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Emtenani S, Linnemann BE, Recke A, von Georg A, Goletz S, Schmidt E, van Beek N. Anti-BP230 IgE autoantibodies in bullous pemphigoid intraindividually correlate with disease activity. J Dermatol Sci 2024; 114:64-70. [PMID: 38582700 DOI: 10.1016/j.jdermsci.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/05/2024] [Accepted: 03/21/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Bullous pemphigoid (BP), the most common subepidermal autoimmune blistering disease, is classically defined by the presence of IgG autoantibodies directed against the hemidesmosomal proteins BP180 (type XVII collagen) and BP230 and the predominance of skin lesions. Several studies have addressed the role of anti-BP180 IgE in patients and experimental models, while data on anti-BP230 IgE are scarce. OBJECTIVE To assess anti-BP230 IgE level by ELISA in BP sera and to correlate it with disease severity and clinical characteristics. METHODS BP sera underwent anti-BP230 IgE ELISA and Western blotting against human BP230 fragments. RESULTS We demonstrate that 36/154 (23%) of BP sera were positive for anti-BP230 IgE. Anti-BP230 IgE levels had no correlation with clinical phenotype or disease activity per se. Interestingly, anti-BP230 IgE was significantly associated with disease activity within individuals during the course of the disease. Additionally, anti-BP230 IgE and total IgE levels showed a significant correlation. Notably, anti-BP230 IgG correlated interindividually with disease activity. By Western blotting, the C-terminal domain of BP230 fragments (C2; amino acids 2024-2349 and C3; amino acids 2326-2649), provided the best serological assay for anti-BP230 IgE detection. CONCLUSION As a complementary tool, IgE immunoblotting is recommended to obtain an optimal serological diagnosis, particularly in patients with severe disease without IgG reactivity by BP180- or BP230-specific ELISA. Although the detection of serum anti-BP230 IgE is not of major diagnostic significance, it may be relevant for therapeutic decisions, e.g., for anti-IgE-directed treatment, which has been successfully used in case series of BP.
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Affiliation(s)
- Shirin Emtenani
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Beke E Linnemann
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Andreas Recke
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | | | - Stephanie Goletz
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany; Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Nina van Beek
- Department of Dermatology, University of Lübeck, Lübeck, Germany.
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2
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Zhang Y, Lu Q. Immune cells in skin inflammation, wound healing, and skin cancer. J Leukoc Biol 2024; 115:852-865. [PMID: 37718697 DOI: 10.1093/jleuko/qiad107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 08/22/2023] [Accepted: 09/05/2023] [Indexed: 09/19/2023] Open
Abstract
Given the self-evident importance of cutaneous immunity in the maintenance of body-surface homeostasis, disturbance of the steady-state skin is inextricably intertwined with dysfunction in cutaneous immunity. It is often overlooked by people that skin, well-known as a solid physical barrier, is also a strong immunological barrier, considering the abundant presence of immune cells including lymphocytes, granulocytes, dendritic cells, and macrophages. What's more, humoral immune components including cytokines, immunoglobulins, and antimicrobial peptides are also rich in the skin. This review centers on skin inflammation (acute and chronic, infection and aseptic inflammation), wound healing, and skin cancer to elucidate the elaborate network of immune cells in skin diseases.
