Treatment of pemphigus and linear IgA dermatosis with nicotinamide and tetracycline: a review of 13 cases

S2k guidelines on diagnosis and treatment of linear IgA dermatosis initiated by the European Academy of Dermatology and Venereology

INTRODUCTION

Linear IgA dermatosis (LAD) is a rare subepidermal autoimmune bullous disease (AIBD) defined by predominant or exclusive immune deposits of immunoglobulin A at the basement membrane zone of skin or mucous membranes. This disorder is a rare, clinically and immunologically heterogeneous disease occurring both in children and in adults. The aim of this project is to present the main clinical features of LAD, to propose a diagnostic algorithm and provide management guidelines based primarily on experts' opinion because of the lack of large methodologically sound clinical studies.

METHODS

These guidelines were initiated by the European Academy of Dermatology and Venereology (EADV) Task Force Autoimmune Bullous Diseases (AIBD). To achieve a broad consensus for these S2k consensus-based guidelines, a total of 29 experts from different countries, both European and non-European, including dermatologists, paediatric dermatologists and paediatricians were invited. All members of the guidelines committee agreed to develop consensus-based (S2k) guidelines. Prior to a first virtual consensus meeting, each of the invited authors elaborated a section of the present guidelines focusing on a selected topic, based on the relevant literature. All drafts were circulated among members of the writing group, and recommendations were discussed and voted during two hybrid consensus meetings.

RESULTS

The guidelines summarizes evidence-based and expert opinion-based recommendations (S2 level) on the diagnosis and treatment of LAD.

CONCLUSION

These guidelines will support dermatologists to improve their knowledge on the diagnosis and management of LAD.

Management Options for Linear Immunoglobulin A (IgA) Bullous Dermatosis: A Literature Review

Linear immunoglobulin A (IgA) bullous dermatosis (LABD) is an autoimmune condition with various triggers. Because of the lack of randomized controlled trials on LABD treatment, management options are mostly anecdotal. This paper provides a comprehensive review of treatment options from a literature review of reported treatments to arm clinicians with a guideline for the management of LABD in both pediatric and adult patients as well as those recalcitrant to first-line therapy (dapsone and steroids). We additionally illustrate an algorithm to use for the management of LABD to aid clinicians when faced with unique patient circumstances.

Mitochondrial Autoantibodies and the Role of Apoptosis in Pemphigus Vulgaris

Pemphigus vulgaris (PV) is an IgG autoantibody-mediated, potentially fatal mucocutaneous disease manifested by progressive non-healing erosions and blisters. Beyond acting to inhibit adhesion molecules, PVIgGs elicit a unique process of programmed cell death and detachment of epidermal keratinocytes termed apoptolysis. Mitochondrial damage by antimitochondrial antibodies (AMA) has proven to be a critical link in this process. AMA act synergistically with other autoantibodies in the pathogenesis of PV. Importantly, absorption of AMA inhibits the ability of PVIgGs to induce blisters. Pharmacologic agents that protect mitochondrial function offer a new targeted approach to treating this severe immunoblistering disease.

NUTRITION AND BULLOUS DISEASES

Although relatively uncommon, autoimmune bullous diseases carry the risk of increased mortality and can significantly impact quality of life. This group of diseases is broad and encompasses subepidermal conditions like bullous pemphigoid, cicatricial pemphigoid, epidermolysis bullosa acquisita, dermatitis herpetiformis, and linear IgA bullous dermatosis, as well as intraepidermal conditions like pemphigus and its variants. The pathophysiology of each condition is incompletely understood but broadly involves the formation of autoantibodies targeting skin adhesion proteins, a process which relies on a complex interplay between a dysregulated immune system, genetic predisposition, and environmental factors. We review the impact of nutrition on pathogenesis, clinical course, and treatment of various autoimmune bullous diseases.

