Management of autoimmune bullous diseases: Pharmacology and therapeutics

Evaluation of therapeutic effects of nanofibrous mat containing mycophenolate mofetil on oral lichen planus: In vitro and clinical trial study

Objectives

Recently, topical drug delivery system has gained increasing interest in the treatment of oral lesions. Lichen planus is a chronic inflammatory disease affecting mucous membranes and skin. The current study aimed to fabricate a drug delivery system containing mycophenolate mofetil for the treatment of oral lichen planus lesions.

Methods

Firstly, a nanofibrous mat containing mycophenolate mofetil, zinc oxide nanoparticles, and aloe vera was designed and fabricated. The antimicrobial, cytocompatibility, anti-inflammatory, and antioxidative characteristics of fabricated scaffolds were evaluated. Then, this nanofibrous mat was applied to 12 patients suffering from bilateral erythematous/erosive Oral Lichen planus (OLP) lesions for 2 weeks. The treatment outcomes, including oral symptoms and lesion size, were compared with the routine topical treatment of these lesions; Triamcinolone ointment.

Results

The characterization of nanofibrous mat approved the successful fabrication of scaffolds. The fabricated nanofibers showed notable antimicrobial activity. The amounts of TNF 𝛼, IL6, and reactive oxygen species (ROS) of stimulated human gingival fibroblasts were decreased after exposure to NFs/Myco/Alv/ZnO scaffolds. The clinical trial results demonstrated the same therapeutic effects compared to the commercial ointment, while the symptoms of patients were significantly improved in the mats group.Significance. Considering the successful results of this study, the application of nanofibrous mat can be a promising product for improving treatment outcomes of OLP.

Efficacy of topical non-steroidal immunomodulators in the treatment of oral lichen planus: a systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review was to assess the efficacy and safety of topical non-steroidal immunomodulators (TNSIs) for oral lichen planus (OLP) treatment.

MATERIALS AND METHODS

A search strategy designed for this purpose retrieved 1156 references. After analysis of titles and abstracts, 75 studies were selected for full-text analysis. Only randomized controlled clinical trials were selected, resulting in 28 studies included for qualitative and quantitative analysis.

RESULTS

The meta-analysis showed similar benefits in clinical response and symptom resolution between tacrolimus 0.1% and pimecrolimus 1% in comparison to topical steroids (TS). Pimecrolimus showed superior efficacy of clinical response but not for symptom resolution compared to placebo. Tacrolimus and pimecrolimus showed better performance preventing symptom relapse, while pimecrolimus also prevented clinical relapse better than TS. Cyclosporine was superior to placebo; however, TS showed better efficacy of clinical response. Thalidomide and retinoid were assessed in only one trial each, and both showed similar efficacy to TS. Rapamycin also presented similar clinical response to TS; however, the later showed greater reduction of symptoms. Mycophenolate mofetil 2% mucoadhesive was no better than placebo. No serious adverse effects have been reported. Cyclosporine showed a higher frequency and variety of adverse effects.

CONCLUSIONS

Topical tacrolimus and pimecrolimus are safe and effective alternatives for OLP treatment.

CLINICAL RELEVANCE

TS are usually the first choice for OLP treatment. Because some oral lesions may have a low response to treatment with TS, more topical therapeutic options, such as TNSIs, should be considered before systemic steroids are used.

Efficacy of topical non-steroidal immunomodulators in the treatment of oral lichen planus: a systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review was to assess the efficacy and safety of topical non-steroidal immunomodulators (TNSIs) for oral lichen planus (OLP) treatment.

MATERIALS AND METHODS

A search strategy designed for this purpose retrieved 1156 references. After analysis of titles and abstracts, 75 studies were selected for full-text analysis. Only randomized controlled clinical trials were selected, resulting in 28 studies included for qualitative and quantitative analysis.

