Cicatricial Pemphigoid

Significance of KIR like natural killer cell receptors in autoimmune disorders

Killer cell immunoglobulin-like receptors (KIRs), act as the regulators for the cytolytic activity of natural killer and certain T cells by interacting with the HLA class I ligands. KIRs have been shown to contribute to the pathogenesis of several autoimmune diseases. However, their specific roles are still not very clear. Autoimmune diseases are multifactorial in nature, highlighting the influence of both genetic and environmental factors. The innate immune response plays an important role in autoimmunity as it alters the self-glycans that mimic molecular patterns found on different intracellular pathogens. Natural killer (NK) cells have an important position in the innate immune response. NK cell receptors are encoded by the leukocyte receptor complex located on the chromosome 19q13.4 and lectin-like receptors on chromosome 12p13. This review focuses on the role of KIRs and their relationship with different autoimmune diseases.

[Cicatricial pemphigoid, mucous membrane pemphigoid]

Mucous membrane pemphigoid belongs to the family of sub-epidermal bullous diseases and is clinically characterized by mucosal involvement leading to fibrosis and scarring. Cutaneous involvement is unfrequent and oral mucosa and conjunctivas are the most frequently involves mucosa. Treatment relies on anti-inflammatory and immunosuppressive drugs. The main goal is the limitation of the fibrosing potential of the autoimmune deposits within various mucous membranes.

[Cicatricial conjunctivitis]

Cicatricial conjunctivitis is chronic conjunctivitis with conjunctival fibrosis and may lead to alterations of conjunctival architecture, which are potentially sight-threatening. The patient's medical history, physical exam, and laboratory tests often provide the diagnosis of the underlying disease. Causes of conjunctival cicatrization are autoimmune diseases such as ocular cicatricial pemphigoid, thermal and chemical burns, postinfectious conjunctivitis, Stevens-Johnson syndrome, etc. Medical management varies according to specific causes and may lead to severe side effects. Furthermore, strategies may be necessary to restore corneal transparency and normal palpebral architecture.

Oral mucosal diseases: Mucous membrane pemphigoid

Subepithelial vesiculobullous conditions are chronic autoimmune disorders that arise from reactions directed against components of the hemidesmosomes or basement membrane zones (BMZ) of stratified squamous epithelium to which the term immune-mediated subepithelial blistering diseases (IMSEBD) has been given. Mucous membrane pemphigoid (MMP) is the most common, but variants do exist. Non-immune disorders that involve these epithelial components typically have a genetic basis--the main example being epidermolysis bullosa. All subepithelial vesiculobullous disorders present as blisters and erosions, and diagnosis must be confirmed by biopsy examination with immunostaining, sometimes supplemented by other investigations. No single treatment reliably controls all subepithelial vesiculobullous disorders; the immunological differences within IMSEBD may account for differences in responses to treatment. Currently, as well as improving oral hygiene, immunomodulatory treatment is used to control the oral lesions of MMP, but it is not known if its specific subsets reliably respond to different agents.

Ocular manifestations of blistering diseases

Ocular manifestations are a comorbidity of a group of chronic autoimmune blistering diseases that includes mucous membrane pemphigoid, linear immunoglobulin A disease, epidermolysis bullosa acquisita, and ocular pemphigus vulgaris. Various diagnostic measures differentiate between the diseases and allow for appropriate treatment including a specific selection of immunomodulatory medications. New treatment modalities offer alternatives that may minimize disease severity and residual tissue damage and may reduce treatment-related complications.

Esophageal involvement in cicatricial pemphigoid: a rare cause of dysphagia

Cicatricial pemphigoid is a rare, autoimmune, blistering disorder affecting the mucous membranes and skin. Esophageal involvement affects a small proportion of affected individuals and may present up to 10 years after the initial onset of the disease. We present a case of esophageal cicatricial pemphigoid that presented initially as linear IgA disease. We describe the successful treatment of dysphagia by graded esophageal dilatations.