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Affiliation(s)
- Yuhan Zhang
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Jiangwangmiao Street No. 12, Xuanwu, Nanjing 210042, China
- Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Jiangwangmiao Street No. 12, Xuanwu, Nanjing 210042, China
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing 210042, China
| | - Qianjin Lu
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Jiangwangmiao Street No. 12, Xuanwu, Nanjing 210042, China
- Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Jiangwangmiao Street No. 12, Xuanwu, Nanjing 210042, China
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing 210042, China
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3
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Ruan Y, Xu C, Zhang T, Zhu L, Wang H, Wang J, Zhu H, Huang C, Pan M. Single-Cell Profiling Unveils the Inflammatory Heterogeneity within Cutaneous Lesions of Bullous Pemphigoid. J Invest Dermatol 2024:S0022-202X(24)00209-4. [PMID: 38537929 DOI: 10.1016/j.jid.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/05/2024] [Accepted: 02/20/2024] [Indexed: 05/02/2024]
Abstract
Bullous pemphigoid (BP) is a subepidermal blistering skin disease with a complex pathogenesis involving various immune cells. However, the transcriptional features of these cells remain poorly defined. In this study, we constructed a comprehensive and single-cell resolution atlas of various immune cells within BP skin lesions through integrative single-cell analysis, flow cytometry, and multiplex immunohistochemistry. We observed prominent expansion and transcriptional changes in mast cells, macrophages, basophils, and neutrophils within BP lesions. Mast cells within the lesions adopted an active state and exhibited an elevated capacity for producing proinflammatory mediators. We observed an imbalance of macrophages/dendritic cells within BP lesions. Two macrophage subpopulations (NLRP3+ and C1q+) with distinct transcriptional profiles were identified and upregulated effector programs. T-peripheral helper-like T helper 2 cells were expanded in skin lesions and peripheral blood of patients with BP and were capable of promoting B-cell responses. In addition, we observed clonally expanded granzyme B-positive CD8+ T cells within BP lesions. Chemokine receptor mapping revealed the potential roles of macrophages and mast cells in recruiting pathogenic immune cells and underlying mechanisms within BP lesions. Thus, this study reveals key immune pathogenic features of BP lesions, thereby providing valuable insights for potential therapeutic interventions in this disease.
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Affiliation(s)
- Yue Ruan
- Department of Dermatology, Center for Immune-Related Diseases at Shanghai Institute of Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chuqiao Xu
- Department of Dermatology, Center for Immune-Related Diseases at Shanghai Institute of Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tianyu Zhang
- Department of Dermatology, Center for Immune-Related Diseases at Shanghai Institute of Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Biliary Tract Disease Research, Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Key Laboratory of Cell Differentiation and Apoptosis of the Chinese Ministry of Education, Faculty of Basic Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Zhu
- Department of Dermatology, Center for Immune-Related Diseases at Shanghai Institute of Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hailun Wang
- Department of Dermatology, Center for Immune-Related Diseases at Shanghai Institute of Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingying Wang
- Department of Dermatology, Center for Immune-Related Diseases at Shanghai Institute of Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haiqin Zhu
- Department of Dermatology, Center for Immune-Related Diseases at Shanghai Institute of Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chuanxin Huang
- Department of Dermatology, Center for Immune-Related Diseases at Shanghai Institute of Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Biliary Tract Disease Research, Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Key Laboratory of Cell Differentiation and Apoptosis of the Chinese Ministry of Education, Faculty of Basic Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Meng Pan
- Department of Dermatology, Center for Immune-Related Diseases at Shanghai Institute of Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Jordan TJ, Chen J, Li N, Burette S, Wan L, Chen L, Culton DA, Geng S, Googe P, Thomas NE, Diaz LA, Liu Z. The Eotaxin-1/CCR3 Axis and Matrix Metalloproteinase-9 Are Critical in Anti-NC16A IgE-Induced Bullous Pemphigoid. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2023; 211:1216-1223. [PMID: 37672029 PMCID: PMC10592335 DOI: 10.4049/jimmunol.2300080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/13/2023] [Indexed: 09/07/2023]
