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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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Henry J, Bursztejn AC, Bonhomme A, Cuny JF, Mitcov M, Blanchard-Laumonnier E, Schmutz JL. Épidermolyse bulleuse acquise à type de pemphigoïde de Brunsting-Perry : difficultés diagnostiques et thérapeutiques. Ann Dermatol Venereol 2020; 147:439-445. [DOI: 10.1016/j.annder.2020.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 11/29/2018] [Accepted: 01/17/2020] [Indexed: 11/26/2022]
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Koga H, Prost-Squarcioni C, Iwata H, Jonkman MF, Ludwig RJ, Bieber K. Epidermolysis Bullosa Acquisita: The 2019 Update. Front Med (Lausanne) 2019; 5:362. [PMID: 30687710 PMCID: PMC6335340 DOI: 10.3389/fmed.2018.00362] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 12/19/2018] [Indexed: 11/13/2022] Open
Abstract
Epidermolysis bullosa acquisita (EBA) is an orphan autoimmune disease. Patients with EBA suffer from chronic inflammation as well as blistering and scarring of the skin and mucous membranes. Current treatment options rely on non-specific immunosuppression, which in many cases, does not lead to a remission of treatment. Hence, novel treatment options are urgently needed for the care of EBA patients. During the past decade, decisive clinical observations, and frequent use of pre-clinical model systems have tremendously increased our understanding of EBA pathogenesis. Herein, we review all of the aspects of EBA, starting with a detailed description of epidemiology, clinical presentation, diagnosis, and current treatment options. Of note, pattern analysis via direct immunofluorescence microscopy of a perilesional skin lesion and novel serological test systems have significantly facilitated diagnosis of the disease. Next, a state-of the art review of the current understanding of EBA pathogenesis, emerging treatments and future perspectives is provided. Based on pre-clinical model systems, cytokines and kinases are among the most promising therapeutic targets, whereas high doses of IgG (IVIG) and the anti-CD20 antibody rituximab are among the most promising "established" EBA therapeutics. We also aim to raise awareness of EBA, as well as initiate basic and clinical research in this field, to further improve the already improved but still unsatisfactory conditions for those diagnosed with this condition.
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Affiliation(s)
- Hiroshi Koga
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Fukuoka, Japan
| | - Catherine Prost-Squarcioni
- Department of Dermatology, APHP, Avicenne Hospital, Referral Center for Autoimmune Bullous Diseases, Bobigny, France
| | - Hiroaki Iwata
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Marcel F Jonkman
- Department of Dermatology, Center for Blistering Diseases, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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Iwata H, Vorobyev A, Koga H, Recke A, Zillikens D, Prost-Squarcioni C, Ishii N, Hashimoto T, Ludwig RJ. Meta-analysis of the clinical and immunopathological characteristics and treatment outcomes in epidermolysis bullosa acquisita patients. Orphanet J Rare Dis 2018; 13:153. [PMID: 30180870 PMCID: PMC6122731 DOI: 10.1186/s13023-018-0896-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/22/2018] [Indexed: 12/31/2022] Open
Abstract
Background Epidermolysis bullosa acquisita (EBA) is an orphan autoimmune disease. Several clinical phenotypes have been described, but subepidermal blistering is characteristic of all variants. Limited data on clinical and immunopathological characteristics and treatment outcomes in EBA are available. To fill this gap, we collected this information from EBA cases, meeting current diagnostic criteria, published between 1971 and 2016. Results We identified 1159 EBA cases. This number must be, however, interpreted with caution, as it is not possible to check for multiple reporting. The analysis of all cases indicated that EBA affects all age groups (median: 50 years, range: 1 to 94 years) at an equal gender distribution. Non-mechanobullous (non-MB) forms of EBA were observed in 55% of patients, whereas the mechanobullous variant (MB-EBA) or a combination of both variants was described in 38 or 7% of patients, respectively. Type VII collagen (COL7)-specific autoantibodies were primarily of the IgG isotype, but anti-COL7 IgA, IgM and IgE were also documented. Comparison of the 2 clinical EBA types showed a higher frequency of IgA deposits in non-MB EBA as opposed to MB EBA. Mucous membrane involvement was observed in 23% of patients, and 4.4% of cases were associated with other chronic inflammatory diseases. Of note, IgA deposits were more frequently observed in cases with mucous membrane involvement. Our analysis indicated that EBA is difficult to treat and that the choice of treatment varies widely. Chi square was applied to identify medications associated with complete remission (CR). Considering all EBA cases, intravenous immunoglobulin (IVIG, p = 0.0047) and rituximab (p = 0.0114) were associated with CR. Subgroup analysis demonstrated that no treatment was associated with CR for non-MB EBA, while IVIG (p = 0.003) was associated with CR in MB EBA. Conclusions Within the limitations of the study, we here document the clinical and immunopathological characteristics and treatment outcomes in a large cohort of EBA patients. The observed associations of single drugs with treatment outcome may serve as a guide to develop clinical trials. Electronic supplementary material The online version of this article (10.1186/s13023-018-0896-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hiroaki Iwata
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany.,Present address: Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Artem Vorobyev
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Hiroshi Koga
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany.,Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Kurume, Fukuoka, Japan
| | - Andreas Recke
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Catherine Prost-Squarcioni
- Referral center for auto-immune bullous diseases, Department of Dermatology, APHP, Avicenne Hospital, Bobigny, France
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Kurume, Fukuoka, Japan
| | - Takashi Hashimoto
- Department of Dermatology, Faculty of Medicine, Osaka City University, Osaka, Japan
| | - Ralf J Ludwig
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany. .,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.