Cicatricial pemphigoid-induced phimosis

Cicatricial pemphigoid is an autoimmune bullous disease that has a predilection for mucous membranes and often results in scarring. We describe a case of cicatricial pemphigoid with severe involvement of the glans penis, which, despite systemic therapy, led to phimosis.

Immunofluorescence in dermatology

The accurate diagnosis of bullous and other immune diseases of the skin requires evaluation of clinical, histologic, and immunofluorescence findings. Immunofluorescence testing is invaluable in confirming a diagnosis that is suspected by clinical or histologic examination. This is especially true in subepidermal bullous diseases that often have overlap in the clinical and histologic findings. Direct immunofluorescence is performed on perilesional skin for patients with bullous diseases and lesional skin for patients with connective tissue diseases and vasculitis.

Cicatricial pemphigoid

Cicatricial pemphigoid (CP) is a heterogeneous group of rare, chronic, subepithelial blistering disorders of the mucous membranes and, occasionally, the skin, which can have serious and rarely fatal consequences. The most common clinical features are desquamative gingivitis, oral erosions, and conjunctival fibrosis. Skin lesions occur less frequently and may present as widespread vesicles and bullae, as in bullous pemphigoid (BP). In some patients, the scarring can be a source of significant morbidity because it can result in odynophagia, strictures of the upper aerodigestive tract, or corneal opacities leading to eventual blindness. This article is a comprehensive review and discusses clinical, pathologic, and pathophysiologic aspects of this group of disorders collectively known as CP. (J Am Acad Dermatol 2000;43:571-91.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the clinical spectrum of CP, the histopathologic and immunopathologic characteristics, the differential diagnosis, the treatment, and the natural history of the disease. Furthermore, this learning activity should facilitate early diagnosis of CP and should promote the idea that the involvement of other specialists, including ophthalmologists, otolaryngologists, gastroenterologists, and oral medicine specialists, as appropriate, will aid in providing these patients with the highest quality of care.

Cicatricial pemphigoid diagnosed by the use of indirect immunofluorescence

BACKGROUND

A thorough work-up is paramount in the accurate diagnosis of oral erosive diseases.

OBJECTIVE

A case of pemphigoid with negative direct immunofluorescence but positive indirect immunofluorescence is presented.

METHODS AND RESULTS

A 77-year-old man presented with erosions of the oral and glans mucosa and with esophageal stenosis. Histologic examination revealed nonspecific mucositis. Indirect immunofluorescence was characteristic of pemphigoid.

CONCLUSION

This case illustrates the importance of performing a complete diagnostic work-up in the evaluation of patients with oral erosive disease.

Update on mucous membrane pemphigoid: a heterogeneous immune-mediated subepithelial blistering entity

Most oral involvement in the skin diseases (dermatoses) is related to mucous membrane pemphigoid or lichen planus. Mucous membrane pemphigoid was the subject of a European Symposium held in Turin, Italy, in June 1997. This review is based on that symposium. Mucous membrane pemphigoid is a subepithelial vesiculobullous disorder mainly of late middle age; it has a slight predilection for women. Whereas mucous membrane pemphigoid was formerly considered a single entity, it is now quite evident that a number of subepithelial vesiculobullous disorders may produce similar clinical pictures and also that a range of variants of mucous membrane pemphigoid exists, with antibodies directed against various hemidesmosomal components or components of the epithelial basement membrane. The term immune-mediated subepithelial blistering diseases has therefore been used. Diagnosis and management of immune-mediated subepithelial blistering diseases on clinical grounds alone are impossible; a full history, general and oral examinations, and biopsy with immunostaining are now invariably required, sometimes supplemented with other investigations. Most patients with mucous membrane pemphigoid affecting the mouth manifest desquamative gingivitis, a fairly common complaint typically seen in women who are middle-aged or older. Oral vesicles and erosions may also occur, and there can be a positive Nikolsky sign. Some patients have lesions of other stratified squamous epithelia, presenting as conjunctival, nasal, oesophageal, laryngeal, vulval, penile, or anal involvement. Apart from improving oral hygiene, immunomodulatory-in particular, immunosuppressive-therapy is typically required to control oral lesions in mucous membrane pemphigoid. No single treatment regimen reliably controls all these disorders.

