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Khandpur S, Sharma P, Sharma VK, Das D, Sharma A, Bhari N, Sreenivas V. Comparison of the Clinical Efficacy of Rituximab Infusion and Dexamethasone-Cyclophosphamide Pulse Therapy and Their Effect on Serum Th1, Th2, and Th17 Cytokines in Pemphigus Vulgaris-A Prospective, Nonrandomized, Comparative Pilot Study. Indian Dermatol Online J 2024; 15:464-472. [PMID: 38845632 PMCID: PMC11152478 DOI: 10.4103/idoj.idoj_558_23] [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: 07/21/2023] [Revised: 09/15/2023] [Accepted: 10/24/2023] [Indexed: 06/09/2024] Open
Abstract
Background Rituximab infusion and dexamethasone-cyclophosphamide pulse (DCP) are the two most popular regimens used in pemphigus vulgaris (PV) in India. Objective The present study compared the clinical efficacy of rituximab and DCP in Indian PV patients and their effects on serum Th1,2, and 17 cytokine levels. Materials and Methods A total of 37 patients received DCP (Group A, n = 22) or rituximab (Group B, rheumatoid arthritis protocol (n = 15)) as per patients' preference. They were monitored for clinical response, adverse events (AEs), changes in serum anti-desmoglein-1,3 antibody titers and Th1,2 and 17 cytokine levels at baseline and weeks 20 and 52. Results The proportion of patients attaining disease control, remission, and relapse in groups A and B were 82% and 93%; 73% and 93%; and 27% and 50%, respectively, after a median duration of 2 months each for disease control; 4 and 4.5 months for remission; and 5 and 7 months for relapse post remission. The musculoskeletal AEs were the highest in the two groups. Significant and comparable decreases in anti-dsg1 and 3 titers from baseline to weeks 20 and 52 were observed in both groups. Th1 and Th17 cytokine levels decreased, while Th2 cytokines increased post-treatment in both groups. However, no correlation was found between change in body surface area of involvement by PV and anti-dsg titers and cytokine levels before and after therapy in both groups. Conclusion Comparable clinical efficacy between DCP and rituximab was observed.
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Affiliation(s)
- Sujay Khandpur
- Department of Dermatology and Venereology, AIIMS, New Delhi, India
| | - Preeti Sharma
- Department of Dermatology and Venereology, AIIMS, New Delhi, India
| | - Vinod K. Sharma
- Department of Dermatology and Venereology, Sharda University, Delhi, India
| | | | | | - Neetu Bhari
- Department of Dermatology and Venereology, AIIMS, New Delhi, India
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Ruiz S, Puebla B, Hernandez N, Rubio V, Young E, Mir H. Pemphigus Vulgaris: More Than Just a Skin Disease. Ann Plast Surg 2023; 91:62-63. [PMID: 37450862 DOI: 10.1097/sap.0000000000003589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Pemphigus is a group of autoimmune diseases of the skin and mucous membranes that is characterized by multiple bullae formation. It is caused by autoantibodies directed against the cell surface of keratinocytes, resulting in the loss of cell-cell adhesion of keratinocytes. This disease can be very debilitating and difficult to treat if large surface areas are involved. METHODS We performed a retrospective review of a complex case of pemphigus vulgaris in a 24-year-old man who develop partial-thickness skin lesions distributed throughout the entire body with a total body surface of 80% short after an episode of strep throat treated with amoxicillin. RESULTS The patient had a complicated hospital course in which the standard treatment of the disease led to adverse effects that were successfully managed at our busy burn center. CONCLUSIONS Pemphigus vulgaris is a complex skin disease in which treatment techniques carry their risk and must be tailored to the patient's specific needs. Treatment of this conditions at a burn center would be beneficial as demonstrated with conditions like Stevens-Johnson syndrome and toxic epidermal necrolysis.
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Affiliation(s)
- Samuel Ruiz
- From the Department of Surgery, Kendall Regional Medical Center
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Chu CY, Lee CH, Lee HE, Cho YT, Hsu CK, Chan TC, Hsieh SC, Wei KC. Taiwanese dermatological association (TDA) consensus for the management of pemphigus. J Formos Med Assoc 2023; 122:540-548. [PMID: 36564301 DOI: 10.1016/j.jfma.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 10/14/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
Pemphigus is an uncommon but life-threatening autoimmune blistering disease characterized by the presence of antibodies against desmogleins. Without effective treatment, pemphigus can result in significant morbidity and mortality. Existing consensus statements on pemphigus management from international medical groups provide varying guidelines, especially on treatment. Thus, on January 4, 2020, a panel of seven dermatology experts from the Taiwanese Dermatological Association (TDA) and one rheumatology expert convened to develop a consensus for the management of pemphigus. These experts with extensive experience in pemphigus management were recommended by their respective teaching hospitals and primary care clinics in Taiwan and by the TDA. The meeting reviewed the available consensus statements from international dermatology groups, including the European Dermatology Forum (EDF), the European Academy of Dermatology and Venereology (EADV), and the International Bullous Diseases Consensus Group. Using these guidelines as a basis for discussion and consensus formulation, these experts formulated their consensus statement that provides practical, concise but comprehensive recommendations as to the diagnosis, treatment, and monitoring of pemphigus patients in Taiwan. This consensus serves as a clinical reference for physicians for the management of pemphigus in Taiwan or wherever it may be applicable.
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Affiliation(s)
- Chia-Yu Chu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Chih-Hung Lee
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hua-En Lee
- Department of Dermatology, Chang Gung Memorial Hospital, Taipei Branch, Taiwan
| | | | - Chao-Kai Hsu
- Department of Dermatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tom C Chan
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Song-Chou Hsieh
- Division of Rheumatology, Immunology, and Allergy, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kai-Che Wei
- Department of Dermatology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Bhat R, Tonutti A, Timilsina S, Selmi C, Gershwin ME. Perspectives on Mycophenolate Mofetil in the Management of Autoimmunity. Clin Rev Allergy Immunol 2023:10.1007/s12016-023-08963-3. [PMID: 37338709 DOI: 10.1007/s12016-023-08963-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/21/2023]
Abstract
Before becoming a cornerstone in the treatment of numerous immune-mediated diseases, mycophenolate mofetil (MMF) was first introduced as an immunosuppressive agent in transplant immunology and later received the attention of rheumatologists and clinicians involved in the management of autoimmune diseases. MMF is now a widespread immunosuppressive drug for the treatment of several conditions, including lupus nephritis, interstitial lung disease associated with systemic sclerosis, and anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis while being efficacious also as rescue therapy in various orphan diseases, including dermatomyositis and IgA-associated nephropathy. Similarly, case reports or series support a possible use of MMF in other rare autoimmune diseases. Beyond modulating lymphocyte activation, MMF acts on other immune and non-immune cells and these effects may explain the therapeutic profile of this medication. The effects of MMF are broadly characterized by the impact on the immune system and the antiproliferative and antifibrotic changes induced. In this latter case, mechanistic data on fibroblasts may in the future allow to reevaluate the use of MMF in selected patients with inflammatory arthritis or systemic sclerosis. Attention must be paid towards the possible occurrence of adverse events, such as gastrointestinal complaints and teratogenicity, while the risk of infections and cancer related to MMF needs to be further investigated.
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Affiliation(s)
- Rithika Bhat
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, USA
| | - Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Suraj Timilsina
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, USA
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, USA.