RESULTS

The meta-analysis showed similar benefits in clinical response and symptom resolution between tacrolimus 0.1% and pimecrolimus 1% in comparison to topical steroids (TS). Pimecrolimus showed superior efficacy of clinical response but not for symptom resolution compared to placebo. Tacrolimus and pimecrolimus showed better performance preventing symptom relapse, while pimecrolimus also prevented clinical relapse better than TS. Cyclosporine was superior to placebo; however, TS showed better efficacy of clinical response. Thalidomide and retinoid were assessed in only one trial each, and both showed similar efficacy to TS. Rapamycin also presented similar clinical response to TS; however, the later showed greater reduction of symptoms. Mycophenolate mofetil 2% mucoadhesive was no better than placebo. No serious adverse effects have been reported. Cyclosporine showed a higher frequency and variety of adverse effects.

CONCLUSIONS

Topical tacrolimus and pimecrolimus are safe and effective alternatives for OLP treatment.

CLINICAL RELEVANCE

TS are usually the first choice for OLP treatment. Because some oral lesions may have a low response to treatment with TS, more topical therapeutic options, such as TNSIs, should be considered before systemic steroids are used.

Treatment options for autoimmune bullous dermatoses other than systemic steroids: A systematic review and network meta-analysis

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.

Treatment of oral lichen planus with mucoadhesive mycophenolate mofetil patch: A randomized clinical trial

Objectives

Oral lichen planus (OLP) is a chronic inflammatory disease of unknown etiology which is known as a premalignant disease. A complete cure has not been found for this condition. Mycophenolate mofetil (MMF) is a new drug that seems to be effective in improving OLP lesions. But there are no studies on the efficacy of mucoadhesive form of MMF in ulcerative OLP. Therefore, this study was performed to determine the therapeutic effect of MMF mucoadhesive on OLP lesions.

Material and methods

Twenty‐seven patients with OLP, were enrolled in two groups. All the patients were instructed to place the MMF 2% mucoadhesive on the lesion twice daily for 4 weeks. Lesion size was measured by a sterile digital caulis (mm) and the severity of burning sensation and pain by visual analogue scale (VAS; cm) at baseline and weekly follow‐ups.

Results

There was no significant difference in burning sensation and lesion size at Weeks 1, 2, and 3 in both groups. In Group A, at Week 4, there was significant reduction in pain and burning sensation and lesion size on both sides (p = .048, .012). The difference in lesion size on control sides was not significant. In Group B, at Week 4, there was significant reduction in pain and burning sensation and lesion size (p = .004). No side effects were reported by the patients.

Conclusions

Based on the results, 2% MMF mucoadhesive was effective in decreasing burning sensation and pain severity and ulcer size of ulcerative OLP and the effect was time‐dependent.

Japanese guidelines for the management of pemphigoid (including epidermolysis bullosa acquisita)

The pemphigoid group is a category of autoimmune subepidermal blistering diseases in which autoantibodies deposit linearly at the epidermal basement membrane zone (BMZ). The main subtypes of pemphigoid mediated by immunoglobulin G autoantibodies are bullous pemphigoid (BP), mucous membrane pemphigoid (MMP) and epidermolysis bullosa acquisita (EBA). To establish the first guidelines approved by the Japanese Dermatological Association for the management of pemphigoid diseases, the Committee for Guidelines for the Management of Pemphigoid Diseases (Including EBA) was founded as part of the Study Group for Rare Intractable Skin Diseases under the Ministry of Health, Labor and Welfare Research Project on Overcoming Intractable Diseases. These guidelines aim to provide current information for the management of BP, MMP and EBA in Japan. Based on evidence, the guidelines summarize the clinical and immunological manifestations, pathophysiologies, diagnostic criteria, disease severity determination criteria, treatment algorithms and treatment recommendations. Because of the rarity of these diseases, there are few clinical studies with a high degree of evidence, so several parts of these guidelines were established based on the opinions of the Committee. To further optimize these guidelines, periodic revision in line with the new evidence is necessary.

Consensus on the treatment of autoimmune bullous dermatoses: pemphigus vulgaris and pemphigus foliaceus - Brazilian Society of Dermatology

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.