Characterization of the antibody response in oesophageal cicatricial pemphigoid

Cicatricial pemphigoid (CP) is a subepidermal, autoimmune bullous dermatosis. It is classified as a clinical subset of bullous pemphigoid (BP). However, it differs from BP in some significant ways: (i) in CP mucosal involvement with clinical scarring is prominent; (ii) there is a prominent IgA class antibody response alone or in addition to the IgG class antibody response; and (iii) there is a heterogeneous antibody response in CP, whereas in BP the majority of the antibodies are directed against a 180-kDa hemidesmosomal protein, bullous pemphigoid antigen 2 (BPAg2). Oesophageal involvement in CP is a rare, but often devastating manifestation. In this study we examined the humoral autoimmune response in oesophageal CP, in an attempt to characterize the autoantibody reactivity profile. We used direct and indirect immunofluorescence and Western immunoblotting using normal human skin and oesophagus substrates. We studied patient sera over time in order to search for evidence of epitope spreading in these patients. All patients had positive direct immunofluorescence of perilesional oesophageal epithelium. All patients had positive circulating antibasement membrane zone autoantibody titres. There was a significant IgA class in addition to an IgG class autoantibody response. IgA and IgG antibodies demonstrated significant reactivity with BPAg2 and the 97 kDa linear IgA disease antigen on Western immunoblot suggesting intraprotein epitope spreading. There was no evidence of interprotein epitope spreading over time. Our findings suggest that there is a heterogeneous antibody response in oesophageal CP with the predominant antigen being BPAg2.

Three different autoimmune bullous diseases in one family: is there a common genetic base?

We report an unusual familial occurrence of autoimmune bullous diseases. Three members of a family suffered from three different autoimmune bullous diseases: pemphigus vulgaris (PV), linear IgA disease (LAD) and cicatricial pemphigoid (CP). The HLA type was determined in five family members: all were positive for HLA-DQ5/DR6, which is reported to be associated with susceptibility to PV. The CP patient was DQ7(3) positive, which is in concordance with enhanced susceptibility to ocular CP and CP. The LAD patient was B8 and DR3 negative but positive for HLA-A1. Our study supports the hypothesis that there is a genetically transmitted susceptibility to autoimmune bullous diseases but that additional factors seem necessary actually to develop a particular disease.

The blistering diseases

The intent and purpose of the authors is to familiarize the reader with the principles that govern the diagnosis and management of autoimmune mucocutaneous blistering diseases. The purpose was not to be all-inclusive but illustrative. There are several other blistering diseases that have not been discussed because of the limited scope of this article. Of these, toxic epidermal necrolysis, erythema multiforme, and the like warrant the same attention and early recognition. These are covered in different articles. For the same reasons, certain genetically linked blistering diseases have not been discussed.

Mucocutaneous features of autoimmune blistering diseases

This review will describe adult onset mucocutaneous/autoimmune diseases that involve defects in cell-to-cell, cell-to-matrix, or cell-to-basement membrane adhesion. Included in this group are pemphigus, cicatricial pemphigoid, linear IgA bullous dermatosis, epidermolysis bullosa acquisita, and bullous systemic lupus erythematous. Detection and treatment of blistering disorders that manifest early in the oral cavity may prevent widespread involvement of skin. During the past few years, targets of autoantibodies have been clarified and new targets have been identified, allowing better understanding of the pathophysiology involved in these diseases. New information about more effective regimens with fewer side effects has also been obtained, presenting new treatment options. Clinical manifestations and management of these disorders will be described as well as histopathologic, ultrastructural, and immunopathologic studies that distinguish each disorder and facilitate diagnosis and treatment.

