A retrospective study of the management of oral mucous membrane pemphigoid with dapsone

Dapsone Use in Dermatology

Dapsone, initially synthesized for textile dyeing, gained recognition in the 1930s for its antibacterial properties, leading to its utilization in dermatology for leprosy and dermatitis herpetiformis. Despite US Food and Drug Administration (FDA) approval for these conditions, dapsone's off-label uses have expanded, making it a valuable option in various dermatologic conditions. This review seeks to highlight the common uses of dapsone in its FDA indications and off-label indications. Diseases in which dapsone is considered first-line therapy or adjunctive therapy are reviewed, with highlights from the resources included. An overview of dapsone's pharmacokinetics, pharmacodynamics, indications, dosages, and safety profile are also reviewed. Dapsone's versatility and safety profile make it a cost-effective treatment option in dermatology, particularly for patients with limited access to specialized medications. Ongoing clinical trials are also described exploring dapsone's efficacy in novel dermatologic uses. Dapsone has been a valuable adjunctive therapy across various dermatologic conditions for years and evidence for its use continues to expand.

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.

Dental Considerations in Patients with Oral Mucosal Diseases

Oral mucosal diseases represent a significant health care burden, rendering a complex patient population in which interdisciplinary care among dermatologists, primary dental providers, and dental specialists is required for optimal care. Oral mucosal diseases often cause painful ulceration and blistering which can impede a patient's ability to perform dental home care and the dental professional's ability to deliver routine and complex treatment. It is crucial to consider the environment of the oral cavity. It is paramount to be aware of the potential side effects that certain medications may cause and the possible interactions with other medications the patient is using.

Management of mucous membrane pemphigoid in a joint oral medicine-dermatology clinic

BACKGROUND

Mucous membrane pemphigoid (MMP) comprises a group of immunobullous diseases involving the mucosa and skin. Potential sequelae include painful mucosal erosions, vision loss and laryngeal stenosis.

AIM

To characterize the features of patients with MMP seen within an Oral Medicine setting, including clinical features, immunofluorescence results and response to treatment.

METHODS

A retrospective case note analysis was undertaken. Treatment effect was divided into response and nonresponse using predetermined adjective terms.

RESULTS

In total, 42 cases of MMP were identified (18 men, 24 women), mean age 65 years (range 36-85 years). Oral involvement was most common on the gingivae (n = 38; 90.5%) while the most common extraoral sites involved were ocular (n = 13; 31.0%) and skin (n = 12; 28.6%). Features of MMP were found in 21 of 34 (61.8%) of routine biopsies, 31 of 34 (91.2%) direct immunofluorescence samples and 8 of 25 (32.0%) indirect immunofluorescence samples. Topical corticosteroids provided effective symptom control in 9 of 42 cases (21.4%), while systemic therapy was used in 31 of 42 patients (73.8%). Dapsone was prescribed for 25 patients, of whom 18 (72.0%) responded. Mycophenolate mofetil was used in 13 cases and had a response rate of 46.2%. Overall, 27 of 42 patients (64.3%) achieved a response using a tolerable topical or systemic treatment.

CONCLUSION

This series demonstrates that MMP has a female predominance and is a disease of older age, with a predilection for specific oral sites. Direct immunofluorescence has a high sensitivity in detecting features of MMP. Although some patients achieve adequate symptom control with topical corticosteroids, many require systemic therapy.

[Oral care recommendations for patients with oral autoimmune bullous diseases]

BACKGROUND

Autoimmune bullous diseases (AIBD) may cause chronic oral lesions that progress insidiously.

AIMS

To provide recommendations for optimal oral-dental management of patients presenting AIBD with oral involvement.

PATIENTS AND METHODS

In the absence of scientific studies with high levels of proof, these recommendations have been drawn up at two meetings by a committee of experts on AIBD comprising 7 dermatologists, 1 stomatologist, 1 maxillofacial surgeon, 2 odontologists and 4 parodontologists.