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Abstract
Awareness of the extraintestinal manifestations of Crohn disease is increasing in dermatology and gastroenterology, with enhanced identification of entities that range from granulomatous diseases recapitulating the underlying inflammatory bowel disease to reactive conditions and associated dermatoses. In this review, the underlying etiopathology of Crohn disease is discussed, and how this mirrors certain skin manifestations that present in a subset of patients is explored. The array of extraintestinal manifestations that do not share a similar pathology, but which are often seen in association with inflammatory bowel disease, is also discussed. Treatment and pathogenetic mechanisms, where available, are discussed.
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Affiliation(s)
- Joshua W Hagen
- Department of Dermatology, University of Pittsburgh Medical Center, Medical Arts Building, 3708 Fifth Avenue, 5th Floor, Pittsburgh, PA 15213, USA
| | - Jason M Swoger
- Department of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, 200 Lothrop street, C-Wing, Mezzanine, Pittsburgh, PA 15213, USA
| | - Lisa M Grandinetti
- Department of Dermatology, University of Pittsburgh Medical Center, Medical Arts Building, 3708 Fifth Avenue, 5th Floor, Pittsburgh, PA 15213, USA.
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Bizikova P, Linder KE, Wofford JA, Mamo LB, Dunston SM, Olivry T. Canine epidermolysis bullosa acquisita: a retrospective study of 20 cases. Vet Dermatol 2015; 26:441-50, e102-3. [DOI: 10.1111/vde.12255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2015] [Indexed: 01/20/2023]
Affiliation(s)
- Petra Bizikova
- Department of Clinical Sciences; College of Veterinary Medicine; North Carolina State University; 1060 William Moore Drive Raleigh NC 27607 USA
- Center for Comparative Medicine and Translational Research; North Carolina State University; 1060 William Moore Drive Raleigh NC 27607 USA
| | - Keith E. Linder
- Center for Comparative Medicine and Translational Research; North Carolina State University; 1060 William Moore Drive Raleigh NC 27607 USA
- Department of Population Health and Pathobiology; College of Veterinary Medicine; North Carolina State University; 1060 William Moore Drive Raleigh NC 27607 USA
| | - Jessica A. Wofford
- Department of Clinical Sciences; College of Veterinary Medicine; North Carolina State University; 1060 William Moore Drive Raleigh NC 27607 USA
| | - Lisa B. Mamo
- Department of Clinical Sciences; College of Veterinary Medicine; North Carolina State University; 1060 William Moore Drive Raleigh NC 27607 USA
| | - Stanley M. Dunston
- Department of Clinical Sciences; College of Veterinary Medicine; North Carolina State University; 1060 William Moore Drive Raleigh NC 27607 USA
| | - Thierry Olivry
- Department of Clinical Sciences; College of Veterinary Medicine; North Carolina State University; 1060 William Moore Drive Raleigh NC 27607 USA
- Center for Comparative Medicine and Translational Research; North Carolina State University; 1060 William Moore Drive Raleigh NC 27607 USA
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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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Calabresi V, Sinistro A, Cozzani E, Cerasaro C, Lolicato F, Muscianese M, Parodi A, Didona B, Zambruno G, Di Zenzo G. Sensitivity of different assays for the serological diagnosis of epidermolysis bullosa acquisita: analysis of a cohort of 24 Italian patients. J Eur Acad Dermatol Venereol 2014; 28:483-90. [PMID: 24321031 DOI: 10.1111/jdv.12129] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 02/04/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Epidermolysis bullosa acquisita (EBA) is an autoimmune blistering disease characterized by tissue-bound and circulating autoantibodies to the dermal-epidermal junction. The