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Rokni AM, Ayasse M, Ahmed A, Guggina L, Kantor RW, Silverberg JI. Association of autoimmune blistering disease, and specifically, pemphigus vulgaris, with cardiovascular disease and its risk factors: a systematic review and meta-analysis. Arch Dermatol Res 2023; 315:207-213. [PMID: 35262797 DOI: 10.1007/s00403-022-02346-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 10/27/2021] [Accepted: 02/23/2022] [Indexed: 01/19/2023]
Abstract
Previous studies have found conflicting results about the association of autoimmune blistering disease (AIBD) with cardiovascular disease (CVD) risk. The objective of the study was to systematically review the relationship of AIBD, including pemphigus vulgaris (PV), and its treatment with CVD and CVD risk factors. MEDLINE, EMBASE, Cochrane, LILACS, SCOPUS, and Web of Science were searched. We included all studies of CVD and CVD risk factors in AIBD patients. Two reviewers performed title and/or abstract review and data extraction. Pooled random-effects meta-analysis was performed. Forty papers met inclusion criteria. AIBD was associated with higher odds of diabetes (DM) (odds ratio [95% confidence interval]: 1.809 [1.258-2.601]), hypertension (HTN) (1.393 [1.088-1.784]), dyslipidemia (2.177 [1.163-4.073]) and heart failure (1.919 [1.603-2.298]), but was not associated with obesity, stroke, angina, heart attack, or arrhythmia. The pooled random-effects prevalence for treatment-related adverse events (AEs) in AIBD was 13.7% for DM, 10.7% for HTN, and 17.1% for CVD. Sensitivity analysis of high-quality studies revealed similar results. AIBD patients have increased CVD risk factors and heart failure. Systemic corticosteroid treatment results in CVD-related AEs in AIBD. Increased CVD screening and prevention strategies are warranted in AIBD.
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Affiliation(s)
- Alex M Rokni
- The University of Illinois at Chicago, Chicago, IL, USA
| | | | - Adnan Ahmed
- AMITA Health Saint Joseph Hospital Chicago, Chicago, IL, USA
| | - Lauren Guggina
- Departments of Medicine and Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert W Kantor
- Department of Dermatology, State University of New York Downstate Medical Center, Brooklyn, NY, USA
| | - Jonathan I Silverberg
- Department of Dermatology, the George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue NW Suite 2B-425, Washington, DC, 20037, USA.
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Kridin K, Mruwat N, Ludwig RJ. Association of Rituximab With Risk of Long-term Cardiovascular and Metabolic Outcomes in Patients With Pemphigus. JAMA Dermatol 2023; 159:56-61. [PMID: 36449276 PMCID: PMC9713679 DOI: 10.1001/jamadermatol.2022.5182] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/10/2022] [Indexed: 12/03/2022]
Abstract
Importance The association of different therapeutic approaches with long-term cardiovascular and metabolic outcomes in patients with pemphigus remains to be precisely evaluated. Objective To assess the risk of long-term cardiovascular and metabolic outcomes and all-cause mortality in patients with pemphigus managed by rituximab compared with those receiving treatment with first-line corticosteroid-sparing agents (azathioprine and mycophenolate mofetil [MMF]). Design, Setting, and Participants A global population-based retrospective cohort study compared 961 patients with pemphigus that was managed with rituximab with those treated with azathioprine or MMF (n = 961) regarding the risk of several cardiovascular and metabolic outcomes. Propensity score matching was performed to optimize comparability. Patients were enrolled from the Global Collaborative Network of TriNetX platform. Main Outcomes and Measures Risk of myocardial infarction, stroke, peripheral vascular disease, pulmonary embolism, hypertension, hyperlipidemia, type 2 diabetes, obesity, osteoporosis, and avascular bone necrosis. Results Of 1602 participants, 855 (53.4%) were women and 747 (46.6%) were men; the mean (SD) age was 54.8 (16.6) years for those treated with rituximab and 54.4 (18.2) years for those treated with azathioprine or MMF. Compared with those treated by azathioprine/MMF, patients treated with rituximab experienced a lower risk of myocardial infarction (relative risk [RR], 0.45; 95% CI, 0.24-0.86; P = .01), stroke (RR, 0.42; 95% CI, 0.26-0.69; P < .001), peripheral vascular disease (RR, 0.47; 95% CI, 0.28-0.79; P = .003), hypertension (RR, 0.48; 95% CI, 0.38-0.63; P < .001), hyperlipidemia (RR, 0.45; 95% CI, 0.32-0.64; P < .001), type 2 diabetes (RR, 0.63; 95% CI, 0.51-0.77; P < .001), obesity (RR, 0.49; 95% CI, 0.34-0.72; P < .001), and osteoporosis (RR, 0.46; 95% CI, 0.30-0.71; P < .001). The all-cause mortality was comparable between patients in both groups (hazard ratio, 0.94; 95% CI, 0.62-1.43; log-rank P = .77). Conclusions and Relevance The results of this cohort study suggest that rituximab was associated with protection against long-term cardiovascular and metabolic outcomes compared with conventional immunosuppressants. This agent might be particularly preferred in individuals with preexisting cardiovascular and metabolic risk factors.
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Affiliation(s)
- Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Unit of Dermatology and Skin Research Laboratory, Barch Padeh Medical Center, Poriya, Israel
| | - Noor Mruwat
- Unit of Dermatology and Skin Research Laboratory, Barch Padeh Medical Center, Poriya, Israel
| | - Ralf J. Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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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, Salehi Farid A, Balighi K, Mahmoudi H, Daneshpazhooh M. Exacerbation of Autoimmune Bullous Diseases After Severe Acute Respiratory Syndrome Coronavirus 2 Vaccination: Is There Any Association? Front Med (Lausanne) 2022; 9:957169. [PMID: 35928293 PMCID: PMC9344059 DOI: 10.3389/fmed.2022.957169] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/23/2022] [Indexed: 12/24/2022] Open
Abstract
Background and AimThere have been concerns regarding the potential exacerbation of autoimmune bullous diseases (AIBDs) following vaccination against COVID-19 during the pandemic. In the current study, vaccine safety was evaluated in patients with AIBDs.MethodsIn this study, patients with AIBDs were contacted via face-to-face visits or phone calls. Patient demographics, vaccine-related information, pre- and post-vaccine disease status, and complications were recorded. The exacerbation was considered either relapse in the remission/controlled phase of the disease or disease worsening in the active phase. The univariate and multivariate logistic regression tests were employed to determine the potential risk factors of disease exacerbation.ResultsOf the patients contacted, 446 (74.3%) reported receiving at least one dose of vaccine injection (54.7% female). Post-vaccine exacerbation occurred in 66 (14.8%) patients. Besides, there were 5 (1.1%) patients with AIBD diagnosis after vaccination. According to the analysis, for every three patients who received vaccines during the active phase of the disease one experienced disease exacerbation. The rate of disease exacerbation increased by three percent with every passing month from the last rituximab infusion. Active disease in the past year was another risk factor with a number needed to harm of 10.ConclusionRisk of AIBD exacerbation after the COVID-19 vaccine is not high enough to prevent vaccination. This unwanted side effect, can be reduced if the disease is controlled at the time of vaccination.
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Shah BJ, Mistry D, Shah SR. Long term efficacy and safety analysis of single cycle of biosimilar Rituximab in pemphigus: A retrospective study of 76 patients from India. Dermatol Ther 2022; 35:e15704. [PMID: 35808907 DOI: 10.1111/dth.15704] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 06/24/2022] [Accepted: 07/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pemphigus poses a therapeutic challenge and Rituximab is increasingly used in its treatment. Long term data regarding efficacy and safety of Rituximab in pemphigus is limited. METHODS This study was a retrospective analysis of 76 pemphigus patients with primary endpoint being the percentage of patients achieving complete remission (CR) on/off therapy. Secondary endpoints were time to relapse, mean cumulative dose of prednisolone after Rituximab infusion, mean duration of follow up and adverse events to Rituximab if any. RESULTS A total of 62 (82.7%) attained complete remission on/off treatment, out of which 42 were off therapy. Mean interval between first dose rituximab administration and complete remission off treatment was 6.9 ± 3.7 months. Complete remission off treatment was sustained for a mean duration of 21.4 ± 17.8 months before relapse. Over a mean follow-up duration of 42.7 ± 24.9 months (median 41, maximum 83 months), 22 of 62 patients (35.5%) who had achieved complete remission after the first cycle of rituximab relapsed. A mean total cumulative dose of 8716.3 ± 10533.8 mg prednisolone was prescribed over a mean duration of 18.05 ± 15.64 months after the first cycle of rituximab. Adverse events were noted in 18 out of 76 patients (23.7%) which included infusion reactions (n=3), minor infections (n=7), transitory disease flare (n=6) and mortality (n=2). No statistically significant correlation was found between remission/relapse rates and age, gender, pemphigus subtype or disease duration. CONCLUSION This study substantiates the long-term efficacy and safety of single cycle of Rituximab in pemphigus.