Abstract
Bullous pemphigoid (BP) is the most common autoimmune bullous skin disease of humans and is characterized by eosinophilic inflammation and circulating and tissue-bound IgG and IgE autoantibodies directed against two hemidesmosomal proteins: BP180 and BP230. The noncollagenous 16A domain (NC16A) of BP180 has been found to contain major epitopes recognized by autoantibodies in BP. We recently established the pathogenicity of anti-NC16A IgE through passive transfer of patient-derived autoantibodies to double-humanized mice that express the human high-affinity IgE receptor, FcεRI, and human NC16A domain (FcεRI/NC16A). In this model, anti-NC16A IgEs recruit eosinophils to mediate tissue injury and clinical disease in FcεRI/NC16A mice. The objective of this study was to characterize the molecular and cellular events that underlie eosinophil recruitment and eosinophil-dependent tissue injury in anti-NC16A IgE-induced BP. We show that anti-NC16A IgEs significantly increase levels of key eosinophil chemoattractants, eotaxin-1 and eotaxin-2, as well as the proteolytic enzyme matrix metalloproteinase-9 (MMP-9) in the lesional skin of FcεRI/NC16A mice. Importantly, neutralization of eotaxin-1, but not eotaxin-2, and blockade of the main eotaxin receptor, CCR3, drastically reduce anti-NC16A IgE-induced disease activity. We further show that anti-NC16A IgE/NC16A immune complexes induce the release of MMP-9 from eosinophils, and that MMP-9-deficient mice are resistant to anti-NC16A IgE-induced BP. Lastly, we find significantly increased levels of eotaxin-1, eotaxin-2, and MMP-9 in blister fluids of BP patients. Taken together, this study establishes the eotaxin-1/CCR3 axis and MMP-9 as key players in anti-NC16A IgE-induced BP and candidate therapeutic targets for future drug development and testing.
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Affiliation(s)
- Tyler J.M. Jordan
- Departments of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Clinical Sciences, North Carolina State University, Raleigh, NC 27607, USA
| | - Jinbo Chen
- Departments of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Dermatology, Wuhan No. 1 Hospital, Wuhan 430022, China
| | - Ning Li
- Departments of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Susan Burette
- Departments of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Li Wan
- Department of Dermatology, Wuhan No. 1 Hospital, Wuhan 430022, China
- Dermatology Hospital of Southern Medical University, Guangzhou 510091, China
| | - Liuqing Chen
- Department of Dermatology, Wuhan No. 1 Hospital, Wuhan 430022, China
| | - Donna A. Culton
- Departments of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Songmei Geng
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi’an Jiaotong University, Xi’an, Shaanxi 710004, China
| | - Paul Googe
- Departments of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Nancy E. Thomas
- Departments of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Luis A. Diaz
- Departments of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Zhi Liu
- Departments of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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5
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Toh WH, Lee HE, Chen CB. Targeting type 2 inflammation in bullous pemphigoid: current and emerging therapeutic approaches. Front Med (Lausanne) 2023; 10:1196946. [PMID: 37614956 PMCID: PMC10442825 DOI: 10.3389/fmed.2023.1196946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023] Open
Abstract
Bullous pemphigoid (BP) is one of the most common autoimmune bullous diseases and mainly affects an elderly population with multi-morbidity. Due to the frailty of many BP patients, existing treatment options are limited. The blisters associated with BP result from IgG and IgE autoantibodies binding to the central components of hemidesmosome, BP180, and BP230, stimulating a destructive inflammatory process. The known characteristic features of BP, such as intense pruritus, urticarial prodrome, peripheral eosinophilia, elevated IgE, as well as recent expanding evidence from in vitro and in vivo studies implicate type 2 inflammation as an important driver of BP pathogenesis. Type 2 inflammation is an inflammatory pathway involving a subset of CD4+ T cells that secrete IL-4, IL-5, and IL-13, IgE-secreting B cells, and granulocytes, such as eosinophils, mast cells, and basophils. It is believed that effectors in type 2 inflammation may serve as novel and effective treatment targets for BP. This review focuses on recent understandings of BP pathogenesis with a particular emphasis on the role of type 2 inflammation. We summarize current clinical evidence of using rituximab (B-cell depletion), omalizumab (anti-IgE antibody), and dupilumab (anti-IL-4/13 antibody) in the treatment of BP. The latest advances in emerging targeted therapeutic approaches for BP treatment are also discussed.