Fogo selvagem: endemic pemphigus foliaceus

Fogo selvagem or endemic pemphigus foliaceus is an autoimmune acantholytic anti-cadherin bullous disease that primarily affects seborrheic areas, which might disseminate. Brazil has the world's largest number of patients, mainly in the Central-West region, but the disease has also been reported in other South American countries. It affects young people and adults who have been exposed to rural areas, with occurrence of familial cases. Anti-desmoglein-1 autoantibodies are directed against desmosomal structures, with loss of adhesion of the upper layers of the epidermis, causing superficial blisters. The etiology is multifactorial and includes genetic, immune, and environmental factors, highlighting hematophagous insect bites; drug-related factors are occasionally involved. Flaccid blisters readily rupture to yield erosive-crusty lesions that sometimes resemble seborrheic dermatitis, actinic keratosis, and chronic cutaneous lupus erythematosus. The clinical presentation varies from localized to disseminated lesions. Clinical suspicion should be confirmed with histopathological and immunofluorescence tests, among others. The progression is usually chronic, and therapy varies according to clinical presentation, but generally requires systemic corticosteroid therapy associated with adjuvant immunosuppressive treatment to decrease the adverse effects of corticosteroids. Once the disease is under control, many patients remain stable on low-dose medication, and a significant proportion achieve remission.

Evaluation of anti-desmoglein-1 and anti-desmoglein-3 autoantibody titers in pemphigus patients at the time of the initial diagnosis and after clinical remission

It has been suggested that anti-desmoglein autoantibody titers could be helpful in follow-up and therapeutic management of pemphigus patients. However, there is no consensus regarding the relationship between anti-desmoglein autoantibody titers and clinical activity of pemphigus.The aim of our study was to evaluate if clinical remission of pemphigus relates to the presence of anti-desmoglein autoantibodies.Thirty patients with pemphigus vulgaris and 7 patients with pemphigus foliaceous were included in the study. Assessment of autoantibody titers was carried out at the time of the initial diagnosis and after the clinical remission using an enzyme-linked immunosorbent assay-based assay.Our results indicate that pemphigus clinical remission did not necessarily imply a serological remission, and consequently it is necessary to establish if withdrawal of the immunosuppressive regimen in pemphigus should be based exclusively on the achievement of clinical remission or also on the serological findings.

Epidermolysis bullosa and the partnership with autoimmunity: what should we assimilate?

Bullous skin diseases are characterized by genetic abnormalities related to structural epidermal proteins or organ-specific autoantibodies against the same proteins and are revealed by blister formation on skin or mucous membranes, with differences in blister depth, morphology, and topography. Both inherited and autoimmune forms of these disorders can be framed in the context of epidermolysis bullosa. Their clinical spectrum varies from early lethal to mild variants with normal life expectancy, and several distinct phenotypes differ for age of onset, extent, location and depth of skin and mucous lesions, or scarring severity. Recently, different inflammatory processes blended with autoimmune phenomena have been demonstrated in both inherited and acquired epidermolysis bullosa, revealing that this overlapping might cause substantial implications in terms of disease course and outcome. Although several associations between epidermolysis bullosa in its different variants and autoimmune diseases have been reported, it is not yet completely clear how it happens and why this association occurs in only some patients. Autoantibodies are the primary cause of the disease in acquired epidermolysis bullosa, whereas they can be produced as a secondary event due to genetically determined skin damage in inherited epidermolysis bullosa, contributing significantly to the worsening of the disease. The awareness of this overlap may help in identifying new therapeutic approaches with immunosuppressive drugs that could have a significant impact in terms of prognosis.

Epidermolysis bullosa acquisita

The article describes present-day information on the pathogenesis, clinical picture, treatment and differential diagnostics of epidermolysis bullosa acquisita, an autoimmune skin disease caused by the production of anti-Type VII collagen autoantibodies and manifested mainly by subepidermal blisters and erosions. The authors present the results of a case study of a rare form of epidermolysis bullosa - epidermolysis bullosa acquisita in a male patient aged 53. A combined therapy with peroral prednisolone and subcutaneous injections of methotrexate had a positive effect in the form of epithelialization of most of the erosions.

Double-blind placebo-controlled trial of dapsone in antihistamine refractory chronic idiopathic urticaria

BACKGROUND

Management of antihistamine refractory chronic idiopathic urticaria (CIU) has poorly defined therapeutic options.

OBJECTIVE

To evaluate the efficacy of dapsone (4,4'-diaminodiphenylsulfone) in antihistamine refractory CIU compared with placebo.