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Affiliation(s)
- Bela J Shah
- B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India
| | - Deval Mistry
- B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India
| | - Shikha R Shah
- B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India
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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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Jain K, Thakur V, Handa S, Thakur N, Shilpa, Sachdeva N, Mahajan R, De D. A randomised clinical trial to assess the adjuvant potential of methotrexate to corticosteroids in mucosal or limited mucocutaneous pemphigus vulgaris. Sci Rep 2022; 12:7525. [PMID: 35534494 PMCID: PMC9085868 DOI: 10.1038/s41598-022-11387-2] [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: 12/08/2021] [Accepted: 04/11/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractGlucocorticoids are the mainstay of treatment for pemphigus vulgaris (PV). However, the requirement of high doses for long durations often leads to serious adverse events. Methotrexate as an adjuvant has shown potential in retrospective studies but randomized trials are lacking. The objective of the study was to assess the adjuvant potential of methotrexate in mucosal/limited mucocutaneous PV. In this randomised prospective study, 44 patients with mucosal/limited mucocutaneous PV were randomised (1:1) to receive either prednisolone 1 mg/kg/day (later fixed at a maximum dose of 60 mg/day) alone or with methotrexate 0.3 mg/kg/week for 9-months study period. Prednisolone dose was tapered once there was an 80% reduction in Pemphigus Disease Activity Index. Outcome measures were total cumulative dose of prednisolone, the proportion of patients achieving disease control, time taken for disease control and remission on minimal treatment, and adverse effects. No significant difference in the total cumulative dose of prednisolone among the groups was observed (p = 0.68). Disease control was achieved in 95.5% and 86.4% of patients in the prednisolone alone group, and prednisolone and methotrexate group respectively (p = 0.61). No statistically significant difference was observed among the groups with respect to the proportion of patients achieving remission, time taken for disease control and remission, and the number of adverse events. Our study showed no additional benefit of methotrexate to prednisolone in the treatment of mucosal/limited mucocutaneous PV.Trial registration: CTRI/2018/07/015002; Registered on 23/07/2018]; Trial Registered Retrospectively. http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=24964&EncHid=&modid=&compid=%27,%2724964det%27.
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Evaluation of the toxicity of glucocorticoids in patients with autoimmune blistering disease using the Glucocorticoid Toxicity Index: A cohort study. JAAD Int 2022; 6:68-76. [PMID: 35059661 PMCID: PMC8760348 DOI: 10.1016/j.jdin.2021.09.003] [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: 09/10/2021] [Indexed: 11/22/2022] Open
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Ujiie H, Yamagami J, Takahashi H, Izumi K, Iwata H, Wang G, Sawamura D, Amagai M, Zillikens D. The pathogeneses of pemphigus and pemphigoid diseases. J Dermatol Sci 2021; 104:154-163. [PMID: 34916040 DOI: 10.1016/j.jdermsci.2021.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/22/2021] [Accepted: 11/06/2021] [Indexed: 12/21/2022]
Abstract
Autoimmune bullous diseases (AIBDs) are skin disorders which are mainly induced by autoantibodies against desmosomal or hemidesmosomal structural proteins. Previous studies using patients' samples and animal disease models identified target antigens and elucidated the mechanisms of blister formation. Pemphigus has been the subject of more active clinical and basic research than any other AIBD. These efforts have revealed the pathogenesis of pemphigus, which in turn has led to optimal diagnostic methods and novel therapies, such as rituximab. In bullous pemphigoid (BP), studies with passive-transfer mouse models using rabbit anti-mouse BP180 antibodies and studies with passive-transfer or active mouse models using autoantigen-humanized mice elucidated the immune reactions to BP180 in vivo. Recently, dipeptidyl peptidase-4 inhibitors have attracted attention as a trigger for BP. For epidermolysis bullosa acquisita (EBA), investigations using mouse models are actively under way and several molecules have been identified as targets for novel therapies. In this review, we give an overview and discussion of the recent progress in our understanding of the pathogenesis of pemphigus, BP, and EBA. Further studies on the breakdown of self-tolerance and on the identification of key molecules that are relevant to blister formation may expand our understanding of the etiology of AIBDs and lead to the development of novel therapeutic strategies.
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Affiliation(s)
- Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Jun Yamagami
- Department of Dermatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hayato Takahashi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Izumi
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Gang Wang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Daisuke Sawamura
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Detlef Zillikens
- Center for Research on Inflammation of the Skin (CRIS), University of Lübeck, Lübeck, Germany; Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany, University of Lübeck, Lübeck, Germany
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14
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Burns RD, Vetos D, Muraga R. A Case of Severe Bullous Dermatitis With Mixed Bullous Pemphigoid and Pemphigus Vulgaris Cutaneous Manifestations. Cureus 2021; 13:e20433. [PMID: 35047270 PMCID: PMC8759978 DOI: 10.7759/cureus.20433] [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] [Accepted: 12/15/2021] [Indexed: 11/05/2022] Open
Abstract
Bullous dermatoses include the rare, chronic autoimmune diseases pemphigus vulgaris and bullous pemphigoid. These diseases are traditionally taught to be differentiated by the presence of mucosal lesions (pemphigus vulgaris) and bullae without mucosal involvement (bullous pemphigoid). In the clinical setting, however, these diseases often contain overlapping features that present challenges to care teams without access to dermatologic care and leave patients without a clear treatment pathway. The ability to differentiate these two diseases clinically is imperative as it determines treatment regimens which when applied can mitigate unnecessary morbidity and mortality. Identifying these conditions clinically for the correct treatment also allows providers to rely less on laboratory assessments which are often unavailable or may take considerable time to result. This report details the clinical course of a patient who presented with an undifferentiated bullous dermatitis with features of both pemphigus vulgaris and bullous pemphigoid and aims to highlight the features of presentation which overlap between pemphigus vulgaris and bullous pemphigoid and those which are more characteristic for one over the other.
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Malik AM, Tupchong S, Huang S, Are A, Hsu S, Motaparthi K. An Updated Review of Pemphigus Diseases. Medicina (B Aires) 2021; 57:medicina57101080. [PMID: 34684117 PMCID: PMC8540565 DOI: 10.3390/medicina57101080] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 01/19/2023] Open
Abstract
Clinicians may encounter a variety of skin conditions that present with vesiculobullous lesions in their everyday practice. Pemphigus vulgaris, pemphigus foliaceus, IgA pemphigus, and paraneoplastic pemphigus represent the spectrum of autoimmune bullous dermatoses of the pemphigus family. The pemphigus family of diseases is characterized by significant morbidity and mortality. Considering the risks associated with a delayed diagnosis or misdiagnosis and the potential for overlap in clinical features and treatment, evaluation for suspected pemphigus disease often requires thorough clinical assessment and laboratory testing. Diagnosis is focused on individual biopsies for histopathology and direct immunofluorescence. Additional laboratory methods used for diagnosis include indirect immunofluorescence and enzyme-linked immunosorbent assay. Recent advancements, including anti-CD20 therapy, have improved the efficacy and reduced the morbidity of pemphigus treatment. This contribution presents updates on the pathophysiology, clinical features, diagnostic work-up, and medical management of pemphigus. Improved strategies for diagnosis and clinical assessment are reviewed, and newer treatment options are discussed.
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Affiliation(s)
- Ali M. Malik
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (A.M.M.); (A.A.)
| | - Sarah Tupchong
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA;
| | - 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; (A.M.M.); (A.A.)
| | - 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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Comparison of Guidelines for Management of Pemphigus: a Review of Systemic Corticosteroids, Rituximab, and Other Immunosuppressive Therapies. Clin Rev Allergy Immunol 2021; 61:351-362. [PMID: 34350539 DOI: 10.1007/s12016-021-08882-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2021] [Indexed: 10/20/2022]
Abstract
Pemphigus is a severe autoimmune bullous dermatosis that affects the skin and/or mucosa, and it may be life-threatening without proper treatment. The guidelines and/or consensus statements for treatment vary widely between groups. We selected 6 guidelines and consensus statements established by different associations about the management of pemphigus vulgaris (PV) and/or pemphigus foliaceus (PF) to review, compare, and contrast the similarities and differences of these recommendations and provide optimal management suggestions to physicians. Corticosteroids remain a first-line therapy for pemphigus, but there are many differences in initial dose, tapering schedule, and management of relapse between different guidelines. Rituximab is a monoclonal antibody targeting CD20-positive B lymphocytes that is approved as a first-line therapy in moderate-to-severe pemphigus. Immunosuppressive agents, such as azathioprine (AZA) and mycophenolate mofetil (MMF), are also widely used as corticosteroid-sparing drugs, but the adjuvant applications and dosage regimens of different recommendations are not standardized. We attribute these differences to the clinical scoring adopted, the standards for disease severity evaluation, the publication year of each guideline, and local and regional healthcare differences.