autoantibody target is type VII collagen (Col VII) which is involved in dermal-epidermal adhesion. Diagnosis is made by clinical and histopathological findings, linear deposition of autoantibodies at the dermal-epidermal junction detected by direct immunofluorescence, and binding to the dermal side of salt-split skin by indirect immunofluorescence (IIF). However, the detection of specific anti-Col VII reactivity has an important confirmatory value. METHODS The humoral immune response in EBA sera was analysed by (i) IIF on human skin, (ii) a commercial Col VII ELISA, and (iii) immunoblotting on Col VII produced by an epithelial cell line. OBJECTIVE The aim of this study was to compare the sensitivity of different approaches for the serological diagnosis of EBA. RESULTS The vast majority of EBA sera (79.2%) bound to the Col VII non-collagenous domains by a commercial ELISA, while a small proportion of patients (12.5%) exclusively reacted to the collagenous domain by immunoblotting. Of note, the autoantibodies reactivity to Col VII was more frequently detected by IB (91.7%) than by IIF (83.3%) and ELISA (79.2%). Interestingly, 2 out of 24 sera recognized Col VII epitopes undetectable in the native secreted protein but present in the context of extracellular matrix proteins, as assessed by immunomapping on Col VII-deficient skin. CONCLUSION Our findings show that the use of multiple assays allows to improve diagnostic performance. An algorithm for efficient serological diagnosis of EBA is proposed.
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McKinley SK, Huang JT, Tan J, Kroshinsky D, Gellis S. A case of recalcitrant epidermolysis bullosa acquisita responsive to rituximab therapy. Pediatr Dermatol 2014; 31:241-4. [PMID: 23106762 DOI: 10.1111/pde.12006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Epidermolysis bullosa acquisita (EBA) is an autoimmune blistering disorder that occurs infrequently in children. Although typically associated with a good prognosis in children, there are rare cases that are refractory to treatment with conventional immunosuppressive therapy. Rituximab, an anti-CD20 monoclonal antibody, has been reported to be effective in the adult form of EBA. We report a case of a child with severe and recalcitrant EBA exhibiting a sustained response to treatment with rituximab.
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Affiliation(s)
- Sophia K McKinley
- Harvard Medical School, Children's Hospital Boston, Boston, Massachusetts
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Baum S, Sakka N, Artsi O, Trau H, Barzilai A. Diagnosis and classification of autoimmune blistering diseases. Autoimmun Rev 2014; 13:482-9. [PMID: 24434358 DOI: 10.1016/j.autrev.2014.01.047] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 11/13/2013] [Indexed: 02/09/2023]
Abstract
Blistering skin diseases are a group of autoimmune disorders that are characterized by autoantibodies against structural proteins of the epidermis or the dermal-epidermal junction and clinically by blisters and erosions on skin and/or mucous membranes. Since clinical criteria and histopathological characteristics are not sufficient for diagnosis, direct immunofluorescence microscopy of a biopsy specimen or serological tests are needed for exact diagnosis. The differentiation between the various disorders became more important since prognosis as well as different treatment options are nowadays available for the various diseases. Moreover, some bullous diseases may indicate the presence of an underlying malignancy. The detection of serum autoantibodies have been shown to correlate with disease activity and thus may be helpful in deciding treatment options for these patients.
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Affiliation(s)
- Sharon Baum
- Department of Dermatology, Chaim Sheba Medical Center, Tel-Aviv University, Sackler School of Medicine, Tel Hashomer, Israel.
