen-Housz-Oro S, Chosidow O, Pauwels C, Picard C, Roujeau JC, Sigal M, Tancrede-Bohin E, Templier I, Eming R, Hertl M, D'Incan M, Joly P, Musette P. Long-Term Remissions of Severe Pemphigus After Rituximab Therapy Are Associated with Prolonged Failure of Desmoglein B Cell Response. Sci Transl Med 2013; 5:175ra30. [DOI: 10.1126/scitranslmed.3005166] [Citation(s) in RCA: 164] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Clinical relevance of autoantibodies in patients with autoimmune bullous dermatosis. Clin Dev Immunol 2012; 2012:369546. [PMID: 23320017 PMCID: PMC3540916 DOI: 10.1155/2012/369546] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 12/10/2012] [Indexed: 12/02/2022]
Abstract
The authors present their experience related to the diagnosis, treatment, and followup of 431 patients with bullous pemphigoid, 14 patients with juvenile bullous pemphigoid, and 273 patients with pemphigus. The detection of autoantibodies plays an outstanding role in the diagnosis and differential diagnosis. Paraneoplastic pemphigoid is suggested to be a distinct entity from the group of bullous pemphigoid in view of the linear C3 deposits along the basement membrane of the perilesional skin and the “ladder” configuration of autoantibodies demonstrated by western blot analysis. It is proposed that IgA pemphigoid should be differentiated from the linear IgA dermatoses. Immunosuppressive therapy is recommended in which the maintenance dose of corticosteroid is administered every second day, thereby reducing the side effects of the corticosteroids. Following the detection of IgA antibodies (IgA pemphigoid, linear IgA bullous dermatosis, and IgA pemphigus), diamino diphenyl sulfone (dapsone) therapy is preferred alone or in combination. The clinical relevance of autoantibodies in patients with autoimmune bullous dermatosis is stressed.
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Abstract
Treatment modalities and therapeutic response experience support the use of immunotherapy in the treatment of many diseases in all fields of medicine. The aim of this article is to conduct and present a review of literature on the use of immunotherapy in the treatment of skin diseases analyzing scientific literature available up to January 2012. Studies that presented evidence-based data were selected. The article discusses how blocking or reverting the effect of a specific immunologic disequilibrium can treat dermatoses and intends to transfer a large amount of immunotherapy knowledge into a historical perspective for physicians naive to immunotherapy practices.
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Affiliation(s)
- Robyn S Fallen
- Michael G. DeGroote School of Medicine, Waterloo Regional Campus, McMaster University, 10-B Victoria Street South, Kitchener, Ontario N2G 1C5, Canada
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