Subepithelial autoimmune bullous dermatoses disease activity assessment and therapy

Subepidermal (subepithelial) autoimmune blistering dermatoses are a group of rare skin disorders characterized by the disruption of the dermal-epidermal junction through the action of autoantibodies. The fourth article in this continuing medical education series presents the current validated disease activity scoring systems, serologic parameters, treatments, and clinical trials for bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, bullous systemic lupus erythematosus, anti-p200 pemphigoid, linear IgA bullous dermatosis, and dermatitis herpetiformis.

Intraepithelial autoimmune bullous dermatoses disease activity assessment and therapy

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.

Linear immunoglobulin A dermatosis: A case report

We present the case of a sixty five year old woman with two months history of pruritus and hyperpigmented annular lesions on the trunk, buttocks and upper extremities. In addition, she presents vesicles with healthy skin on the basis, in the flexor aspect of wrists. No evidence of mucosal involvement. Histological study showed subepidermal vesicular dermatitis with inflammatory infiltrate of neutrophils and eosinophils. Direct immunofluorescence evidenced linear and continuous deposition of immunoglobulin A in basement membrane zone, compatible with linear immunoglobulin A disease.

Paraneoplastic Pemphigus and Autoimmune Blistering Diseases Associated with Neoplasm: Characteristics, Diagnosis, Associated Neoplasms, Proposed Pathogenesis, Treatment

Autoimmune paraneoplastic and neoplasm-associated skin syndromes are characterized by autoimmune-mediated cutaneous lesions in the presence of a neoplasm. The identification of these syndromes provides information about the underlying tumor, systemic symptoms, and debilitating complications. The recognition of these syndromes is particularly helpful in cases of skin lesions presenting as the first sign of the malignancy, and the underlying malignancy can be treated in a timely manner. Autoimmune paraneoplastic and neoplasm-associated bullous skin syndromes are characterized by blister formation due to an autoimmune response to components of the epidermis or basement membrane in the context of a neoplasm. The clinical manifestations, histopathology and immunopathology findings, target antigens, associated neoplasm, current diagnostic criteria, current understanding of pathogenesis, and treatment options for a selection of four diseases are reviewed. Paraneoplastic pemphigus manifests with clinically distinct painful mucosal erosions and polymorphic cutaneous lesions, and is often associated with lymphoproliferative neoplasm. In contrast, bullous pemphigoid associated with neoplasm presents with large tense subepidermal bullae of the skin, and mild mucosal involvement, but without unique clinical features. Mucous membrane pemphigoid associated with neoplasm is a disorder of chronic subepithelial blisters that evolve into erosions and ulcerations that heal with scarring, and involves stratified squamous mucosal surfaces. Linear IgA dermatosis associated with neoplasm is characterized by annularly grouped pruritic papules, vesicles, and bullae along the extensor surfaces of elbows, knees, and buttocks. Physicians should be aware that these autoimmune paraneoplastic and neoplasm-associated syndromes can manifest distinct or similar clinical features as compared with the non-neoplastic counterparts.

Management of Pemphigus Vulgaris

INTRODUCTION

Pemphigus vulgaris (PV) is a chronic, autoimmune, vesiculobullous disease. As a result of the relative rarity of PV, published randomized controlled trials (RCTs) are limited, which makes it difficult to evaluate the efficacy of different treatment regimens in this disease. This also precludes conduct of a meta-analysis.

METHODS

English-language publications describing treatment outcomes of patients with PV were identified by searches of electronic databases through May 2015, and additionally by review of the bibliography of these publications. A total of 89 papers, which included 21 case reports, 47 case series, 8 RCTs, and 13 observational studies, were identified. The findings from these publications, including information on disease course and prognosis, medications used, treatment responses, and side effects, are summarized in the tables and text of this review.