RESULTS

The oral lesions associated with AIBD may be classified into three grades of severity: severe (generalised erosive gingivitis affecting at least 30% of dental sites), moderate (localised erosive gingivitis affecting less than 30% of dental sites) and controlled (no erosive oral lesions). Good oral-dental hygiene suited to the severity of the oral lesions, must be practised continually by these patients so as to avoid the formation of dental plaque, which aggravates symptoms. Dental and parodontal care must be considered in accordance with the severity grade of the oral lesions: in severe cases, the dental plaque must be eliminated manually with a curette, but several types of care (descaling, treatment for tooth decay, non-urgent extractions, etc.) must be suspended until the grade of severity is moderate or until the disease is stabilised.

Dapsone in the treatment of pemphigus vulgaris: adverse effects and its importance as a corticosteroid sparing agent

Pemphigus vulgaris is an autoimmune disease characterized by suprabasal blisters with acantholysis, which has a fatal course in a large number of untreated patients. Systemic corticosteroid therapy is considered first-line therapy. Adjuvant treatment with the goal of sparing corticosteroids include, among others, dapsone. This drug is not without side effects and its use requires clinical and laboratory control. We present a patient with PV initially managed with suboptimal dose of prednisone, evolving into drug-induced hepatitis after introduction of dapsone.

Oral mucosal diseases: evaluation and management

Oral mucosal diseases encompass several common conditions that affect the general population. Some of these disorders present with signs and symptoms that are pathognomonic for the condition, whereas others present with similar features that can make clinical diagnosis difficult to achieve. It is important for physicians to have a clear understanding of these disorders to provide appropriate care to patients. This article reviews clinical aspects of common oral mucosal disorders, including candidiasis, herpes simplex viral infections, aphthous stomatitis, lichen planus, pemphigus vulgaris, and mucous membrane pemphigoid.

Mucous membrane pemphigoid

Mucous membrane pemphigoid (MMP) is chronic and frequently associated with exacerbations and remissions of clinical signs and symptoms. Clinicians should use pathologic and immunonologic techniques to help diagnose patients. Multidisciplinary collaboration is often necessary for the diagnosis and proper treatment of MMP. Systemic adjuvant immunosuppressive therapy is necessary for patients with progressive disease. In spite of the advances in available immunosuppressive medications and biologics, scarring is a significant complication in many cases. Surgical intervention is not curable; however, it may be necessary for restoring function and improving quality of life.

Biopsy techniques and diagnoses & treatment of mucocutaneous lesions

Oral mucosal lesions are commonly encountered in clinical practice. One study reported that they occurred in approximately 27.9% of patients aged 17 years and older and in 10.3% of children aged 2 to 17 years. The diagnosis and treatment of mucosal diseases should be an integral part of the general practitioner's practice. According to an American Dental Association survey conducted in 2007, 44% of biopsies were performed by a general practictioner. Understanding of the fundamentals of diagnosing mucocutaneous lesions requires a sound knowledge of their origin and clinical course, and of biopsy methods using contemporary diagnostic tools and techniques.

Treatment strategies in mucous membrane pemphigoid

Mucous membrane pemphigoid (MMP) is an autoimmune blistering disorder that is characterized by subepithelial bullae. Various basement membrane zone components have been identified as targets of autoantibodies in MMP. Considerable variability exists in the clinical presentation of MMP. Mucous membranes that may be involved include the oral cavity, conjunctiva, nasopharynx, larynx, esophagus, genitourinary tract, and anus. A multidisciplinary approach is essential in the management of MMP. Early recognition of this disorder and treatment may decrease disease-related complications. The choice of agents for treatment of MMP is based upon the sites of involvement, clinical severity, and disease progression. For more severe disease, or with rapid progression, systemic corticosteroids are the agents of choice for initial treatment, combined with steroid-sparing agents for long-term maintenance. Due to the rarity of this disease, large controlled studies comparing the efficacy of various agents are lacking.

Low-level laser therapy in the treatment of mucous membrane pemphigoid: a promising procedure

BACKGROUND

Mucous membrane pemphigoid is a heterogeneous group of autoimmune, subepithelial, blistering diseases. A combination of topical and systemic steroid treatment is often used when managing patients with mucous membrane pemphigoid. The use of systemic steroids presents an increased risk of adverse side effects. Consequently, effective alternative modalities of therapy should be considered, such as the application of low-level laser therapy (LLLT).