METHODS

Twenty-two patients with antihistamine refractory CIU were randomly assigned to 100 mg of dapsone daily or placebo for 6 weeks in a 14-week double-blind, placebo-controlled crossover trial. End points were measured from a daily diary that reflected the weekly hive score, the weekly itch score, and a visual analog scale (VAS) score. Secondary to a carryover effect, the first period results were analyzed as a parallel design that compared placebo with dapsone directly by using repeated-measures analysis.

RESULTS

After 6 weeks, the patients in the dapsone arm showed mean improvement over baseline in VAS (2.3 [95% CI, 0.6-4.1], P = .01), urticaria score (-3.5 [95% CI, -6.2 to -0.9], P = .01), and itch score (-4.8 [95% CI, -7.6 to -2.1], P = .001), whereas the placebo arm showed no improvement over baseline for VAS, urticaria, or itch scores. Dapsone showed greater improvement compared with placebo for itch (P = .047) and VAS (P = .04). Of the 22 patients, 3 showed complete resolution of hives and itch with dapsone, whereas 31% and 41% had ≥ 50% resolution of hives and itch, respectively. No serious adverse effects were observed with dapsone.

CONCLUSION

To our knowledge, this is the first double-blind, placebo controlled study of dapsone in CIU and indicates that dapsone has efficacy in patients with antihistamine refractory CIU.

Pulse therapy in pemphigus: report of 11 cases

In this study, five cases of pemphigus vulgaris and two cases of pemphigus foliaceus were treated with cyclophosphamide pulse therapy associated with prednisone, resulting in the need for a smaller maintenance dose of prednisone. In three cases of pemphigus vulgaris and one case of pemphigus foliaceus, dexamethasone and cyclophosphamide pulse therapy associated with prednisone helped the lesions to heal more rapidly. Neither treatment however prevented the recurrence of the disease. Amenorrhea, myelotoxicity and Stevens-Johnson syndrome were among the cyclophosphamide side effects. All the patients treated with prednisone experienced known side effects.

Efficacy and safety of azathioprine and dapsone as an adjuvant in the treatment of bullous pemphigoid

BACKGROUND

Bullous pemphigoid is a chronic, blistering and autoimmune disease, common in old age. The treatment usually includes systemic steroids, however, these cause high morbidity rates, and then different products that function as adjuvants have been tried. At present, there are no studies to determine which adjuvant offers a better efficacy and safety profile.

METHODS

We performed a retrospective study which included the records of patients with bullous pemphigoid, treated either with azathioprine or dapsone. We evaluated the time to achieve complete remission, the time to inhibit disease progression, and the control of pruritus.

RESULTS

Fifteen records of patients were selected, eight (53%) treated with azathioprine and seven (47%) with dapsone. Complete remission was achieved at week six in both groups. We found no difference in the inhibition of disease progression (p=0.083). Pruritus was controlled at four weeks of treatment in both treatments.

CONCLUSIONS

Both products are effective as adjuvant in the treatment of bullous pemphigoid, with an acceptable safety profile.

Epidemiology of pemphigus in the western region of Turkey: retrospective analysis of 87 patients

BACKGROUND

Pemphigus is a worldwide disease and varies in its clinical profile and epidemiology in different regions of the world. The disease is rare and few epidemiological data are available.

OBJECTIVE

The purpose of this study was to evaluate the epidemiologic, clinical, and therapeutic features of pemphigus in the western region of Turkey.

METHODS

We retrospectively investigated a total of 87 patients with pemphigus. The parameters including age at diagnosis, sex, diagnostic delay, diagnostic methods, hospitalizations, distribution of skin lesions, duration and dose of therapy, side effects, and duration of follow-up were evaluated.

RESULTS

The mean age at the onset was 48 years. The average annual incidence of the disease was seven new patients and estimated annual incidence rate was 0.18 per 100,000 inhabitants. The male-to-female ratio was 1/1.64. All patients were treated with systemic corticosteroids. The mean initial dose was 100 mg prednisolone equivalent. Thirty-three (37.9%) patients received azathioprine as adjuvant therapy. The mean time to control the disease activity was 23 days in our study group. Ten patients (11.5%) were in clinical remission without treatment, 41 patients (47.1%) were on low dose steroid (≤ 10 mg daily), and 28 (32.2%) were using > 10 mg/day corticosteroid at the end of the study period.