RESULTS

Prior to availability of corticosteroid therapy, PV had a high fatality rate. Early publications from the 1970s reported high-dose, prolonged corticosteroid use and significant associated side effects. Later reports described use of corticosteroids along with steroid-sparing adjuvants, which allows a reduction in the total dose of corticosteroids and a reduction in observed mortality and morbidity. For the majority of patients in these reports, a long-term course on medications lasting about 5-10 years was observed; however, subgroups of patients requiring shorter courses or needing longer-term therapy have also been described. Early diagnosis of PV and early initiation of treatment were prognostic factors. In recent publications, commonly used initial regimens include corticosteroids in combination with mycophenolate or azathioprine; whereas, for patients with inadequate response to these regimens, adjuvants such as intravenous immunoglobulin (IVIg) or rituximab are used.

CONCLUSION

The review findings emphasize the importance of early diagnosis, early initiation of treatment, and use of steroid-sparing adjuvants to allow a reduced total dose and duration on corticosteroids. Also highlighted is the need for more RCTs.

Mechanisms of mitochondrial damage in keratinocytes by pemphigus vulgaris antibodies

The development of nonhormonal treatment of pemphigus vulgaris (PV) has been hampered by a lack of clear understanding of the mechanisms leading to keratinocyte (KC) detachment and death in pemphigus. In this study, we sought to identify changes in the vital mitochondrial functions in KCs treated with the sera from PV patients and healthy donors. PV sera significantly increased proton leakage from KCs, suggesting that PV IgGs increase production of reactive oxygen species. Indeed, measurement of intracellular reactive oxygen species production showed a drastic increase of cell staining in response to treatment by PV sera, which was confirmed by FACS analysis. Exposure of KCs to PV sera also caused dramatic changes in the mitochondrial membrane potential detected with the JC-1 dye. These changes can trigger the mitochondria-mediated intrinsic apoptosis. Although sera from different PV patients elicited unique patterns of mitochondrial damage, the mitochondria-protecting drugs nicotinamide (also called niacinamide), minocycline, and cyclosporine A exhibited a uniform protective effect. Their therapeutic activity was validated in the passive transfer model of PV in neonatal BALB/c mice. The highest efficacy of mitochondrial protection of the combination of these drugs found in mitochondrial assay was consistent with the ability of the same drug combination to abolish acantholysis in mouse skin. These findings provide a theoretical background for clinical reports of the efficacy of mitochondria-protecting drugs in PV patients. Pharmacological protection of mitochondria and/or compensation of an altered mitochondrial function may therefore become a novel approach to development of personalized nonhormonal therapies of patients with this potentially lethal autoimmune blistering disease.

Treatment of chronic bullous disease of childhood

Chronic bullous disease of childhood (CBDC) is generally a self-limited disease of prepubescent children that resolves within months to years. However, as discussed in the previous issue of Dermatologic Clinics, the disease is associated with significant morbidity and usually requires systemic therapy. Treatment is aimed at controlling blistering while avoiding adverse reactions. There are several anecdotal reports of treatment options, but controlled or comparative studies are lacking. This article discusses the management options of CBDC in more detail.

Muscarinic receptor agonists and antagonists: effects on keratinocyte functions

The stratified epithelium enveloping the skin and lining the surfaces of oral and vaginal mucosa is comprised by keratinocytes that synthesize, secrete, degrade, and respond to acetylcholine via muscarinic and nicotinic receptors. The two pathways may compete or synergize with one another, so that net biologic effect represents the biologic sum of the effects of distinct acetylcholine receptors expressed by a keratinocyte at a particular stage of its development. Keratinocytes express a unique combination of muscarinic receptor subtypes at each stage of their development. Experimental results indicate that muscarinic receptors expressed in human keratinocytes regulate their viability, proliferation, migration, adhesion, and terminal differentiation, hair follicle cycling, and secretion of humectants, cytokines, and growth factors. Learning the muscarinic pharmacology of keratinocyte development and functions has salient clinical implications for patients with nonhealing wounds, mucocutaneous cancers, and various autoimmune and inflammatory diseases. Successful therapy of pemphigus lesions with topical pilocarpine and disappearance of psoriatic lesions due to systemic atropine therapy illustrate that such therapeutic approach is feasible.