METHODS

A patient presented with mucous membrane pemphigoid and was successfully treated with the application of local corticosteroids and LLLT using an 810-nm diode laser. The lesions were treated by LLLT over a period of 7 days using a continuous waveform for 40 seconds and an energy density of 5 J/cm(2).

RESULTS

After treatment, a significant improvement in tissue color and consistency was observed. The patient was followed every month for a period of 12 months, and the lesions healed uneventfully.

CONCLUSION

The results reported in this case show that the healing of mucous membrane pemphigoid was achieved when LLLT was used as an adjunct to the application of a local corticosteroid.

[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.

Efficacy of dapsone in the treatment of pemphigus and pemphigoid: analysis of current data

Dapsone is a chemotherapeutic agent primarily used in treating leprosy, Pneumocystis jiroveci (previously carinii) pneumonia, and malaria. It is also used as an adjuvant in the treatment of pemphigus and pemphigoid. To assess the role of dapsone in the treatment of pemphigus and pemphigoid, a retrospective review of reports in the English-language literature was conducted. Information on the number of patients treated, their average age, prior therapies, indications for use, protocol (dose and interval) used, concomitant therapies, reported adverse effects, and clinical outcomes were analyzed. There were 35 case reports/series published describing the use of dapsone in a total of 427 patients. Data on 55 pemphigus patients were obtained from several case reports and some case series and one randomized controlled trial. Of these, 32 patients with pemphigus vulgaris and 14 patients with pemphigus foliaceus responded to dapsone. Data from 13 case series, each including at least five patients, accounted for 372 patients with pemphigoid. The overall response rates to dapsone, when given either alone or in combination with corticosteroids or immunosuppressive agents, were 84% in mucous membrane pemphigoid, and 81% in bullous pemphigoid. Hemolysis was the most common adverse effect observed. Dapsone is a promising and useful agent in patients with autoimmune mucocutaneous blistering diseases, especially in mucous membrane pemphigoid. It can be used as a corticosteroid-sparing agent. Therefore, its combined use with oral corticosteroids may be useful in pemphigus vulgaris and bullous pemphigoid. Adverse effects of dapsone are dose dependent and usually reversible. Hemolysis and concomitant anemia secondary to hemolysis are expected in most patients. In the opinion of the authors, dapsone is underutilized in the treatment of autoimmune mucocutaneous blistering diseases.

Systemic treatment in severe cases of recurrent aphthous stomatitis: an open trial

PURPOSE

This study aimed to evaluate the efficacy of the systemic drugs thalidomide, dapsone, colchicine, and pentoxifylline in the treatment of severe manifestations of RAS.

METHODS

An open, 4-year clinical trial was carried out for 21 consecutive patients with severe RAS. Initially, patients were given a 2-week course of prednisone to bring them to a baseline status. Simultaneously, one of the four test drugs was assigned to each patient to be taken for a period of 6 months. During the course of the trial, patients were switched to one of the other three drugs whenever side effects or a lack of satisfactory results occurred, and the 6-month limit of the treatment was then reset.

RESULTS

The most efficient and best-tolerated drug was thalidomide, which was administered to a total of eight patients and resulted in complete remission in seven (87.5%). Dapsone was prescribed for a total of nine patients, of whom eight (89%) showed improvement in their symptoms, while five showed complete remission. Colchicine was administered to a total of ten patients, with benefits observed in nine (90%), of whom four showed complete remission. Pentoxyfilline was administered to a total of five patients, with benefits observed in three (60%), of whom one patient showed complete remission.

CONCLUSION

The therapeutic methods used in this trial provided significant symptom relief. Patients experienced relapses of the lesions; however, this occurred after withdrawal of their medication during the follow-up period.

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.

The management of oral pemphigus vulgaris with systemic corticosteroid and dapsone

BACKGROUND AND AIMS

Oral pemphigus vulgaris is a chronic autoimmune mucocutaneous intraepi-thelial disease that primarily affects patients over the age of fifty, resulting in mucosal ulceration and is a potentially life-threatening disease. The purpose of this study was to investigate the efficacy of dap-sone in combination with systemic corticosteroids to treat the oral lesions of oral pemphigus.