CONCLUSION

Pemphigus vulgaris (PV) is the most common clinical subtype in the western part of Turkey. The disease is more frequent in the fifth decade of life and has a female predominance in our region. The patients with both oral mucosa and skin involvement need higher corticosteroid dose, more time to control the disease activity and longer hospitalization time when compared with the patients with oral mucosa involvement alone.

Epidermolysis bullosa acquisita: autoimmunity to anchoring fibril collagen

Epidermolysis bullosa acquisita (EBA) is a rare and acquired autoimmune subepidermal bullous disease of skin and mucosa. EBA includes various distinct clinical manifestations resembling genetic dystrophic epidermolysis bullosa (DEB), Bullous pemphigus, Brunsting-Perry pemphigoid, or cicatricial pemphigoid. These patients have autoantibodies against type VII collagen (C7), an integral component of anchoring fibrils (AFs), which are responsible for attaching the dermis to the epidermis. Destruction or perturbation of the normal functioning AFs clinically results in skin fragility, blisters, erosions, scars, milia, and nail loss, all features reminiscent of genetic dystrophic epidermolysis bullosa. These anti-C7 antibodies are "pathogenic" because when injected into a mouse, the mouse develops an EBA-like blistering disease. Currently, treatment is often unsatisfactory; however, some success has been achieved with colchicine, dapsone, photopheresis, plasmapheresis, infliximab, rituximab, and IVIG.

Epidermolysis bullosa acquisita

Epidermolysis bullosa acquisita (EBA) is a rare, acquired, chronic subepidermal bullous disease of the skin and mucosa characterized by autoantibodies to type VII collagen (C7) structures, a major component of anchoring fibrils, which attach the epidermis to the dermis. EBA patients have tissue-bound and circulating antitype C7 autoantibodies that attack type C7 and result in a reduction or perturbation of normally functioning anchoring fibrils. Patients with EBA have skin fragility, blisters, erosions, scars, milia, and nail loss, all features reminiscent of genetic dystrophic epidermolysis bullosa. These immunoglobulin G antitype C7 antibodies are pathogenic, because when they are injected into mice, the mice develop an EBA-like blistering disease. In addition to the classical mechanobullous presentation, EBA also has several other distinct clinical syndromes similar to bullous pemphigoid, Brunsting-Perry pemphigoid, or cicatricial pemphigoid. Although treatment for EBA is often unsatisfactory, some therapeutic success has been achieved with colchicine, dapsone, plasmapheresis, photopheresis, infliximab, and intravenous immunoglobulin.

Diagnosis and treatment of patients with autoimmune bullous disorders in Germany

In Germany, more than 2000 new patients per year have been calculated to be diagnosed with autoimmune blistering diseases. In a recent survey, the most frequently applied treatment regimens for bullous pemphigoid were class IV topical corticosteroids and oral prednisolone 0.5 mg or 1.0 mg/kg/d plus dapsone or azathioprine. For pemphigus, two-thirds of the clinics applied oral prednisolone at doses of 1.0 mg or 1.5 mg/kg/d and in more than 80% of departments, azathioprine was chosen as concomitant immunosuppressant. High-dose intravenous immunoglobulin, rituximab, and immunoadsorption are increasingly used for refractory patients. Treatment and diagnostic costs are covered by the health insurances when applied according to published expert recommendations.

The diagnosis and treatment of autoimmune blistering skin diseases

BACKGROUND

Autoimmune blistering skin diseases are a heterogeneous group of disorders associated with autoantibodies that are directed against desmosomal structural proteins (in pemphigus diseases) or hemidesmosomal ones (in pemphigoid diseases and epidermolysis bullosa acquisita), or else against epidermal/ tissue transglutaminases (in dermatitis herpetiformis). Knowledge of the clinical presentation of these disorders and of the relevant diagnostic procedures is important not just for dermatologists, but also for general practitioners, ophthalmologists, ENT specialists, dentists, gynecologists, and pediatricians.

METHODS

The literature on the subject was selectively reviewed. There are no existing guidelines available in Germany.