Pemphigus autoimmunity: hypotheses and realities

The goal of contemporary research in pemphigus vulgaris and pemphigus foliaceus is to achieve and maintain clinical remission without corticosteroids. Recent advances of knowledge on pemphigus autoimmunity scrutinize old dogmas, resolve controversies, and open novel perspectives for treatment. Elucidation of intimate mechanisms of keratinocyte detachment and death in pemphigus has challenged the monopathogenic explanation of disease immunopathology. Over 50 organ-specific and non-organ-specific antigens can be targeted by pemphigus autoimmunity, including desmosomal cadherins and other adhesion molecules, PERP cholinergic and other cell membrane (CM) receptors, and mitochondrial proteins. The initial insult is sustained by the autoantibodies to the cell membrane receptor antigens triggering the intracellular signaling by Src, epidermal growth factor receptor kinase, protein kinases A and C, phospholipase C, mTOR, p38 MAPK, JNK, other tyrosine kinases, and calmodulin that cause basal cell shrinkage and ripping desmosomes off the CM. Autoantibodies synergize with effectors of apoptotic and oncotic pathways, serine proteases, and inflammatory cytokines to overcome the natural resistance and activate the cell death program in keratinocytes. The process of keratinocyte shrinkage/detachment and death via apoptosis/oncosis has been termed apoptolysis to emphasize that it is triggered by the same signal effectors and mediated by the same cell death enzymes. The natural course of pemphigus has improved due to a substantial progress in developing of the steroid-sparing therapies combining the immunosuppressive and direct anti-acantholytic effects. Further elucidation of the molecular mechanisms mediating immune dysregulation and apoptolysis in pemphigus should improve our understanding of disease pathogenesis and facilitate development of steroid-free treatment of patients.

Approach to the patient with autoimmune mucocutaneous blistering diseases

Autoimmune mucocutaneous blistering diseases (AMBD) are a rare group of dermatoses that can be potentially fatal. There are many subtypes and their clinical presentation can vary from being localized to general involvement. It is crucial that a diagnosis be made as early as possible and appropriate treatments are implemented. This article will discuss the diagnosis and available treatments of the major AMBDs. There are very few case-controlled studies regarding the treatments of these diseases. Most of the treatments used for these diseases are based on anecdotal reports. Hence, a synopsis of the conventional treatments and some brief recommendations will also be discussed. A brief discussion regarding "rescue" therapies that have been used for those patients with more recalcitrant cases of AMBD will also be presented.

Cleavage isn't everything: potential novel mechanisms of exfoliative toxin-mediated blistering

This Commentary describes breakthroughs in understanding the interactions between desmoglein 1 and plakogloben in staphylococcal-mediated blistering skin diseases.

Tetracycline and niacinamide control bullous pemphigoid but not pemphigus foliaceus when these conditions coexist

Pemphigus and pemphigoid are different types of autoimmune bullous disease and can occur in the same patient. We report a female patient with this condition. At first, we diagnosed her with bullous pemphigoid, and we treated her with tetracycline, niacinamide and a topical steroid. Tense bullas disappeared shortly after that, but crusted erythemas mainly on her head and trunk persisted. We examined BP180 and desmoglein 1 enzyme-linked immunosorbent assays, and also histological features, which showed coexistence of bullous pemphigoid and pemphigus foliaceus concurrently. Therefore, we tried prednisolone, which could control both conditions. This case showed that tetracycline and niacinamide could control bullous pemphigoid, but could not control pemphigus foliaceus, and that prednisolone was effective for both conditions.