Bullous pemphigoid and cicatricial pemphigoid autoantibodies react with ultrastructurally separable epitopes on the BP180 ectodomain: evidence that BP180 spans the lamina lucida

The BP180 antigen is a hemidesmosomal glycoprotein that is recognized by autoantibodies associated with three autoimmune disorders, bullous pemphigoid (BP), herpes gestationis (HG), and cicatricial pemphigoid (CP). BP and HG sera have been shown to recognize a common extracellular site located near the membrane-spanning domain of this protein, whereas CP sera react predominantly with a distinct site near the C terminus. In the current study, the main immunogenic sites on the BP180 ectodomain were ultrastructurally localized using six BP sera, four CP sera, and two rabbit antisera. The immunolocalization pattern of BP sera was largely restricted to the upper lamina lucida region immediately subjacent to the epidermal hemidesmosome and closely resembled that of a rabbit antiserum directed against the NC16A (membrane-proximal) domain of BP180. CP sera, on the other hand, exhibited a lower lamina lucida/lamina densa labeling pattern that was strikingly similar to that of rabbit antibodies to the BP180 C-terminal region. Finally, antibodies to the BP180 C-terminal region co-localized with an anti-laminin-5 antibody in the anchoring filament zone. These findings strongly suggest that the BP180 extracellular domain exists in an extended conformation, with the C terminus of this protein projecting into the lamina densa. These data support the hypothesis that BP180 contributes to the structure and function of the anchoring filaments. Differences in the ultrastructural mapping of BP and CP autoantibodies appear to correlate with epitope mapping data, which, together, may help to explain the clinical heterogeneity observed in this group of bullous disorders.

Stenosis of the esophagus in cicatricial pemphigoid resolved by colon interposition: report of a case

We present herein the exceedingly uncommon case of a patient with cicatricial pemphigoid (CP) who gradually developed conjunctival, oral, and esophageal involvement. Despite long-term medical management with dapsone and disulone, the ocular lesions progressed to produce further scarring, which led to ankyloblepharon, symblepharon, and ultimately, blindness of the right eye. After a period of 5 years the patient developed a total esophageal stricture, intractable by dilation, necessitating esophageal reconstruction. The details of an original procedure using a continuous colic loop are described, highlighting the better tolerance of this technique by a high-risk patient. A discussion on the recent advances in diagnosing bullous dermatoses is presented following this case report.

Cicatricial pemphigoid autoantibodies react with multiple sites on the BP180 extracellular domain

Cicatricial pemphigoid (CP) is an autoimmune blistering disease that primarily affects mucosal tissues. Autoantibodies to laminin-5 have previously been detected in certain patients with a CP-like disease; however, individuals that exhibit this reactivity profile apparently represent a small subset of CP patients. In the present investigation, 0 of 18 CP sera showed reactivity with laminin-5 by immunoblotting. In contrast, 18 of 23 CP sera (78%) recognized a 180-kDa epidermal antigen that, by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, co-migrated with BP180, a hemidesmosomal glycoprotein associated with two other autoimmune blistering diseases, bullous pemphigoid and herpes gestationis. To investigate further the CP autoimmune response, various segments of human BP180 were expressed as bacterial fusion proteins and assayed by immunoblotting for reactivity with CP patients' sera. The results of this investigation demonstrated that the BP180 autoantigen is indeed a major target of CP autoantibodies. Further, two distinct CP-reactive sites were identified on the extracellular domain of the BP180 protein, one located in the non-collagenous (NC) 16A domain (at or near the previously defined autoantibody-reactive site recognized by bullous pemphigoid and herpes gestationis sera) and the other in the carboxy-terminal region of this protein. Sixteen of 23 CP sera (70%) reacted with one or both of these antigenic sites of BP180. Other immunologic data suggested that BP180 may harbor additional CP-reactive sites. In conclusion, there are now three bullous diseases, bullous pemphigoid, herpes gestationis, and cicatricial pemphigoid, that are known to be associated with an autoimmune response against the extracellular domain of the BP180 antigen.