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17
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Intraepithelial autoimmune bullous dermatoses disease activity assessment and therapy. J Am Acad Dermatol 2021; 84:1523-1537. [PMID: 33684497 DOI: 10.1016/j.jaad.2021.02.073] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 02/19/2021] [Accepted: 02/21/2021] [Indexed: 12/30/2022]
Abstract
Intraepithelial autoimmune blistering dermatoses are a rare group of skin disorders characterized by disruptions of inter-keratinocyte connections within the epidermis through the action of autoantibodies. The second article in this continuing medical education series presents validated disease activity scoring systems, serologic parameters of disease, treatments, and clinical trials for pemphigus and its subtypes.
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18
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Zhang W, Wei S, Peng X, Xie S, Zhang Z, Zeng K, Lai K. Short-Term Intravenous Infusion of Cyclophosphamide in the Treatment of Refractory Pemphigus Vulgaris: A Retrospective Study. Dermatology 2020; 237:185-190. [PMID: 32814321 DOI: 10.1159/000508671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/14/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pemphigus is an autoimmune disease of the skin and mucous membranes. Glucocorticoids have been the most effective drug for the treatment of pemphigus; however, some patients are insensitive to glucocorticoid therapy. Cyclophosphamide has been extensively used in the treatment of pemphigus. OBJECTIVES To observe and evaluate the efficacy and safety of high-dose glucocorticoid with weekly intravenous cyclophosphamide in the treatment of refractory pemphigus vulgaris insensitive to glucocorticoids. METHODS Clinical data of 19 patients with refractory pemphigus vulgaris (insensitive to glucocorticoid) who were treated with high-dose glucocorticoids(1.5 mg/kg/day prednisone) and weekly intravenous infusion of cyclophosphamide, and 24 patients who were sensitive to glucocorticoid therapy received a medium dose of glucocorticoid alone (1 mg/kg/day prednisone) were retrospectively analyzed. RESULTS By the time the disease was brought under control, the average total dose of cyclophosphamide was 2.02 g. Comparison between the glucocorticoid-insensitive and glucocorticoid-sensitive groups showed that the average time to disease control was 2.68 vs. 2 weeks, and the average daily dosage of steroid was 1.33 ± 0.53 vs. 0.90 ± 0.28 mg/kg. At the 12- and 18-month follow-ups, the recurrence rate of the glucocorticoid-insensitive group was significantly lower than that of the sensitive group (5.3 vs. 37.5%, 15.8 vs. 45.8%). No serious adverse reactions were observed. CONCLUSION High-dose glucocorticoid plus weekly intravenous infusion of cyclophosphamide safely, effectively, and rapidly controlled the conditions of the patients with refractory pemphigus who were insensitive to glucocorticoids, shortened the duration of hospitalization, avoided the risk of complications that could be caused by further increasing the dose of glucocorticoids (>1.5 mg/kg/day), and lowered the recurrence rate within 18 months.
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Affiliation(s)
- Wenjing Zhang
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shanshan Wei
- Department of Dermatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xuebiao Peng
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shuangde Xie
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiwen Zhang
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Kang Zeng
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Kuan Lai
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, China,
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19
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Network meta-analysis-based comparison of first-line steroid-sparing adjuvants in the treatment of pemphigus vulgaris and pemphigus foliaceus. J Am Acad Dermatol 2020; 85:176-186. [PMID: 32798583 DOI: 10.1016/j.jaad.2020.08.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/05/2020] [Accepted: 08/01/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Steroid-sparing adjuvants may enhance oral glucocorticoid benefits in pemphigus treatment. Selecting the optimal therapeutic option among various first-line steroid-sparing adjuvants is often a clinical challenge due to the lack of head-to-head clinical trials. OBJECTIVE To determine the best first-line steroid-sparing adjuvants for pemphigus treatment. METHODS Randomized controlled trials comparing different steroid-sparing adjuvants in patients with pemphigus were identified through a systematic literature search and subjected to a network meta-analysis. The primary outcomes were the proportion of remission and the mean cumulative glucocorticoid dose. RESULTS Ten trials involving 592 patients were analyzed. Among the 7 steroid-sparing adjuvants evaluated, rituximab was the most effective for achieving remission and was more effective than steroid alone (odds ratio, 14.35; 95% confidence interval [CI], 4.71-43.68). Rituximab, azathioprine, and cyclophosphamide pulse therapy enabled the reduction of the cumulative glucocorticoid doses compared to the use of steroid alone: mean differences, -11,830.5 mg (95% CI, -14,089.48 to -9571.52), -3032.48 mg (-4700.74 to -1364.22), and -2469.54 mg (-4128.42 to -810.66), respectively. LIMITATIONS The results were driven primarily by a small number of studies, and the effect estimates are imprecise because of indirect comparisons. CONCLUSION Network meta-analysis showed that rituximab appears to be an efficacious, well tolerated steroid-sparing adjuvant for pemphigus.
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20
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Schmidt E, Sticherling M, Sárdy M, Eming R, Goebeler M, Hertl M, Hofmann SC, Hunzelmann N, Kern JS, Kramer H, Nast A, Orzechowski HD, Pfeiffer C, Schuster V, Sitaru C, Zidane M, Zillikens D, Worm M. S2k‐Leitlinie zur Therapie des Pemphigus vulgaris/foliaceus und des bullösen Pemphigoids: 2019 Update. J Dtsch Dermatol Ges 2020; 18:516-527. [PMID: 32413222 DOI: 10.1111/ddg.14097_g] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Enno Schmidt
- Klinik für Dermatologie, Universität zu Lübeck, Lübeck, Deutschland.,Lübecker Institut für Experimentelle Dermatologie (LIED), Universität zu Lübeck, Lübeck, Deutschland
| | | | - Miklós Sárdy
- Klinik und Poliklinik für Dermatologie und Allergologie, Klinikum der Universität München (LMU), München, Deutschland
| | - Rüdiger Eming
- Klinik für Dermatologie und Allergologie, Universitätsklinikum, Marburg, Deutschland
| | - Matthias Goebeler
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Michael Hertl
- Klinik für Dermatologie und Allergologie, Universitätsklinikum, Marburg, Deutschland
| | - Silke C Hofmann
- Zentrum für Dermatologie, Allergologie und Dermatochirurgie, Helios Klinikum Wuppertal, Wuppertal, Deutschland
| | - Nicolas Hunzelmann
- Klinik und Poliklinik für Dermatologie und Venerologie, Universität zu Köln, Köln, Deutschland
| | - Johannes S Kern
- Klinik für Dermatologie und Venerologie, Universitätsklinikum Freiburg, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | | | - Alexander Nast
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence based Medicine (dEBM), Berlin, Deutschland
| | - Hans-Dieter Orzechowski
- Gilead Sciences GmbH, Martinsried, Deutschland.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Insitut für Klinische Pharmakologie und Toxikologie, Berlin, Deutschland
| | - Christiane Pfeiffer
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Volker Schuster
- Pädiatrische Immunologie und Rheumatologie, Universitätsklinik und Poliklinik für Kinder und Jugendliche, Leipzig, Deutschland
| | - Cassian Sitaru
- Klinik für Dermatologie und Venerologie, Universitätsklinikum Freiburg, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Miriam Zidane
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence based Medicine (dEBM), Berlin, Deutschland
| | - Detlef Zillikens
- Klinik für Dermatologie, Universität zu Lübeck, Lübeck, Deutschland
| | - Margitta Worm
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Dermatologie, Venerologie und Allergologie, Allergie-Centrum, Berlin, Deutschland