Pemphigus in the XXI Century: New life to an old story

In this new century of pemphigus research, the search for novel treatments is switching from a monospecific approach, focused on immunosuppression, to a polyspecific approach that includes drugs acting on novel pathophysiologic pathways. Current research argues that acantholysis in pemphigus occurs as an active process resulting from intracellular signaling triggered as a result of IgG binding to the keratinocyte membrane antigens in a receptor-ligand fashion. Recent progress regarding the pathophysiology of pemphigus acantholysis led to, or was accompanied by, breakthrough discoveries of safer treatments. Both the identification of cell-surface receptors to acetylcholine among the nondesmoglein (Dsg) targets for pemphigus antibodies, and the elucidation of the cholinergic control of keratinocyte cell adhesion provide an explanation for the therapeutic efficacy of cholinomimetics in patients with pemphigus. In patients' skin, Fas-L, TNFalpha, and, probably, IL-1alpha act as autocrine/paracrine co-factors for anti-keratinocyte IgG. Thus, it appears that an array of interconnected signaling cascades is responsible for acantholysis and cell death in pemphigus. Future studies should define the signaling pathways mediating acantholysis that occur in individual pemphigus patients and identify the membrane proteins (receptors) triggering signaling along a specific pathway upon their ligation by autoantibodies. It will be important to determine which pathway 1) leads directly to a loss of cell-cell adhesion (primary pathway), 2) which is being activated due to cell shrinkage/detachment (secondary pathway), 3) which contributes to utilization of altered proteins and organelles (scavenging pathway), and 4) which represents the cell defense (protective pathway). To dissect out the signaling pathways originating from binding of pemphigus IgG to non-Dsg targets on the keratinocyte plasma membrane experiments should be performed in cultures of murine keratinocytes grown from the Dsg3-/- mice or human keratinocytes with the knocked-down expression of the Dsg1 and/or Dsg3 gene by the RNA interference.

Significance of autoimmunity to non-desmoglein targets in pemphigus

The pathogenesis of pemphigus vulgaris (PV) is a highly controversial, "hot" topic that has received considerable enrichment in recent years by both clinical and basic researchers. On the one hand, the classical view of desmogleins (Dsg) as main targets of this autoimmune disease is supported by the characterization of pathogenic anti-Dsg3 antibodies from both patients and animal models. On the other hand, fundamental doubt has been raised towards this monopathogenic view by several independent factors: (1) pemphigus lesions can be induced in Dsg3-knockout (KO) mice; (2) pemphigus sera contain multiple autoantibodies against different adhesion molecules and also cholinergic receptors; (3) experimental inhibition of PV IgG induced acantholysis can be obtained by interference with different signaling cascades regulating both calcium homeostasis and apoptosis; and (4) cholinergic agonists exhibit anti-acantholytic activity both in vitro and in vivo. The field is open for controlled clinical trials and further basic research to unfold the true story of the pemphigus enigma and provide the basis for a better treatment of pemphigus patients.

Pemphigus vulgaris and paraneoplastic pemphigus

The history, epidemiology, pathophysiology, clinical presentation, diagnostic work-up, histopathology, and treatment of PV and PNP have been presented. These life-threatening, autoimmune, mucocutaneous bullous conditions may be encountered first by oral health providers and, therefore, deserve keen understanding and attention by the oral and maxillofacial surgeon. Great diagnostic and management strides have been made, but morbidity and life quality issues remain a reality for these chronically ill patients.

Is erythromycin an effective treatment for chronic bullous disease of childhood? A national survey of members of the British Society for Paediatric Dermatology

Chronic bullous disease of childhood is the commonest acquired blistering disorder of children. Erythromycin has been reported to be beneficial for this condition. A three question survey was e-mailed to all members of the British Society for Paediatric Dermatology to assess the incidence, preferred treatments and experience of oral erythromycin in treating chronic bullous disease of childhood. A second, more detailed questionnaire was sent to members who had used erythromycin. Forty patients were reported to have been treated over the previous 2 years. The preferred treatment was dapsone. Erythromycin alone had been used in five children as first-line oral treatment. In three of these patients the initial improvement was graded as either "good" or "complete resolution." This benefit was only sustained in one child, with the other two relapsing between 4 and 12 weeks. In a further eight children, erythromycin had been used with other oral agents. In five of these children, erythromycin was associated with long-term benefit. These results suggest that erythromycin is unlikely to produce sustained improvement in chronic bullous disease of childhood when used as a sole first-line agent. However, erythromycin can cause an initial improvement, which may be useful whilst awaiting results of diagnostic tests and may confer benefit when used with other systemic treatments.

