Bullous eruption of systemic lupus erythematosus

Successful treatment of bullous lupus with corticosteroids and belimumab: A case report

Cutaneous lupus erythematosus (CLE) is one of the most common manifestations of systemic lupus erythematosus (SLE), although it can manifest as an independent entity as well. Bullous systemic lupus erythematosus (BSLE) is a rare cutaneous manifestation of SLE presenting as tense vesiculobullous eruptions in a photosensitive distribution. Pathophysiology is secondary to autoantibodies against noncollagenous domain 1 and 2 (NC1 and NC2) type VII collagen, and histopathology reveals dense neutrophilic infiltration of the dermis with direct immunofluorescence showing IgG deposition at dermoepidermal junction. There is lack of data on available therapeutic options to treat BSLE, and varying responses to dapsone, methotrexate, azathioprine and corticosteroids have been reported. Belimumab, a fully humanised Change to Immunoglobulin G1λ (IgG1λ) monoclonal antibody targeting soluble B lymphocyte stimulator protein, was the first Food and Drug Administration-approved drug for SLE and has been reported to be effective for CLE. We present the case of a 41-year-old black female with SLE presenting with BSLE, who was successfully treated with corticosteroids and belimumab and did not experience disease relapse even after discontinuation of corticosteroids. To our knowledge, this is the first reported case of successful treatment of BSLE with belimumab, and further research can help determine the role of belimumab in the treatment of BSLE.

Diffuse Bullous Eruptions in an Elderly Woman: Late-Onset Bullous Systemic Lupus Erythematosus

Vesiculobullous eruptions in the elderly represent a diverse range of varying pathophysiologies and can present a significant clinical dilemma to the diagnostician. Diagnosis requires a careful review of clinical history, attention to detail on physical and histomorphological examination, and appropriate immunofluorescence testing. We describe the case of a 73-year-old female who presented to our hospital with a painful blistering skin rash developed over 2 days. Examination of the skin was remarkable for numerous flaccid hemorrhagic bullae on a normal-appearing nonerythematous skin involving both the upper and lower extremities. Histopathology of the biopsy lesion showed interface change at the epidermo-dermal region with subepidermal blister formation, mild dermal fibrosis, and sparse interstitial neutrophilic infiltrate. Immunohistological analysis was significant for positive IgG basement membrane zone antibodies with a dermal pattern of localization on direct immunofluorescence and positive IgG antinuclear antibodies on indirect immunofluorescence. Evidence of antibodies to type VII collagen suggested the diagnosis of epidermolysis bullosa acquisita versus bullous systemic lupus erythematosus (BSLE). A diagnosis of BSLE was made based on positive American College of Rheumatology criteria, acquired vesiculo-bullous eruptions with compatible histopathological and immunofluorescence findings. This case illustrates one of many difficulties a physician encounters while arriving at a diagnosis from a myriad of immunobullous dermatoses. Also, it is important for internists and dermatologists alike to be aware of and differentiate this uncommon and nonspecific cutaneous SLE manifestation from a myriad of disorders presenting with vesiculobullous skin eruptions in the elderly.

Treatment of Bullous Systemic Lupus Erythematosus

Bullous systemic lupus erythematosus (BSLE) is an autoantibody-mediated vesiculobullous disease in patients with SLE. Autoimmunity in BSLE is characterized by the presence of circulating anti-type VII collagen antibodies. BSLE patients often present with multiple, tense, clear fluid-filled vesicles and bullae overlying erythematous edematous plaques. Skin biopsy from BSLE patients shows subepidermal bullae with numerous neutrophils and only occasional eosinophils. Furthermore, immunofluorescence examination showed linear deposition of lgG, lgA, C3, and C1q along the basement membrane zone. BSLE patients with corticosteroids treatment constantly do not receive a marked improvement, while dapsone generally dramatically improved the skin condition. Recently, it has been reported that quite a few cases of BSLE were successfully treated with other immune suppressive drugs. Therefore, a comprehensive review of the treatment of BSLE would be beneficial to cure the disease.

A nonscarring sublamina densa bullous drug eruption

The term bullous drug eruption connotes several heterogeneous diseases in which blisters occur as a complication of the administration of drugs. Blisters may occur in bullous erythema multiforme, fixed drug eruption, or severe dermatitis medicamentosa with blisters. The common denominator is thought to be a hypersensitivity reaction to a systemic medication. Nevertheless, little has been written about the blisters in these disorders, and neither common nor distinct pathogenic mechanisms have been proposed. We describe a patient who had a rapidly progressive bullous eruption that occurred within hours of receiving intravenous trimethoprim-sulfamethoxazole. Routine histologic study of lesional skin demonstrated subepidermal blisters. Transmission electron microscopy and immunomapping of various basement components revealed that the cleavage plane of the blister was well below the lamina densa. After healing of the blistering process, no scarring or milia formation was observed.

Bullous disease in systemic lupus erythematosus

We describe three women with systemic lupus erythematosus and vesiculobullous skin lesions. One patient had a generalized bullous dermatosis and circulating anti-basement membrane zone IgG autoantibodies. Two patients had vesiculobullous lesions limited to the face. All patients had subepidermal blisters and an infiltrate of neutrophils and linear IgG, IgM, IgA, and C3 deposits along the basement membrane zone. These deposits were located in the sublamina densa. Ultrastructural investigation revealed a dermatolytic bullous disease in the patient with the generalized bullous eruption and anti-basement membrane zone autoantibodies and junctional blistering in those patients who had localized blistering.

Cutaneous lesions in systemic lupus erythematosus

The spectrum of cutaneous lesions seen as a presenting feature or during the clinical course of systemic lupus erythematosus is described. Readers are acquainted with the histopathologic features, serologic associations, and pathogenesis when appropriate. Prognostic implications of individual cutaneous manifestations are also addressed.