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21
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Schmidt E, Sticherling M, Sárdy M, Eming R, Goebeler M, Hertl M, Hofmann SC, Hunzelmann N, Kern JS, Kramer H, Nast A, Orzechowski HD, Pfeiffer C, Schuster V, Sitaru C, Zidane M, Zillikens D, Worm M. S2k guidelines for the treatment of pemphigus vulgaris/foliaceus and bullous pemphigoid: 2019 update. J Dtsch Dermatol Ges 2020; 18:516-526. [PMID: 32413212 DOI: 10.1111/ddg.14097] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | | | - Miklós Sárdy
- Department of Dermatology and Venereology, University Hospital Munich (LMU), Munich, Germany
| | - Rüdiger Eming
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Matthias Goebeler
- Department of Dermatology, Venereology, and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps-Universität Marburg, Marburg, Germany
| | - Silke C Hofmann
- Helios University Hospital Wuppertal, Department of Dermatology, Allergology and Dermatosurgery, Wuppertal, Germany
| | - Nicolas Hunzelmann
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - Johannes S Kern
- Department of Dermatology, Medical Center, University of Freiburg, Freiburg, Germany
| | | | - Alexander Nast
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergy, Division of Evidence based Medicine (dEBM), Berlin, Germany
| | - Hans-Dieter Orzechowski
- Gilead Sciences GmbH, Martinsried, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - Christiane Pfeiffer
- Department of Dermatology and Allergology, University Hospital Ulm, Ulm, Germany
| | - Volker Schuster
- Pediatric Immunology and Rheumatology, University Hospital and Outpatient Clinic for Pediatrics, Leipzig, Germany
| | - Cassian Sitaru
- Department of Dermatology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Miriam Zidane
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergy, Division of Evidence based Medicine (dEBM), Berlin, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Margitta Worm
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergy, Allergy Center, Berlin, Germany
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22
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Autoimmune bullous skin diseases, pemphigus and pemphigoid. J Allergy Clin Immunol 2020; 145:1031-1047. [DOI: 10.1016/j.jaci.2020.02.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023]
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23
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Pires CAA, Einecke YS, Pereira NG, Costa CCC, Cunha ACDS, Moreira AG, Rodrigues FDN, Xavier MB. Therapeutic outcomes of pemphigus in a referral service in Northern Brazil: a retrospective study of 32 patients. J DERMATOL TREAT 2020; 32:1031-1034. [PMID: 31935147 DOI: 10.1080/09546634.2020.1714540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Pemphigus are rare chronic autoimmune blistering disorders with challenging therapeutic management. OBJECTIVE To investigate the therapeutic outcomes of pemphigus patients admitted to a dermatology referral service in northern Brazil. MATERIALS AND METHODS We conducted a retrospective analysis of 32 patients with histopathological diagnosis of pemphigus between 2010 and 2016. Clinical and epidemiological data were collected. Therapeutic outcome was evaluated according to the criteria proposed by the International Pemphigus Committee. Pemphigus Disease Area Index (PDAI) was used to quantify disease severity. RESULTS Of the 32 patients, 68.75% had pemphigus vulgaris (PV) and 31.25% had pemphigus foliaceus (PF). Female-to-male ratio was 1:1. The average age was 49.5 years. All patients received oral prednisone as the first-line therapy. Adjuvant immunosuppressive drugs were gradually added in refractory and/or severe cases. After 24 months of treatment, disease control and complete remission rates were 37.5% and 25%, respectively. The mortality rate was 9.37%. PDAI score was significantly lower at 24 months of therapeutic follow-up (p < .0001). CONCLUSION Therapeutic management with corticosteroids and/or immunosuppressive drugs was able to induce disease control/complete remission in most of patients. PDAI was a useful tool for objective assessment of disease severity during therapeutic follow-up.
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Affiliation(s)
| | | | | | | | | | - Amanda Gabay Moreira
- Center of Biological and Health Sciences, Pará State University (UEPA), Belém, Brazil
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24
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Cho YT, Huang YM, Wang LF, Chu CY. Maintenance therapy with azathioprine prolonged duration of remission for pemphigus patients who received rituximab as first-line or add-on therapy. J Formos Med Assoc 2020; 119:230-237. [DOI: 10.1016/j.jfma.2019.04.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/25/2019] [Accepted: 04/29/2019] [Indexed: 11/29/2022] Open
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25
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Sukanjanapong S, Thongtan D, Kanokrungsee S, Suchonwanit P, Chanprapaph K. A Comparison of Azathioprine and Mycophenolate Mofetil as Adjuvant Drugs in Patients with Pemphigus: A Retrospective Cohort Study. Dermatol Ther (Heidelb) 2019; 10:179-189. [PMID: 31865535 PMCID: PMC6994636 DOI: 10.1007/s13555-019-00346-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Azathioprine (AZA) and mycophenolate mofetil (MMF) are both first-line steroid-sparing agents used for the treatment of pemphigus in combination with a corticosteroid, but few studies to date have directly compared these two combination treatment modalities. The aim of this study was to compare the efficacy and safety of each of these agents as adjuvant therapy with the corticosteroid prednisolone for the treatment of pemphigus, using standardized outcome parameters. METHODS This was a retrospective study of patients with pemphigus who received corticosteroid therapy in combination with either AZA or MMF at the Autoimmune Blistering Skin Diseases Clinic of Ramathibodi Hospital (Bangkok) between January 2007 and July 2017. The treatment response was evaluated using early [end of the consolidation phase (ECP)] and late endpoints [complete remission (CR) on therapy, CR off therapy and immunological remission]. Cumulative steroid use, relapse rate and adverse events in each treatment group were also compared. RESULTS Of the 62 patients with pemphigus included in the study, 37 were treated with prednisolone plus AZA as adjuvant (AZA group) and 25 patients were treated with prednisolone plus MMF as adjuvant (MMF group). The majority of patients in both treatment groups reached the ECP (AZA group 88.2%; MMF group 71.4%; between-group difference not statistically significant at p = 0.156); the median time required to achieve this early endpoint was also comparable (p = 0.362). A high percentage of patients in both the AZA and MMF groups attained CR on therapy (AZA 73%; MMF 72%). The total number of patients who achieved CR on and off therapy were comparable in the two groups (p = 0.933 and p = 0.690, respectively). However, the median time for patients to achieve CR on therapy was significantly shorter for those on MMF than for those on AZA (7.3 vs. 12.5 months; p = 0.019), and the cumulative steroid dose required for patients to achieve CR both on and off therapy was significantly lower in the MMF group than in the AZA group (p = 0.007 and p = 0.043, respectively). CONCLUSION While corticosteroid in combination with either AZA or MMF is an effective therapeutic regimen for the treatment of pemphigus, MMF demonstrates a shorter time to achieve CR on therapy and has a significantly higher steroid-sparing effect.
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Affiliation(s)
- Siriorn Sukanjanapong
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital-Mahidol University, Bangkok, Thailand
| | - Darin Thongtan
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital-Mahidol University, Bangkok, Thailand
| | - Silada Kanokrungsee
- Skin Center, Srinakharinwirot University, Wattana District, Bangkok, Thailand
| | - Poonkiat Suchonwanit
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital-Mahidol University, Bangkok, Thailand
| | - Kumutnart Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital-Mahidol University, Bangkok, Thailand.