Differential coupling of M1 muscarinic and alpha7 nicotinic receptors to inhibition of pemphigus acantholysis

The mechanisms mediating and regulating assembly and disassembly of intercellular junctions is a subject of intensive research. The IgG autoantibodies produced in patients with the immunoblistering skin disease pemphigus vulgaris (PV) can induce keratinocyte (KC) dyshesion (acantholysis) via mechanisms that involve signaling kinases targeting intercellular adhesion molecules, thus providing a useful model to study the physiologic regulation of KC cohesion. Previous studies showed that activation of Src and protein kinase C are the earliest events in the PV IgG-induced intracellular phosphorylation cascades and that cholinergic agonists are effective for treating patients with pemphigus. In this study, we sought to elucidate the molecular mechanisms allowing cholinergic agonists to inhibit PV IgG-induced acantholysis and phosphorylation of KC adhesion molecules. The extent of acantholysis in KC monolayers correlated closely with the degree of PV IgG-induced phosphorylation of p120- and beta-catenins, with classic isoforms of protein kinase C mediating serine phosphorylation of beta-catenin and Src-tyrosine phosphorylation of p120-catenin. The M(1) muscarinic agonist pilocarpine blocked phosphorylation of both catenins, which could be abolised by the M(1) antagonist MT7. The alpha7 nicotinic agonist AR-R17779 inhibited phosphorylation of P120-cateinin. The alpha7 antagonist methyllycaconitine abolished the effect of AR-R17779. Okadaic acid abrogated protective effects of agonists on phosphorylation of beta-catenin, and pervanadate, on that of p120-catenin. Stimulation of KCs with pilocarpine significantly (p < 0.05) elevated both serine/threonine and tyrosine phosphatase activities in KCs. AR-R17779 both stimulated tyrosine phosphatase and decreased PV IgG-induced Src activity. Methyllycaconitine released Src activity in intact KCs and caused acantholysis. Thus, downstream signaling from M(1) abolished PV IgG-dependent catenin phosphorylation due to activation of both serine/threonine and tyrosine phosphatases, whereas alpha7 action involved both activation of tyrosine phosphatase and inhibition of Src. These findings identified novel paradigm of regulation of signaling kinases associated with cholinergic receptors and provided mechanistic explanation of therapeutic activity of cholinomimetics in PV patients.

Pemphigus and associated environmental factors: a case?control study

BACKGROUND

Recent reports have revealed the relatively high incidence of pemphigus in Iran. Occupational exposure and personal habits have been suggested to play a role in the aetiopathogenesis of this life-threatening disease.

AIM

In order to analyse the association of environmental factors with pemphigus, we conducted a case-control study to evaluate the possible role of smoking, pesticide exposure and hormonal factors in Iran.

METHODS

This study was conducted in Iran using a structured questionnaire. Questions included information on patients' smoking habits, occupational exposure to pesticides, use of oral contraception (OC) and number of pregnancies.

RESULTS

We enrolled 210 patients with pemphigus and 205 control subjects. Fewer of patients with pemphigus (17.1%) reported a current or past history of smoking, which was statistically different from the control group (27.3% smokers). The duration of smoking and the number of cigarettes smoked daily was also significantly lower in patients. Although OC use was significantly higher in women with pemphigus, the mean number of pregnancies was not different between the two groups. Occupational exposure to pesticides was significantly higher in patients with pemphigus (14.8%) than in controls (5.4%); patients with pemphigus were exposed to pesticides three times more often than were healthy subjects.

CONCLUSION

As a positive history of smoking was lower in patients with pemphigus compared with healthy subjects, it seems that smoking is a protective factor in pemphigus. This should encourage further investigations, searching for novel therapies. If pesticides and OC are confirmed as triggering factors, their cessation might reduce the need for pharmacological therapy.