RESULTS

The recently developed sensitive and specific assays for circulating autoantibodies in these diseases now enable a serological diagnosis in about 90% of cases. The incidence of autoimmune blistering skin diseases in Germany has doubled in the last 10 years, to a current figure of about 25 new cases per million persons per year, because of improved diagnostic techniques as well as the aging of the population. Accurate and specific diagnosis is the prerequisite for reliable prognostication and appropriate treatment. For severe and intractable cases, more effective treatments have recently become available, including immunoadsorption, high-dose intravenous immunoglobulin, the anti-CD20 antibody rituximab, and combinations of the above.

CONCLUSION

The diagnostic assessment of autoimmune blistering skin diseases can be expected to improve in the near future as new serological testing systems are developed that employ recombinant forms of the target antigens. The treatments currently in use still need to be validated by prospective, controlled trials.

High-dose intravenous immunoglobulin (IVIG) therapy in autoimmune skin blistering diseases

Treatment of autoimmune bullous skin diseases can often be challenging and primarily consists of systemic corticosteroids and a variety of immunosuppressants. Current treatment strategies are effective in most cases but hampered by the side effects of long-term immunosuppressive treatment. Intravenous immunoglobulin (IVIG) is one potential promising therapy for patients with autoimmune bullous skin diseases, and evidence of its effectiveness and safety is increasing. A number of autoimmune bullous skin diseases have been identified in which IVIG treatment may be beneficial. However, experience with IVIG in patients with autoimmune skin blistering disease is limited, where it is recommended for patients not responding to conventional therapy. The mode of action of IVIG in autoimmune diseases, including bullous diseases is far from being completely understood. We here summarize the clinical evidence supporting the notion, that IVIG is a promising therapeutic agent for the treatment of patients with autoimmune bullous skin disease. In addition, we review the proposed modes of action. In the future, randomized controlled trials are necessary to better determine the efficacy and adverse effects of IVIG in the treatment of autoimmune bullous skin diseases. In addition, insights into IVIG's mode of action might enable us to develop novel therapeutics to overcome the current shortage of IVIG.

Gold: an old drug still working in refractory pemphigus

BACKGROUND

The mainstay of treatment for pemphigus is systemic corticosteroids. Different adjuvants have been used to reduce side-effects of long-term corticotherapy. Gold is an anti-inflammatory drug used in autoimmune diseases, whose use has waned with the advent of new immunosuppressive agents.

OBJECTIVE

To study the outcome of the use of intramuscular gold treatment of pemphigus vulgaris refractory to previous therapies.

METHODS

Thirteen patients with pemphigus vulgaris who had failed to respond to several prior therapies were treated with aurothiomalate, as a steroid-sparing agent. Patients were monitored to assess disease activity and gold toxicity.

RESULTS

Seven patients achieved complete remission. Four patients were able to taper prednisone doses, although pemphigus flared when prednisone was discontinued or reduced. Toxicity was observed in the other two patients.

CONCLUSIONS

In 53.4% of the patients, the use of chrysotherapy resulted in the complete clearing of the disease, discontinuation of all systemic therapies and induced a long-term clinical remission. Prednisone doses were able to be reduced in the remaining 46.6%. Any side-effects were reversible with drug discontinuation. Gold therapy showed efficacy as a secondary line treatment in refractory pemphigus vulgaris.

Chronic hepatitis B reactivation: a word of caution regarding the use of systemic glucocorticosteroid therapy

Background The potentially fatal complications associated with viral hepatitis B (HBV) reactivation have not been characterized in bullous/connective tissue disease patients receiving prolonged systemic glucocorticosteroids (GCs). Objectives This study reports HBV reactivation following GC therapy for a case series of pemphigus vulgaris and dermatomyositis. Methods The retrospective study cohort comprised 98 patients who received at least 6 months of systemic GC therapy. Results Four cases of HBV carriers with viral hepatitis flare were identified. Two patients suffered fulminant hepatitis and died, while the remaining two patients experienced recurrent hepatitis flare following antiviral medication. The mean time from the start of GCs to the time of HBV reactivation was 10.5 months. Conclusions HBV infection is an important global public health problem. Fatal HBV reactivation may occur following long-term systemic GC therapy. Given the risk of mortality, all bullous/connective tissue disease patients should be screened for serum hepatitis B markers before commencing systemic GC therapy.