MATERIALS AND METHODS

Twenty patients diagnosed with oral pemphigus were selected. Oral mani-festations were graded according to the severity of disease from 1 to 3. All patients were treated initially with systemic corticosteroids. Each was assigned to one of 4 groups according to their response to ther-apy. Patients who responded less than 50% healing of lesions began a trial of dapsone. After 4 weeks, signs and symptoms were recorded, and if a patient was lesion-free, the dapsone dosage was gradually tapered.

RESULTS

Five patients with mild to moderate disease were treated with systemic corticosteroids alone. 15 patients with moderate to severe disease were treated with systemic corticosteroid and dapsone ther-apy. Of these, 10 patients had significant benefits, while 5 patients did not respond to dapsone adjuvant. Conclusions. The use of dapsone in combination with systemic corticosteroids is a useful method for treatment of oral pemphigus.

CONCLUSIONS

The use of dapsone in combination with systemic corticosteroids is a useful method for treatment of oral pemphigus.

Development of ocular disease in patients with mucous membrane pemphigoid involving the oral mucosa

AIM

To determine the rate of development of ocular disease in patients presenting with mucous membrane pemphigoid (MMP) involving their oral mucosa.

METHODS

Diagnosis of oral MMP was made on the basis of clinical signs, histology, and direct and indirect immunofluorescence. Age, race, sex, age at diagnosis, progression of eye signs, duration of follow up, and time to progression of ocular disease were recorded.

RESULTS

30 patients with established oral MMP were reviewed. The mean age at diagnosis was 65.2 years (range 46-84 years) and 16/30 (53%) were male. At initial ocular review nine (30%) patients showed ocular signs of pemphigoid, of whom two had mild (IIA IIIB), four moderate (IIB IIIC), and three severe (IIC IIID) disease. The mean interval between diagnosis of oral MMP and first ophthalmic review was 19.3 months (range 0-144). Over the period of follow up two (7%) patients developed ocular disease at 19 months and 48 months, respectively, despite having had no evidence of ocular involvement at presentation. In total, 11 (37%) patients with oral disease eventually showed ocular disease with a calculated incidence rate for the development of ocular disease of 0.03 per person year over 5 years.

CONCLUSIONS

MMP may affect different tissues at different stages, often separated by many years. Patients with MMP involving their oral mucosa are at significant risk of developing ocular disease and should remain under ophthalmic review.

Successful treatment of mucous membrane pemphigoid with tacrolimus

Mucous membrane pemphigoid (MMP) is a heterogeneous group of autoimmune, chronic inflammatory ubepithelial vesiculobullous disorders, predominantly affects the mucous membranes of the oral cavity and eyes of the elderly population. Oral manifestations of pemphigoid include desquamative gingivitis, ulcers, erythematous patches, erosions, vesicles and bullae located on the attached gingiva, palate, buccal mucosa, labial mucosa, and tongue. Diagnosis is based on history, clinical features and a biopsy stained with hematoxylin and eosin (H&E), and also direct and indirect immunofluorescence. Topical and systemic corticosteroids are the most commonly used medications for managing pemphigoid. Recently, topical tacrolimus has been successfully used in the treatment of ocular and skin pemphigoid. In this report we present a patient with longterm recalcitrant MMP that did not respond to conventional treatment but as treated successfully with tacrolimus ointment.

Number III Mucous membrane pemphigoid

Mucous membrane pemphigoid (MMP) is a sub-epithelial vesiculobullous disorder. It is now quite evident that a number of sub-epithelial vesiculobullous disorders may produce similar clinical pictures, and also that a range of variants of MMP exist, with antibodies directed against various hemidesmosomal components or components of the epithelial basement membrane. The term immune-mediated sub-epithelial blistering diseases (IMSEBD) has therefore been used. Immunological differences may account for the significant differences in their clinical presentation and responses to therapy, but unfortunately data on this are few. The diagnosis and management of IMSEBD on clinical grounds alone is impossible and a full history, general, and oral examination, and biopsy with immunostaining are now invariably required, sometimes supplemented with other investigations. No single treatment regimen reliably controls all these disorders, and it is not known if the specific subsets of MMP will respond to different drugs. Currently, apart from improving oral hygiene, immunomodulatory-especially immunosuppressive-therapy is typically used to control oral lesions. The present paper reviews pemphigoid, describing the present understanding of this fascinating clinical phenotype, summarising the increasing number of subsets with sometimes-different natural histories and immunological features, and outlining current clinical practice.