| | - Nicole Sakka
- Department of Dermatology, Chaim Sheba Medical Center, Tel-Aviv University, Sackler School of Medicine, Tel Hashomer, Israel
| | - Ofir Artsi
- Department of Dermatology, Chaim Sheba Medical Center, Tel-Aviv University, Sackler School of Medicine, Tel Hashomer, Israel
| | - Henri Trau
- Department of Dermatology, Chaim Sheba Medical Center, Tel-Aviv University, Sackler School of Medicine, Tel Hashomer, Israel
| | - Aviv Barzilai
- Department of Dermatology, Chaim Sheba Medical Center, Tel-Aviv University, Sackler School of Medicine, Tel Hashomer, Israel
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Otten JV, Hashimoto T, Hertl M, Payne AS, Sitaru C. Molecular diagnosis in autoimmune skin blistering conditions. Curr Mol Med 2014; 14:69-95. [PMID: 24160488 PMCID: PMC3905716 DOI: 10.2174/15665240113136660079] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 03/12/2013] [Accepted: 06/04/2013] [Indexed: 12/22/2022]
Abstract
Blister formation in skin and mucous membranes results from a loss of cell-cell or cell-matrix adhesion and is a common outcome of pathological events in a variety of conditions, including autoimmune and genetic diseases, viral and bacterial infections, or injury by physical and chemical factors. Autoantibodies against structural components maintaining cell-cell and cell-matrix adhesion induce tissue damage in autoimmune blistering diseases. Detection of these autoantibodies either tissue-bound or circulating in serum is essential to diagnose the autoimmune nature of disease. Various immunofluorescence methods as well as molecular immunoassays, including enzyme-linked immunosorbent assay and immunoblotting, belong to the modern diagnostic algorithms for these disorders. There is still a considerable need to increase awareness of the rare autoimmune blistering diseases, which often show a severe, chronic-relapsing course, among physicians and the public. This review article describes the immunopathological features of autoimmune bullous diseases and the molecular immunoassays currently available for their diagnosis and monitoring.
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Affiliation(s)
| | | | | | | | - C Sitaru
- Department of Dermatology, University of Freiburg, Hauptstrasse 7, D-79104 Freiburg, Germany.
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Sensitive and specific assays for routine serological diagnosis of epidermolysis bullosa acquisita. J Am Acad Dermatol 2013; 68:e89-95. [DOI: 10.1016/j.jaad.2011.12.032] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 12/16/2011] [Accepted: 12/24/2011] [Indexed: 11/23/2022]
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Kim JH, Kim SC. Epidermolysis bullosa acquisita. J Eur Acad Dermatol Venereol 2013; 27:1204-13. [PMID: 23368767 DOI: 10.1111/jdv.12096] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 12/17/2012] [Indexed: 12/29/2022]
Abstract
Epidermolysis bullosa acquisita (EBA) is a chronic autoimmune subepidermal bullous disease with clinical features similar to the genetic form of dystrophic epidermolysis bullosa. EBA is characterized by the presence of autoantibodies against type VII collagen which is a major component of the anchoring fibrils at the dermal-epidermal junction. EBA can be divided into two main clinical types; mechanobullous and inflammatory EBA. Mechanobullous EBA, referred to as classic EBA, presents with skin fragility, blisters and dystrophic changes on trauma-prone areas. Inflammatory EBA resembles other autoimmune subepidermal bullous diseases. Compelling evidence from mouse models supports a pathogenic role of autoantibodies against type VII collagen in EBA. Treatment of EBA is often unsatisfactory. The most widely used systemic treatment is corticosteroids. Colchicine and dapsone have been reported to be good treatment modalities when combined with corticosteroids. Some intractable cases of EBA have successfully been treated with intravenous immunoglobulin or rituximab.
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Affiliation(s)
- J H Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Shetty S, Ahmed AR. Critical analysis of the use of rituximab in mucous membrane pemphigoid: a review of the literature. J Am Acad Dermatol 2012. [PMID: 23200198 DOI: 10.1016/j.jaad.2012.10.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Mucous membrane pemphigoid (MMP) is an autoimmune blistering disease. In patients who do not respond to conventional therapy, rituximab (RTX) may be an option. The current literature on the treatment of MMP with RTX is limited. OBJECTIVE In this review, the data on 28 patients with MMP treated with RTX are critically analyzed. The goal is to provide objective information useful in decision making and treatment. METHODS A PubMed search using the key words "rituximab" and "mucous membrane pemphigoid" was made in the English language only. The studies were divided into case reports and case series. RESULTS In the final analysis, 20 of 28 patients had a complete response, 3 had a partial response, 2 were nonresponders, and 1 had stabilization of disease. In 1 patient, stabilization of upper airway disease was observed but the patient developed bilateral blindness as a result of progression of disease. Hence, the patient was considered a treatment failure. One died from infection. At least half of the patients were treated with a second cycle because of relapse or lack of response. LIMITATIONS Long-term follow-up after RTX therapy is lacking. Hence, the clinical benefit of inducing long-term remissions cannot be assessed. Responses of individual mucosal sites cannot be differentiated. Studies on B-cell levels and antibody responses are lacking. CONCLUSION Using the protocol described, RTX benefits patients with recalcitrant MMP. Some patients fail treatment or experience a relapse. The ability of RTX to influence the clinical course of MMP remains to be determined.
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Affiliation(s)
- Shawn Shetty
- Center For Blistering Diseases, Boston, Massachusetts 02135, USA
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