Canadian consensus statement on the use of intravenous immunoglobulin therapy in dermatology

BACKGROUND

As a safe, well-tolerated, and potentially beneficial therapy, intravenous immunoglobulin (IVIG) has been increasingly used by dermatologists to treat immune-mediated skin disease. However, practical and comprehensive guidelines for the use of IVIG have yet to be established.

OBJECTIVE

To develop the first Canadian consensus statement on the use of IVIG therapy in skin disease.

METHODS

A group of Canadian dermatologists convened to discuss current issues in IVIG therapy. The participants reviewed and evaluated the literature and shared clinical experience. Using a modified Delphi process, a consensus statement was developed.

RESULTS

Herein we provide a brief overview of pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, Stevens-Johnson syndrome, and toxic epidermal necrolysis. Recommendations for the management of these diseases are detailed, and therapeutic algorithms for the treatment of various autoimmune mucocutaneous blistering diseases are presented. The appropriate use of IVIG therapy is placed in context for each disease.

CONCLUSION

Although preliminary data suggest that IVIG is a safe and effective therapy for many skin disorders, uncontrolled clinical trials, case series, and anecdotal case reports dominate the literature. Collaborative randomized controlled trials are required to firmly establish the role of IVIG in dermatology.

Therapy of autoimmune bullous diseases

Autoimmune bullous diseases result from an immune response to molecular components of the desmosome or basement membrane. Bullous diseases are associated with a high degree of morbidity and occasional mortality. Therapy of bullous diseases consists of suppressing the immune system, controlling inflammation and improving healing of erosions. The therapeutic agents used in the treatment of bullous diseases may be associated with high morbidity and occasional mortality. Successful treatment requires understanding of the pathophysiology of the disease process and the pharmacology of the drugs being used.

Bullous pemphigoid associated with hypereosinophilic syndrome: simultaneous response to imatinib

Hypereosinophilic syndrome is a myeloproliferative disorder defined by unexplained, persistent hypereosinophilia with cutaneous or systemic involvement. We describe a patient with coexistence of hypereosinophilic syndrome and bullous pemphigoid. Treatment with the novel tyrosine kinase inhibitor imatinib mesylate resulted in durable remission of hypereosinophilia and skin lesions.

Epidermolysis bullosa acquisita: diagnosis by fluorescence overlay antigen mapping and clinical response to high-dose intravenous immunoglobulin

Epidermolysis bullosa acquisita (EBA) is a chronic, subepidermal blistering disease characterized by the presence of autoantibodies to type VII collagen, located below the lamina densa of the basement membrane zone (BMZ). There is a large clinical and histological overlap between EBA and other subepidermal autoimmune bullous diseases, therefore, complex immunological techniques are required to make an accurate diagnosis. Therapy of EBA is also a difficult issue. Most patients do not respond to several common immunosuppressive agents. We describe a patient who has shown a good response to high-dose intravenous immunoglobulin therapy.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Pemphigus

Pemphigus is a rare autoimmune disease that results in blistering of the skin and oral cavity. It is caused by autoantibodies directed against cell-surface antigens on keratinocytes, which when targeted lose their cellular adhesion properties and separate from one another to form blisters within the epidermis. Differences in the particular antigens targeted by the antibodies and in the distribution of these antigens in the different regions of the body and in the separate layers of the epidermis result in different clinical manifestations of the disease. The disease is diagnosed based on its clinical manifestations (flaccid blisters and erosions on skin and oral mucosa), histology (epidermal acantholysis), and immunological abnormalities (circulating and tissue-fixed antibodies against keratinocyte surface antigens). Pemphigus, which if left untreated is almost always fatal, is generally managed with topical, oral, or intralesional corticosteroids. Other options include plasmapheresis and intravenous immunoglobulin (IVIg), coupled with cytotoxic drugs. Immunosupressants, anti-inflammatory drugs, and antibiotics are used as adjuvants, but apart from IVIg, these therapy options are non-specific and more research is needed to develop treatments with improved side-effect profiles.