Mucous membrane pemphigoid

Mucous membrane pemphigoid (MMP) is a chronic, subepithelial autoimmune disease, which predominantly involves mucosal surfaces and results in mucosal blistering, ulceration, and subsequent scarring. This article discusses the epidemiology, clinical presentation, pathophysiology, diagnosis, and management of MMP, with mention of related subepithelial bullous dermatoses.

Disulone

For 60 years, dapsone has been used as a both antibacterial and anti-inflammatory agent. Dapsone (4,4'-diaminodiphenylsulfone, DDS) continues to be used successfully to treat a wide range of dermatologic disorders, notably those characterized by abnormal neutrophil and eosinophil polynuclear accumulation. A considerable number of other inflammatory as well as bullous dermatoses, of which dermatitis herpetiformis is the best known, have been shown to respond in varying degrees to dapsone, although the indication for the molecule has not been demonstrated in of them all. This article reviews current knowledge on the pharmacokinetics, mechanism of action and side effects of dapsone in dermatology. Despite the lack of controlled studies, the aim of this study is to specify and classify the pathological states in which disulone could be indicated.

Position Paper: Oral Features of Mucocutaneous Disorders

Part of periodontology involves the diagnosis and treatment of a variety of non-plaque-related diseases of the periodontium. The International Workshop for a Classification of Periodontal Diseases and Conditions noted that the periodontist may be called upon to manage non-plaque-related mucocutaneous disorders either alone, or as part of a treatment team consisting of physicians, dentists or other allied health care professionals. This informational paper will review the etiology, clinical manifestations, diagnosis, and treatment of the most common chronic mucocutaneous diseases, including those that may present as desquamative gingivitis or intraoral vesiculobullous lesions. This paper is intended for the use of periodontists and other members of the dental profession.

Cicatricial pemphigoid in the upper aerodigestive tract: diagnosis and management in severe laryngeal stenosis

Pemphigoid is a group of rare, acquired, autoimmune subepithelial blistering diseases. The condition has been subclassified into bullous pemphigoid and cicatricial pemphigoid (CP). Diagnosis is based on clinical presentation, evidence of subepithelialvesicles or bullae on routine histologic analysis, and direct and indirect immunofluorescence studies. Cicatricial pemphigoid is characterized by linear deposition of immunoreactants, principally IgG and complement factor 3, along epithelial basement membranes. Cicatricial pemphigoid usually leads to mucosal scarring. We present a case of severe CP that led to laryngeal and subglottic stenosis and involvement of both eyes and the oral, nasal, and nasopharyngeal mucosae. Treatment with dapsone, corticosteroids, azathioprine sodium, cyclosporine A, cyclophosphamide, methotrexate sodium, and mycophenolate mofetil between 1997 and 2001 only resulted in temporary disease control. The patient has been treated with leflunomide for the past 8 months, and there have been no relapses. Treatment of CP with leflunomide has not been described in the literature until now.

Treatment of oral pemphigoid with intravenous immunoglobulin as monotherapy. Long-term follow-up: influence of treatment on antibody titres to human alpha6 integrin