Pemphigus: a treatment update

Pemphigus is a group of rare autoimmune mucocutaneous bullous diseases with potential significant morbidity and mortality. The two main subtypes are pemphigus vulgaris (PV) and pemphigus foliaceus (PF). Systemic corticosteroid use and other advances in management have dramatically decreased the mortality rate for pemphigus. At present, the primary cause of morbidity and mortality is complications from treatment. Thus, the goal of pemphigus management is to induce and maintain remission with the lowest possible doses of medication and with the fewest side effects. Although our scientific knowledge of pemphigus is advancing and our treatment options are expanding, there are still very few randomized, controlled studies to evaluate the true effectiveness of the available therapies. Here we review the available treatment options and novel therapies for pemphigus and the supporting data.

Cholinergic control of epidermal cohesion

The non-neuronal cholinergic system of human epidermis includes the keratinocyte (KC) acetylcholine (ACh) axis composed of the enzymes mediating ACh synthesis and degradation, and two classes of ACh receptors, the nicotinic and muscarinic ACh receptors, mediating biological effects of the cutaneous cytotransmitter ACh. Regulation of KC cell-cell and cell-matrix adhesion is one of the important biological functions of cutaneous ACh. The downstream targets of ACh effects mediated by distinct ACh receptor subtypes include both the intercellular adhesion molecules, such as classical and desmosomal cadherins, and integrins mediating KC adhesion to a substrate. The signaling pathways include activation or inhibition of kinase cascades resulting in either up- or down-regulation of the expression of cell adhesion molecules or changes in their phosphorylation status, or both. The components of the KC ACh axis are involved in cutaneous blistering in patients with autoimmune pemphigus, junctional and dystrophic forms of epidermolysis bullosa, thermal burns, and mustard-induced vesication. Recent progress with the development of antiacantholytic therapies of patients with pemphigus using cholinomimetics indicates that cholinergic drugs may be a promising approach for other cutaneous blistering disorders.

Use of intravenous immunoglobulin therapy in autoimmune blistering diseases

Autoimmune mucocutaneous blistering diseases (AMBD) are an interesting group of rare diseases that affect the mucous membranes and the skin and are frequently or potentially fatal. The clinical presentation is significantly variable, as is the course and prognosis. The immunopathology is well characterized and the target antigens to which the autoantibodies are directed have been studied by various investigators. A significant majority of the patients respond to conventional therapy, which consists of high-dose long-term systemic corticosteroids and immunosuppressive agents. This treatment program has significantly improved the prognosis in many patients. In such patients, significant side effects of the drugs may appear and produce a very poor quality of life. In patients with progressive diseases, especially those with mucous membrane pemphigoid, the significant sequela; such as blindness, aphonia, and stenosis of the anal and vaginal canals can occur. In several patients treated with conventional immunosuppressive therapy, death occurs as a consequence of prolonged immune suppression leading to opportunistic infections. In this manuscript, the published data on the use of immunoglobulins intravenous (IGIV) in patients with AMBD is presented. The most important features of IGIV in patients with AMBD are: 1) the ability to clinically control the disease; 2) the ability to induce and maintain a long-term clinical remission; 3) a lower incidence of side effects; and 4) a higher quality of life. The important characteristic of the IGIV therapy in the AMBD is two-fold. First, the therapy, when given according to a published protocol, produces a lasting and long-term clinical remission, rather than a temporary arrest of the disease. Second, the therapy, as described in the protocol, has a very definitive endpoint. Consequently, once the patients are treated and go into long-term remission, the therapy is no longer required. The significant positive results obtained with IGIV are to a large extent also due to the associated aggressive topical therapy that was used and the frequent use of sublesional injections with triamcinolone. The rapid and early detection of cutaneous and mucosal infections and their treatment with systemic antibiotics is also a very important feature of IGIV therapy. When patients are under long-term conventional therapy, the infections are often not detected because they lack the ability to mount signs of inflammation. It is also becoming increasingly clear for patients to have a successful outcome, in treatment with IGIV therapy, it is critical that the physician spends a significant amount of time with each patient, monitor the therapy closely, and be familiar with the overall health of the patient. It is also best if the therapies are instituted by a physician who has significant interest and experience in blistering diseases and IGIV therapy.