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26
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Sepandar F, Daneshpazhooh M, Djalali M, Mohammadi H, Yaghubi E, Fakhri Z, Tavakoli H, Ghaedi E, Keshavarz A, Zarei M, Shahrbaf MA, Ghandi N, Darand M, Javanbakht MH. The effect of
l
‐carnitine supplementation on serum levels of omentin‐1, visfatin and SFRP5 and glycemic indices in patients with pemphigus vulgaris: A randomized, double‐blind, placebo‐controlled clinical trial. Phytother Res 2019; 34:859-866. [DOI: 10.1002/ptr.6568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 11/03/2019] [Accepted: 11/12/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Farnaz Sepandar
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical Sciences Tehran Iran
| | - Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Department of DermatologyTehran University of Medical Sciences Tehran Iran
| | - Mahmoud Djalali
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical Sciences Tehran Iran
| | - Hamed Mohammadi
- Department of Clinical Nutrition, School of Nutrition and Food Science, Food Security Research CenterIsfahan University of Medical Sciences Isfahan Iran
| | - Elham Yaghubi
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical Sciences Tehran Iran
| | - Zahra Fakhri
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical Sciences Tehran Iran
| | - Hajar Tavakoli
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical Sciences Tehran Iran
| | - Ehsan Ghaedi
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical Sciences Tehran Iran
| | - Ali Keshavarz
- Department of Clinical Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical Sciences Tehran Iran
| | - Mahnaz Zarei
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical Sciences Tehran Iran
| | | | - Narges Ghandi
- Autoimmune Bullous Diseases Research Center, Department of DermatologyTehran University of Medical Sciences Tehran Iran
| | - Mina Darand
- Student Research Committee, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food TechnologyShahid Beheshti University of Medical Sciences Tehran Iran
| | - Mohamad Hassan Javanbakht
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical Sciences Tehran Iran
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27
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Inpatient Management of Autoimmune Blistering Diseases: an Update, Review, and Practical Guide. CURRENT DERMATOLOGY REPORTS 2019. [DOI: 10.1007/s13671-019-00272-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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28
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Yanovsky RL, McLeod M, Ahmed AR. Treatment of pemphigus vulgaris: part 1 - current therapies. Expert Rev Clin Immunol 2019; 15:1047-1060. [PMID: 31566020 DOI: 10.1080/1744666x.2020.1672535] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: While biologic agents that can be used for treating pemphigus vulgaris (PV) are increasing, themajority of the world's PV patients can afford only corticosteroids (CS) and some immunosuppressive agents (ISA). Areas covered: The spectrum of side effects encountered when PV patients receive high-dose, long-term CS and ISA are presented based on total dose and duration of therapy. The steroid-sparing effect of individual ISA as documented in published studies and their clinical outcomes, in terms of duration of remissions, frequency of relapses and time to relapse, are presented, so that comparisons are possible. Thus, rational choices can be made for the individual patient. Expert opinion: In 2019, the majority of PV patients globally will continue to be treated with CS and ISA. This review will help clinicians and patients become aware of when to anticipate which side effects and if possible, to prevent or avoid them. It provides guidelines to maximize the clinical benefits of ISA in inducing and maintaining remission and minimizing side effects by monitoring them.
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Affiliation(s)
| | - Michael McLeod
- Department of Dermatology, Tufts Medical Center , Boston , MA , USA
| | - A Razzaque Ahmed
- Department of Dermatology, Tufts Medical Center , Boston , MA , USA.,Center for Blistering Diseases , Boston , MA , USA
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29
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Bilgic A, Murrell DF. What is novel in the clinical management of pemphigus. Expert Rev Clin Pharmacol 2019; 12:973-980. [DOI: 10.1080/17512433.2019.1670059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- A. Bilgic
- Antalya Training and Research Hospital, Dermatology Clinic, University of Health Sciences, Antalya, Turkey
| | - D. F. Murrell
- St George Hospital, Department of Dermatology, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
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30
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Yaghubi E, Daneshpazhooh M, DJalali M, Mohammadi H, Sepandar F, Fakhri Z, Ghaedi E, Keshavarz SA, Balighi K, Mahmoudi H, Zarei M, Javanbakht MH. Effects of l-carnitine supplementation on cardiovascular and bone turnover markers in patients with pemphigus vulgaris under corticosteroids treatment: A randomized, double-blind, controlled trial. Dermatol Ther 2019; 32:e13049. [PMID: 31369185 DOI: 10.1111/dth.13049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/14/2019] [Accepted: 07/22/2019] [Indexed: 01/12/2023]
Abstract
Pemphigus vulgaris (PV) is a severe, bullous, autoimmune disease of the skin and mucous membranes. Corticosteroids are usually the main core treatment for controlling PV, which could lead to several side effects such as insulin resistance, osteoporosis, and cardiovascular disorders. The aim of this study is to evaluate the protective effects of l-carnitine (LC) supplementation in PV patients under corticosteroid treatment. In this randomized, double-blind, placebo-controlled clinical trial, 48 patients with PV were divided randomly into two groups to receive 2 g LC (n = 24) or a placebo (n = 24) for 8 weeks, respectively. Serum levels of osteopontin (OPN), bone morphogenic protein 4 (BMP4), cystatin C, systolic and diastolic blood pressure, 25 hydroxyvitamin D3, and LC were evaluated at the beginning and at the end of the study. LC supplementation demonstrated a significant increase in serum carnitine (p < .001). In addition, at the end of the trial, LC supplementation significantly decreased serum BMP4 (p = .003), OPN (p = .03), and cystatin C (p = .001) levels. There was no significant effect on blood pressure in comparison with the placebo. During study, no harmful side effects were reported by patients. These findings indicate that LC supplementation significantly leads to favorable changes in OPN, BMP4, and cystatin C in PV patients under corticosteroid therapy. However, further investigations are required to confirm these results.
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Affiliation(s)
- Elham Yaghubi
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Mahmoud DJalali
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Hamed Mohammadi
- Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farnaz Sepandar
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Zahra Fakhri
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Ehsan Ghaedi
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Seyed Ali Keshavarz
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Kamran Balighi
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Hamidreza Mahmoudi
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Mahnaz Zarei
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Mohammad Hassan Javanbakht
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
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31
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Gheisari M, Faraji Z, Dadras MS, Nasiri S, Robati RM, Moravvej H, Tehranchinia Z, Ghalamkarpour F, Namazi N, Nobari NN. Methylprednisolone pulse therapy plus adjuvant therapy for pemphigus vulgaris: an analysis of 10 years' experience on 312 patients. Dermatol Ther 2019; 32:e13057. [PMID: 31400243 DOI: 10.1111/dth.13057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 07/29/2019] [Accepted: 08/05/2019] [Indexed: 01/22/2023]
Abstract
Steroid pulse therapy has shown satisfactory efficacy and safety in treating pemphigus vulgaris (PV). However, there is a paucity of data about the efficacy and safety of methylprednisolone, despite its frequent administration. The aim of this study is to evaluate the efficacy and safety of steroid pulse therapy in treating PV. In this 10-year retrospective cohort study, 312 patients with PV, who had received methylprednisolone pulse therapy, were included. Data of pulse therapy sessions, adjuvant medications, dosages, remission rates, complications, and mortalities were collected from all patients. A total of 276 patients out of 312 underwent the final follow-up at least 6 months after the last session of pulse therapy. Complete remission off therapy was achieved in 83 patients (30%), and 152 patients (55%) had complete remission on therapy. About 29 (10.5%) patients had lesions of pemphigus at the time of the study follow-up, and 26.8% of remained patients were on the minimal therapy. Methylprednisolone pulse therapy could be considered as an option for proper control of PV in severe cases. It might lead to shorter periods of hospitalization and reduce the need to take long-term high-dose oral steroid therapy.