SUMMARY

Oral pemphigoid (OP) is a chronic autoimmune disease, involving the oral cavity, characterized by a homogenous linear deposition of immunoglobulins, complement, or both along the basement membrane zone (BMZ) and a subepithelial blister formation. The alpha6/beta4 heterodimer is an integrin family of adhesion receptors, which mediates basal cell to matrix interactions. Recent evidence suggests a pathophysiologic role for antibodies against human alpha6 integrin in blister formation in OP, in organ culture studies. Fifty percent of OP patients have been reported to experience disease progression to involve other mucosal tissues, including the eye and larynx. To prevent this extension of disease, systemic therapy with systemic corticosteroids, dapsone, and immunosuppressive agents has been recommended. The use of intravenous immunoglobulin (IVIg) in the treatment of pemphigoid has been recently described. In this study, we present the use of IVIg, in a group of seven patients, with severe OP, in whom systemic conventional treatment was contraindicated. To determine the influence of treatment on antibodies to human alpha6 integrin in OP, seven patients with OP treated with IVIg therapy and a comparable control group of seven patients with OP, treated with conventional therapy, were evaluated at monthly intervals, for a 12 consecutive month treatment period. An effective clinical response was observed in all seven patients treated with IVIg therapy, after a mean treatment period of 4.5 months. IVIg therapy induced a prolonged and sustained clinical remission in all seven patients after a mean treatment period of 26.9 months. A statistically significant difference was observed in the quality of life pre- and post-IVIg therapy (P < 0.001). Both the study and the control groups had a very similar initial serological response to treatment. A statistically significant reduction in the antibody titres was observed after four months of treatment, in both groups (P = 0.015). Thereafter, patients treated with IVIg therapy had a faster rate of decline in the antibody titres, and the difference in the rate of decline between the study and control groups became statistically significant after six months of treatment (P = 0.03). The use of IVIg therapy resulted in reduction of antialpha6 antibody titres and in inducing and maintaining both a sustained, clinical and serological remission.

Oral pemphigoid masquerading as necrotizing ulcerative gingivitis in a child

BACKGROUND

Cicatricial pemphigoid (benign mucous membrane pemphigoid) is an autoimmune vesiculobullous disease that affects mucosal tissues of adults and rarely presents in children. Only 9 cases in the English literature have reported cicatricial pemphigoid in children, primarily as oral mucosal lesions. This paper presents a case of childhood cicatricial pemphigoid that clinically manifested as necrotizing ulcerative gingivitis (NUG).

METHODS

A 9-year-old girl presented with gingival bleeding and discomfort for 2 weeks. NUG was suspected and the patient was treated with antibiotics and an oral hygiene regimen. When the condition did not improve after repeated treatment trials, routine hematoxylin and eosin (H&E) and direct immunofluorescence examinations were performed.

RESULTS

Microscopic examination of H&E stained sections showed a non-specific ulceration with chronic inflammation. Direct immunofluorescence studies of peri-lesional tissue showed linear deposition of C3 at the basement membrane zone that was consistent with a diagnosis of cicatricial pemphigoid.

CONCLUSION

Cicatricial pemphigoid is an autoimmune ulcerative condition that is rarely seen in children. Immunofluorescence studies are essential to differentiate this condition from other ulcerative oral lesions.

Treatment of recalcitrant cicatricial pemphigoid with the tumor necrosis factor alpha antagonist etanercept

The treatment of cicatricial pemphigoid is generally regarded as difficult and usually relies on individual clinical experience. Corticosteroids, as drugs of first choice, often have to be combined with steroid-sparing agents to prevent hazardous, long-term side effects. We describe a 72-year-old woman with long-standing cicatricial pemphigoid recalcitrant to established treatment regimens who responded rapidly and lastingly to therapy with the tumor necrosis factor alpha antagonist etanercept. To our knowledge, this is the first report of its use in the treatment of a bullous autoimmune disease.

Dapsone and sulfapyridine

Dapsone and sulfapyridine are structurally related compounds with anti-microbial and anti-inflammatory effects. Dapsone remains the most important drug for leprosy and is useful in the prophylaxis of Pneumocystis pneumonia in patients with HIV disease. The medical treatment of choice for dermatitis herpetiformis is dapsone; and sulfapyridine also can be used for those patients who are intolerant of dapsone. Other neutrophilic disorders also may respond to these drugs. Toxic side effects of both dapsone and sulfapyridine are mediated through the hydroxylamine metabolite. These include hemolysis, methemoglobinemia, and agranulocytosis. Careful monitoring for possible adverse reactions includes frequently performing complete blood counts and regular blood chemistry profile determinations.