Tetracyclines: nonantibiotic properties and their clinical implications

Tetracyclines are broad-spectrum antibiotics that act as such at the ribosomal level where they interfere with protein synthesis. They were first widely prescribed by dermatologists in the early 1950s when it was discovered that they were effective as a treatment for acne. More recently, biologic actions affecting inflammation, proteolysis, angiogenesis, apoptosis, metal chelation, ionophoresis, and bone metabolism have been researched. The therapeutic effects of tetracycline and its analogues in various diseases have also been investigated. These include rosacea, bullous dermatoses, neutrophilic diseases, pyoderma gangrenosum, sarcoidosis, aortic aneurysms, cancer metastasis, periodontitis, and autoimmune disorders such as rheumatoid arthritis and scleroderma. We review the nonantibiotic properties of tetracycline and its analogues and their potential for clinical application.

Treatment of pemphigus vulgaris. An overview in Mexico

Pemphigus is an autoimmune skin disease that can present in a variety of forms and can prove challenging to manage and treat. An overview of the condition in Mexico is presented. Emphasis is placed on management of the condition, with description of the most commonly used treatments (glucocorticoids, azathioprine), the second line therapies (cyclosporine and mycophenolate mofetil), and additional alternative treatments (cyclophosphamide and dapsone).

Current use of anti-infectives in dermatology

Dermatologic diseases encompass a broad category of pathologic situations. Infection remains a significant aspect of the pathology faced in patient encounters, and it is natural to expect that anti-infectives play a major element in the armamentarium utilized by dermatologists. Aside from the treatment of the classic bacterial and fungal infections, there are now new uses for antiviral agents to help suppress recurrent disease, such as herpes simplex. There is also the novel approach of using anti-infectives, or agents that have been thought to have antimicrobial activity, to treat inflammatory diseases. This review describes anti-infectives, beginning with common antibiotics used to treat bacterial infections. The discussion will then cover the current use of antivirals. Finally, the description of antifungals will be separated, starting with the oral agents and ending with the topical antimycotics. The use of anti-infectives in tropical dermatology has been purposefully left out, and perhaps should be the subject of a separate review. Cutaneous bacterial infections consist chiefly of those microorganisms that colonize the skin, such as species of staphylococcus and streptococcus. Propionibacterium acnes and certain other anaerobes can be involved in folliculitis, pyodermas and in chronic conditions such as hidradenitis suppurativa.

Treatment of autoimmune mucocutaneous blistering diseases with intravenous immunoglobulin therapy

Autoimmune mucocutaneous blistering diseases (AMBDs) are a group of rare diseases that affect the skin and mucous membranes and are potentially fatal. They have variable clinical presentation, course and prognosis. Their immunopathology is well-characterised and target antigens have been studied. Many patients respond to conventional therapy, which consists of high-dose long-term systemic corticosteroids with an immunosuppressive agent, but side effects develop that can produce a poor quality of life. Many patients develop significant sequelae, such as blindness, loss of voice, vaginal and anal stenosis. In most patients cause of death is opportunistic infections secondary to immune suppression. To date, intravenous immunoglobulin (IVIg) has been reported to have benefited 156 patients with AMBDs. Its most important features include the ability to reduce or eliminate conventional therapy, the enabling of clinical control, the ability to induce and maintain long-term clinical remission, the capacity for usage based on a defined protocol with a described end point and a resulting increase in quality of life. IVIg produces the best clinical outcome when combined with aggressive topical therapy, sublesional injections of triamcinolone and rapid detection, and early treatment of cutaneous and mucosal infection. Successful therapy requires a physician to spend significant time with each patient. This manuscript provides the opinion of the author on the current use of IVIg to treat AMBDs.