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Affiliation(s)
- Mehdi Gheisari
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Faraji
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad S Dadras
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Soheila Nasiri
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza M Robati
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamideh Moravvej
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zohreh Tehranchinia
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fariba Ghalamkarpour
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nastaran Namazi
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Niloufar N Nobari
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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32
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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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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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34
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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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35
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Toosi R, Mahmoudi H, Balighi K, Teimourpour A, Alaeen H, Shaghaghi M, Abedini R, Daneshpazhooh M. Efficacy and safety of biosimilar rituximab in patients with pemphigus vulgaris: a prospective observational study. J DERMATOL TREAT 2019; 32:33-40. [DOI: 10.1080/09546634.2019.1617831] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Roja Toosi
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Mahmoudi
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Balighi
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Teimourpour
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hoorieh Alaeen
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Shaghaghi
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Robabeh Abedini
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
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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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37
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Bullous Diseases of the Skin and Mucous Membranes. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00063-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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38
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Overton M, Culton D. Autoimmune Blistering Disorders in the Geriatric Population. CURRENT GERIATRICS REPORTS 2018. [DOI: 10.1007/s13670-018-0265-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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39
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Maderal AD, Lee Salisbury P, Jorizzo JL. Desquamative gingivitis. J Am Acad Dermatol 2018; 78:851-861. [DOI: 10.1016/j.jaad.2017.04.1140] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/30/2017] [Indexed: 10/17/2022]
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40
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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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41
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Kao J, Wang EA, Cheng MY, Ma C, Kiuru M, Maverakis E. Exuberant scale crust of the scalp. JAAD Case Rep 2018; 4:289-291. [PMID: 29693050 PMCID: PMC5911794 DOI: 10.1016/j.jdcr.2017.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jason Kao
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California
| | - Elizabeth A Wang
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California
| | - Michelle Y Cheng
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California
| | - Chelsea Ma
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California
| | - Maija Kiuru
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California.,Department of Pathology, University of California Davis School of Medicine, Sacramento, California
| | - Emanual Maverakis
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California
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42
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Seo JW, Park J, Lee J, Kim MY, Choi HJ, Jeong HJ, Lee JW, Jung SY, Kim WK. A case of pemphigus vulgaris associated with ulcerative colitis. Intest Res 2018; 16:147-150. [PMID: 29422810 PMCID: PMC5797262 DOI: 10.5217/ir.2018.16.1.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/05/2016] [Accepted: 01/02/2017] [Indexed: 12/14/2022] Open
Abstract
Pemphigus vulgaris is an autoimmune bullous disorder characterized by the production of autoantibodies against the intercellular space of the epithelium. It has rarely been reported in association with inflammatory bowel disease. Ulcerative colitis is one of the forms of inflammatory bowel disease. A 62-year-old woman who had been treated for ulcerative colitis for 16 years developed pruritic bullae on the skin of her face and body. Histological findings and direct immunofluorescence examination of the skin showed pemphigus vulgaris. She was treated with systemic steroids, mesalazine, and azathioprine. Her cutaneous lesions have remained in remission and her ulcerative colitis has remained well-controlled. The relationship between pemphigus vulgaris and ulcerative colitis is unclear. An autoimmune response has been suspected in the pathogenesis of ulcerative colitis. Pemphigus vulgaris is also associated with an autoimmune mechanism. To our knowledge, this is the first case of ulcerative colitis associated with pemphigus vulgaris reported in Korea. The association may be causal.
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Affiliation(s)
- Joo Wan Seo
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jongha Park
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Mi Young Kim
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyun Ju Choi
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Heui Jeong Jeong
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ji Woon Lee
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - So Young Jung
- Department of Dermatology, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Woo Kyeong Kim
- Department of Pathology, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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43
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Panda S, Bandyopadhyay D. Rational use of drugs in dermatology: A paradigm lost? Indian J Dermatol Venereol Leprol 2018; 84:1-5. [DOI: 10.4103/ijdvl.ijdvl_886_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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44
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Kakuta R, Yamagami J, Funakoshi T, Takahashi H, Ohyama M, Amagai M. Azathioprine monotherapy in autoimmune blistering diseases: A feasible option for mild to moderate cases. J Dermatol 2017; 45:334-339. [DOI: 10.1111/1346-8138.14173] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 11/07/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Risa Kakuta
- Department of Dermatology; Keio University School of Medicine; Tokyo Japan
| | - Jun Yamagami
- Department of Dermatology; Keio University School of Medicine; Tokyo Japan
| | - Takeru Funakoshi
- Department of Dermatology; Keio University School of Medicine; Tokyo Japan
| | - Hayato Takahashi
- Department of Dermatology; Keio University School of Medicine; Tokyo Japan
| | - Manabu Ohyama
- Department of Dermatology; Kyorin University School of Medicine; Tokyo Japan
| | - Masayuki Amagai
- Department of Dermatology; Keio University School of Medicine; Tokyo Japan
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45
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46
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Tavakolpour S. Current and future treatment options for pemphigus: Is it time to move towards more effective treatments? Int Immunopharmacol 2017; 53:133-142. [DOI: 10.1016/j.intimp.2017.10.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/18/2017] [Accepted: 10/20/2017] [Indexed: 02/07/2023]
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47
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Harman K, Brown D, Exton L, Groves R, Hampton P, Mohd Mustapa M, Setterfield J, Yesudian P, McHenry P, Gibbon K, Buckley D, Leslie T, Mallon E, Wakelin S, Ungureanu S, Hunasehally R, Cork M, Johnston G, Natkunarajah J, Worsnop F, Chiang N, Duarte Williamson C, Donnelly J, Saunders C, Brain A. British Association of Dermatologists’ guidelines for the management of pemphigus vulgaris 2017. Br J Dermatol 2017; 177:1170-1201. [DOI: 10.1111/bjd.15930] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2017] [Indexed: 12/11/2022]
Affiliation(s)
- K.E. Harman
- University Hospitals Leicester Leicester Royal Infirmary Infirmary Square Leicester LE1 5WW U.K
| | - D. Brown
- St John's Institute of Dermatology Guy's and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital Westminster Bridge Road London SE1 7EH U.K
| | - L.S. Exton
- British Association of Dermatologists Willan House, 4 Fitzroy Square London W1T 5HQ U.K
| | - R.W. Groves
- St. John's Institute of Dermatology King's College London Guy's Campus, Great Maze Pond London SE1 9RT U.K
| | - P.J. Hampton
- Royal Victoria Infirmary Queen Victoria Road Newcastle upon Tyne Tyne and Wear NE1 4LP U.K
| | - M.F. Mohd Mustapa
- British Association of Dermatologists Willan House, 4 Fitzroy Square London W1T 5HQ U.K
| | - J.F. Setterfield
- St. John's Institute of Dermatology King's College London Guy's Campus, Great Maze Pond London SE1 9RT U.K
- Mucosal & Salivary Biology Division King's College London Dental Institute Guy's Campus, Great Maze Pond London SE1 9RT U.K
| | - P.D. Yesudian
- Wrexham Maelor Hospital Croesnewydd Road Wrexham LL13 7TD U.K
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Joly P, Maho-Vaillant M, Prost-Squarcioni C, Hebert V, Houivet E, Calbo S, Caillot F, Golinski ML, Labeille B, Picard-Dahan C, Paul C, Richard MA, Bouaziz JD, Duvert-Lehembre S, Bernard P, Caux F, Alexandre M, Ingen-Housz-Oro S, Vabres P, Delaporte E, Quereux G, Dupuy A, Debarbieux S, Avenel-Audran M, D'Incan M, Bedane C, Bénéton N, Jullien D, Dupin N, Misery L, Machet L, Beylot-Barry M, Dereure O, Sassolas B, Vermeulin T, Benichou J, Musette P. First-line rituximab combined with short-term prednisone versus prednisone alone for the treatment of pemphigus (Ritux 3): a prospective, multicentre, parallel-group, open-label randomised trial. Lancet 2017; 389:2031-2040. [PMID: 28342637 DOI: 10.1016/s0140-6736(17)30070-3] [Citation(s) in RCA: 347] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/07/2016] [Accepted: 11/16/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND High doses of corticosteroids are considered the standard treatment for pemphigus. Because long-term corticosteroid treatment can cause severe and even life-threatening side-effects in patients with this disease, we assessed whether first-line use of rituximab as adjuvant therapy could improve the proportion of patients achieving complete remission off-therapy, compared with corticosteroid treatment alone, while decreasing treatment side-effects of corticosteroids. METHODS We did a prospective, multicentre, parallel-group, open-label, randomised trial in 25 dermatology hospital departments in France (Ritux 3). Eligible participants were patients with newly diagnosed pemphigus aged 18-80 years being treated for the first time (not at the time of a relapse). We randomly assigned participants (1:1) to receive either oral prednisone alone, 1·0 or 1·5 mg/kg per day tapered over 12 or 18 months (prednisone alone group), or 1000 mg of intravenous rituximab on days 0 and 14, and 500 mg at months 12 and 18, combined with a short-term prednisone regimen, 0·5 or 1·0 mg/kg per day tapered over 3 or 6 months (rituximab plus short-term prednisone group). Follow-up was for 3 years (study visits were scheduled weekly during the first month of the study, then monthly until month 24, then an additional visit at month 36). Treatment was assigned through central computer-generated randomisation, with stratification according to disease-severity (severe or moderate, based on Harman's criteria). The primary endpoint was the proportion of patients who achieved complete remission off-therapy at month 24 (intention-to-treat analysis). This study is registered with ClinicalTrials.gov, number NCT00784589. FINDINGS Between May 10, 2010, and Dec 7, 2012, we enrolled 91 patients and randomly assigned 90 to treatment (90 were analysed; 1 patient withdrew consent before the random assignment). At month 24, 41 (89%) of 46 patients assigned to rituximab plus short-term prednisone were in complete remission off-therapy versus 15 (34%) of 44 assigned to prednisone alone (absolute difference 55 percentage points, 95% CI 38·4-71·7; p<0·0001. This difference corresponded to a relative risk of success of 2·61 (95% CI 1·71-3·99, p<0·0001), corresponding to 1·82 patients (95% CI 1·39-2·60) who would need to be treated with rituximab plus prednisone (rather than prednisone alone) for one additional success. No patient died during the study. More severe adverse events of grade 3-4 were reported in the prednisone-alone group (53 events in 29 patients; mean 1·20 [SD 1·25]) than in the rituximab plus prednisone group (27 events in 16 patients; mean 0·59 [1·15]; p=0·0021). The most common of these events in both groups were diabetes and endocrine disorder (11 [21%] with prednisone alone vs six [22%] with rituximab plus prednisone), myopathy (ten [19%] vs three [11%]), and bone disorders (five [9%] vs five [19%]). INTERPRETATION Data from our trial suggest that first-line use of rituximab plus short-term prednisone for patients with pemphigus is more effective than using prednisone alone, with fewer adverse events. FUNDING French Ministry of Health, French Society of Dermatology, Roche.
