Lichenoid erythrodermic bullous pemphigoid of the African patient

Autoimmune Subepidermal Bullous Diseases of the Skin and Mucosae: Clinical Features, Diagnosis, and Management

Autoimmune subepidermal blistering diseases of the skin and mucosae constitute a large group of sometimes devastating diseases, encompassing bullous pemphigoid, gestational pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, and anti-p200 pemphigoid. Their clinical presentation is polymorphic. These autoimmune blistering diseases are associated with autoantibodies that target distinct components of the basement membrane zone of stratified epithelia. These autoantigens represent structural proteins important for maintenance of dermo-epidermal integrity. Bullous pemphigoid (BP) is the most common subepidermal autoimmune blistering disease of the skin and mucosae. Although the disease typically presents with a generalized blistering eruption associated with itch, atypical variants with either localized bullous lesions or "non-bullous" presentations are observed in approximately 20% of patients. A peculiar form of BP typically associated with pregnancy is pemphigoid gestationis. In anti-p200 pemphigoid, patients present with tense blisters on erythematosus or normal skin resembling BP, with a predilection for acral surfaces. These patients have antibodies targeting the 200-kDa basement membrane protein. Epidermolysis bullosa is a rare autoimmune blistering disease associated with autoantibodies against type VII collagen that can have several phenotypes including a classical form mimicking dystrophic epidermolysis bullosa, an inflammatory presentation mimicking BP, or mucous membrane pemphigoid-like lesions. Mucous membrane pemphigoid (MMP) is the term agreed upon by international consensus for an autoimmune blistering disorder, which affects one or more mucous membrane and may involve the skin. The condition involves a number of different autoantigens in the basement membrane zone. It may result in severe complications from scarring, such as blindness and strictures. Diagnosis of these diseases relies on direct immunofluorescence microscopy studies and immunoserological assays. Management of affected patients is often challenging. We will here review the clinical and immunopathological features as well as the pathophysiology of this group of organ-specific autoimmune diseases. Finally, we will discuss the diagnostic approach and the principles of management in clinical practice.

Erythroderma: review of a potentially life-threatening dermatosis

Erythroderma, or generalized exfoliative dermatitis, is a disease characterized by erythema and scaling of greater than 90% of the body's surface. The resultant dysmetabolism is potentially life threatening. A detailed history is to identify and treat the underlying cause of this dermatitis. We present two cases of erythroderma in African patients and review this important disease.

[Erythrodermic lichen planus pemphigoides]

Lichen planus pemphigoides is a clinico-histological subtype of lichen planus in which there are bullous lesions similar to those of bullous pemphigoid. Lichen planus is included among the rare causes of erythroderma. We present a case of erythrodermic lichen planus pemphigoides in a 49-year-old female patient who satisfactorily responded to treatment with cyclosporine. A detailed physical examination and immunofluorescence study are key to the diagnosis of lichen planus pemphigoides.

Bullous Pemphigoid

Bullous pemphigoid (BP) is a chronic, autoimmune, blistering disease observed primarily in the elderly population. Several clinical variants have been described, including classic (bullous), localised, nodular, vegetating, erythrodermic, erosive, childhood and drug-induced forms. Autoantibodies target the BP230 and BP180 antigens, located in the hemidesmosomal complex of the skin basement membrane zone. Subsequent complement activation recruits chemical and cellular immune mediators to the skin, ultimately resulting in blister formation. Both autoantibodies and complement may be detected by various immunofluorescent, immune electron microscopy and molecular biology techniques. Recent trials suggest that potent topical corticosteroids should be considered as first-line therapy. Tetracycline with or without nicotinamide may benefit a subset of patients with mild BP. Oral corticosteroids should rarely exceed 0.75 mg/kg/day and corticosteroid-sparing agents may be useful for recalcitrant disease.