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Affiliation(s)
- Wu Han Toh
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, United States
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, United States
- Department of Biology, Johns Hopkins University, Baltimore, MD, United States
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Taoyuan, Taiwan
| | - Hua-En Lee
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Taoyuan, Taiwan
- Department of Dermatology and Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Bing Chen
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Taoyuan, Taiwan
- Department of Dermatology and Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
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6
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Ling X, Shou X, Lou Y, Ling J, Zhang M, Yu T, Gu W. Research progress of omalizumab in the treatment of bullous pemphigoid. J Dermatol 2023; 50:575-587. [PMID: 36971190 DOI: 10.1111/1346-8138.16791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/01/2023] [Accepted: 03/10/2023] [Indexed: 03/29/2023]
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease associated with anti-BP180 and anti-BP230 antibodies. The pathogenic action mechanism of immunoglobulin E (IgE) antibodies in BP has been studied since the 1970s, and IgE antibodies have gradually been confirmed as being important in BP; therefore, anti-IgE therapy may be a new option for the treatment of BP. Omalizumab, as an IgE monoclonal antibody, has been increasingly used clinically to treat BP in recent years. Here, we collected 35 papers investigating omalizumab for BP treatment in a total of 83 patients, and the vast majority of patients showed varying degrees of improvement after treatment, except for a small number of patients with poor clinical outcomes. The patients were then divided into three groups according to dosing frequency and number of doses. Statistical analysis indicated that dosing frequency had little effect on clinical efficacy. While the groups with different numbers of doses were evaluated, the results concluded that clinical efficacy was affected by the number of doses, but there was no positive correlation between the number of doses and clinical efficacy.
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Affiliation(s)
- Xiaoya Ling
- The First Clinical Medical College of Zhejiang Chinese Medicine University, 310053, Hangzhou, China
| | - Xinyang Shou
- The First Clinical Medical College of Zhejiang Chinese Medicine University, 310053, Hangzhou, China
| | - Yufei Lou
- The First Clinical Medical College of Zhejiang Chinese Medicine University, 310053, Hangzhou, China
| | - Jie Ling
- The First Clinical Medical College of Zhejiang Chinese Medicine University, 310053, Hangzhou, China
| | - Mengyuan Zhang
- The First Clinical Medical College of Zhejiang Chinese Medicine University, 310053, Hangzhou, China
| | - Tugen Yu
- The First Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine (Zhejiang Province Hospital of Chinese Medicine), Hangzhou, 310006, China
| | - Weijia Gu
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, 310053, China
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7
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Zeng FAP, Murrell DF. Bullous pemphigoid-What do we know about the most recent therapies? Front Med (Lausanne) 2022; 9:1057096. [PMID: 36405625 PMCID: PMC9669062 DOI: 10.3389/fmed.2022.1057096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/18/2022] [Indexed: 08/25/2023] Open
Abstract
Introduction Bullous pemphigoid (BP) is the most common subtype of autoimmune blistering diseases that primarily affects the elderly and is classically defined by the presence of IgG and/or complement C3 against the BP180 and BP230 hemidesmosome proteins. However, most recent studies have introduced the role of specific eosinophil receptors and chemokine mediators in the pathogenesis of BP which are helpful in identifying new targets for future treatments. Areas covered This review will focus on the involvement of eosinophils in BP, including the processes that lead to their recruitment, activation, and regulation. Subsequently, covering new therapeutic options in relation to the role of eosinophils. Eotaxin enhances the recruitment of eosinophils in BP, with CCR3 chemoreceptor that is expressed on eosinophils being identified as a key binding site for eotaxin-1. The pathogenic role of IgE and IL-4 in BP is corroborated by successful treatments with Omalizumab and Dupilumab, respectively. IL-5, IL-17 and IL-23 inhibitors may be effective given their roles in promoting eosinophilia. Expert opinion Further research into inhibitors of eotaxin, IL-4, IL-5, IL-17, IL-23, CCR3, and specific complement factors are warranted as preliminary studies have largely identified success in treating BP with these agents. Learning from novel treatments for other IgG-mediated autoimmune diseases may be beneficial.