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Affiliation(s)
- Pascal Joly
- Department of Dermatology, Rouen University Hospital and INSERM U1234, Centre de référence des maladies bulleuses autoimmunes, Normandie University, Rouen, France.
| | - Maud Maho-Vaillant
- Department of Dermatology, Rouen University Hospital and INSERM U1234, Centre de référence des maladies bulleuses autoimmunes, Normandie University, Rouen, France
| | | | - Vivien Hebert
- Department of Dermatology, Rouen University Hospital and INSERM U1234, Centre de référence des maladies bulleuses autoimmunes, Normandie University, Rouen, France
| | - Estelle Houivet
- Department of Biostatistics, Rouen University Hospital and INSERM U1219, Normandie University, Rouen, France
| | - Sébastien Calbo
- Department of Dermatology, Rouen University Hospital and INSERM U1234, Centre de référence des maladies bulleuses autoimmunes, Normandie University, Rouen, France
| | - Frédérique Caillot
- Department of Dermatology, Rouen University Hospital and INSERM U1234, Centre de référence des maladies bulleuses autoimmunes, Normandie University, Rouen, France
| | - Marie Laure Golinski
- Department of Dermatology, Rouen University Hospital and INSERM U1234, Centre de référence des maladies bulleuses autoimmunes, Normandie University, Rouen, France
| | - Bruno Labeille
- Department of Dermatology, University of Saint Etienne, Saint Etienne, France
| | | | - Carle Paul
- Department of Dermatology, University of Toulouse, Toulouse, France
| | - Marie-Aleth Richard
- Department of Dermatology, Assistance Publique des Hopitaux de Marseille, Aix Marseille University, UMR 911, INSERM CRO2, Marseille, France
| | - Jean David Bouaziz
- Department of Dermatology of St Louis Hospital, Paris 7 Sorbonne Paris Cité University, Paris, France
| | - Sophie Duvert-Lehembre
- Department of Dermatology, Rouen University Hospital and INSERM U1234, Centre de référence des maladies bulleuses autoimmunes, Normandie University, Rouen, France
| | | | - Frederic Caux
- Department of Dermatology, University of Paris XIII, Bobigny, France
| | - Marina Alexandre
- Department of Dermatology, University of Paris XIII, Bobigny, France
| | | | - Pierre Vabres
- Department of Dermatology Dijon University Hospital, Dijon, France
| | | | - Gaelle Quereux
- Department of Dermatology, University of Nantes, Nantes, France
| | - Alain Dupuy
- Department of Dermatology, University of Rennes, Rennes, France
| | - Sebastien Debarbieux
- Department of Dermatology, Centre Hospitalier Lyon Sud; Pierre Bénite, Lyon, France
| | | | - Michel D'Incan
- Department of Dermatology, University of Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Nathalie Bénéton
- Department of Dermatology, Le Mans General Hospital, Le Mans, France
| | - Denis Jullien
- Department of Dermatology, Edouard Herriot Hospital, Lyon Claude Bernard University, Lyon, France
| | - Nicolas Dupin
- Department of Dermatology, University of Paris V, Paris, France
| | - Laurent Misery
- Department of Dermatology, Brest University Hospital, Brest, France
| | - Laurent Machet
- Department of Dermatology, Tours University Hospital, Tours, France
| | | | - Olivier Dereure
- Department of Dermatology, University of Montpellier, Montpellier, France
| | - Bruno Sassolas
- Department of Internal Medicine, Brest University Hospital, Brest, France
| | - Thomas Vermeulin
- Department of Medical Information and Informatics, Rouen University Hospital, Rouen, France
| | - Jacques Benichou
- Department of Biostatistics, Rouen University Hospital and INSERM U1219, Normandie University, Rouen, France
| | - Philippe Musette
- Department of Dermatology, Rouen University Hospital and INSERM U1234, Centre de référence des maladies bulleuses autoimmunes, Normandie University, Rouen, France
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Abstract
Pemphigus is a group of IgG-mediated autoimmune diseases of stratified squamous epithelia, such as the skin and oral mucosa, in which acantholysis (the loss of cell adhesion) causes blisters and erosions. Pemphigus has three major subtypes: pemphigus vulgaris, pemphigus foliaceus and paraneoplastic pemphigus. IgG autoantibodies are characteristically raised against desmoglein 1 and desmoglein 3, which are cell-cell adhesion molecules found in desmosomes. The sites of blister formation can be physiologically explained by the anti-desmoglein autoantibody profile and tissue-specific expression pattern of desmoglein isoforms. The pathophysiological roles of T cells and B cells have been characterized in mouse models of pemphigus and patients, revealing insights into the mechanisms of autoimmunity. Diagnosis is based on clinical manifestations and confirmed with histological and immunochemical testing. The current first-line treatment is systemic corticosteroids and adjuvant therapies, including immunosuppressive agents, intravenous immunoglobulin and plasmapheresis. Rituximab, a monoclonal antibody against CD20+ B cells, is a promising therapeutic option that may soon become first-line therapy. Pemphigus is one of the best-characterized human autoimmune diseases and provides an ideal paradigm for both basic and clinical research, especially towards the development of antigen-specific immune suppression treatments for autoimmune diseases.
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Is There a Role for Opportunistic Infection Prophylaxis in Pemphigus? An Expert Survey. Am J Clin Dermatol 2017; 18:127-132. [PMID: 27826815 DOI: 10.1007/s40257-016-0233-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Opportunistic infections (OIs) are a dreaded adverse effect of immunosuppressive therapy, leading to the use of opportunistic infection prophylaxis (OIP) in many immunosuppressed conditions. However, guidelines for OIP in pemphigus are lacking. OBJECTIVE Our objective was to evaluate the approach of leading pemphigus experts towards OIP. METHODS We conducted an online survey of OIP trends. RESULTS The survey was completed by 33 experts. Prior to initiation of immunosuppressive therapy, 75% routinely screened for hepatitis viruses, and at least half screened for HIV or tuberculosis. Most experts (76%) prescribed OIP but to <10% of their patients, and the most frequent drugs of choice were sulfamethoxazole/trimethoprim and acyclovir. Most experts agreed that treatment with three or more immunosuppressive agents or a previous history of OIs would lead to the use of OIP that was then discontinued with cessation of immunosuppression. The arguments against OIP were the lack of evidence for its necessity and concern about side effects or emergence of resistant pathogens. The surveyed experts treated patients with severe disease in a tertiary care setting, which may have led to an overestimation of the use of OIP. Infectious disease specialists were not included. CONCLUSION Substantial disparities exist in approaches to OIP for patients with pemphigus, including the decision to treat, type of treatment, and risk stratification among pemphigus experts.
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