Analyse des signes cliniques des malades atteints de pemphigoïde en fonction des antigènes reconnus par leur sérum en immunotransfert

INTRODUCTION

Clinical features and extent of bullous pemphigoid lesions differed widely among patients. The pathogenic role of anti-BPAG2 antibodies has been recently demonstrated. The aim of this study was to analyze the relationship between clinical features of bullous pemphigoid patients and the antigens recognized by their serum.

PATIENTS AND METHODS

One hundred and twelve bullous pemphigoid patients were included in this prospective multicenter study. Inclusion criteria were the following: 1) diagnosis of bullous pemphigoid established on the presence of 3 of the 4 clinical features of bullous pemphigoid, histological picture of bullous pemphigoid and positive direct immunofluorescence; 2) serum available for immunoblotting studies. The clinical and biological findings were prospectively recorded on standard forms. Sera were collected and analyzed using indirect immunofluorescence and immunoblotting on human epidermal extracts.

RESULTS

Analysis of patient's clinical features depending on the antigens recognized by their serum showed that patients whose serum contained anti-BPAG1 antibodies had more frequently pruritus, blisters on the lower limbs and a positive indirect immunofluorescence. Patients whose serum contained anti-BPAG2 antibodies had blisters more frequently localized on the head, and a more frequently negative indirect immunofluorescence. Patients whose serum was negative by immunoblotting had less frequently urticarial and/or eczematous lesions, bullae less frequently localized on the lower part of the trunk, abdomen and lower limbs, lower eosinophilia and a more frequently negative indirect immunofluorescence.

CONCLUSION

Patients with circulating anti-BPAG1 antibodies exhibited the most typical, clinical and biological features of bullous pemphigoid.

Ultrastructural immunocytochemistry of autoimmune bullous diseases

Advanced immunopathological assays have been developed to elucidate the pathophysiology and provide more precise nosological definitions of the immunobullous diseases. Forty-seven patients suffering from autoimmune bullous diseases (intra- or subepidermal) were studied by immunoelectron microscopy (direct and indirect). Peroxidase staining was revealed by diaminobenzidine (determination of immune deposit location) in the majority of the cases of subepidermal bullous diseases, but in less than half of the cases of intraepidermal bullous diseases. Immunoelectron microscopy features contributed in verifying the diagnosis of rare entities such as cicatricial pemphigoid, paraneoplastic autoimmune bullous disease, linear IgA disease and epidermolysis bullosa acquisita.

Paraneoplastic pemphigus with circulating antibodies directed exclusively against the pemphigus vulgaris antigen desmoglein 3

A patient with follicular B-cell lymphoma presented with erythroderma associated with cutaneous and mucosal blisters. Histologic and direct immunofluorescence analysis of lesional skin showed a typical pattern of paraneoplastic pemphigus (PNP). Interestingly, indirect immunofluorescence on rat bladder was negative and immunoblot analysis of the patient's serum on epidermal extracts demonstrated antiepidermal antibodies that only recognized the pemphigus vulgaris antigen desmoglein 3, with no antibodies directed against the different proteins of the plakin family. To our knowledge this has never been reported in the literature. It exemplifies the overlap between pemphigus vulgaris and PNP and the pathogenic role of anti-desmoglein 3 antibodies in PNP. Moreover, it underscores the need to consider clinical, histologic, and immunologic features for the diagnosis of PNP.

Erythroderma

Erythroderma can be caused by a variety of underlying dermatoses, infections, and systemic diseases. Many of the findings on history, physical examination, and laboratory evaluation are nondiagnostic. Distinctive clinical and laboratory features pointing to a specific disease may be evident, however. Conclusive clinicopathologic correlation may require multiple and repeated skin biopsies. The prognosis of erythroderma has improved with the advent of innovative dermatologic therapies (e.g., cyclosporine and synthetic retinoids) and advances in the management of systemic manifestations. Death from sepsis, cardiac failure, adult respiratory distress syndrome, and capillary leak syndrome continue to be rarely reported. A high index of suspicion for these complications must be maintained to facilitate early medical intervention.