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Affiliation(s)
- Faith A. P. Zeng
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Dedee F. Murrell
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Dermatology, St George Hospital, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
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8
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Papara C, Karsten CM, Ujiie H, Schmidt E, Schmidt-Jiménez LF, Baican A, Freire PC, Izumi K, Bieber K, Peipp M, Verschoor A, Ludwig RJ, Köhl J, Zillikens D, Hammers CM. The relevance of complement in pemphigoid diseases: A critical appraisal. Front Immunol 2022; 13:973702. [PMID: 36059476 PMCID: PMC9434693 DOI: 10.3389/fimmu.2022.973702] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
Pemphigoid diseases are autoimmune chronic inflammatory skin diseases, which are characterized by blistering of the skin and/or mucous membranes, and circulating and tissue-bound autoantibodies. The well-established pathomechanisms comprise autoantibodies targeting various structural proteins located at the dermal-epidermal junction, leading to complement factor binding and activation. Several effector cells are thus attracted and activated, which in turn inflict characteristic tissue damage and subepidermal blistering. Moreover, the detection of linear complement deposits in the skin is a diagnostic hallmark of all pemphigoid diseases. However, recent studies showed that blistering might also occur independently of complement. This review reassesses the importance of complement in pemphigoid diseases based on current research by contrasting and contextualizing data from in vitro, murine and human studies.
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Affiliation(s)
- Cristian Papara
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Department of Dermatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Christian M. Karsten
- Institute of Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | | | - Adrian Baican
- Department of Dermatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Patricia C. Freire
- Institute of Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Kentaro Izumi
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Matthias Peipp
- Division of Antibody-Based Immunotherapy, Department of Medicine II, Christian-Albrechts-University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Admar Verschoor
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Ralf J. Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Jörg Köhl
- Institute of Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Christoph M. Hammers
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- *Correspondence: Christoph M. Hammers,
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9
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Cole C, Vinay K, Borradori L, Amber KT. Insights Into the Pathogenesis of Bullous Pemphigoid: The Role of Complement-Independent Mechanisms. Front Immunol 2022; 13:912876. [PMID: 35874745 PMCID: PMC9300999 DOI: 10.3389/fimmu.2022.912876] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Bullous pemphigoid is an autoimmune blistering disease caused by autoantibodies targeting BP180 and BP230. While deposits of IgG and/or complement along the epidermal basement membrane are typically seen suggesting complement -mediated pathogenesis, several recent lines of evidence point towards complement-independent pathways contributing to tissue damage and subepidermal blister formation. Notable pathways include macropinocytosis of IgG-BP180 complexes resulting in depletion of cellular BP180, direct induction of pro-inflammatory cytokines from keratinocytes, as well as IgE autoantibody- and eosinophil-mediated effects. We review these mechanisms which open new perspectives on novel targeted treatment modalities.
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10
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Ujiie H, Rosmarin D, Schön MP, Ständer S, Boch K, Metz M, Maurer M, Thaci D, Schmidt E, Cole C, Amber KT, Didona D, Hertl M, Recke A, Graßhoff H, Hackel A, Schumann A, Riemekasten G, Bieber K, Sprow G, Dan J, Zillikens D, Sezin T, Christiano AM, Wolk K, Sabat R, Kridin K, Werth VP, Ludwig RJ. Unmet Medical Needs in Chronic, Non-communicable Inflammatory Skin Diseases. Front Med (Lausanne) 2022; 9:875492. [PMID: 35755063 PMCID: PMC9218547 DOI: 10.3389/fmed.2022.875492] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/09/2022] [Indexed: 12/15/2022] Open
Abstract
An estimated 20-25% of the population is affected by chronic, non-communicable inflammatory skin diseases. Chronic skin inflammation has many causes. Among the most frequent chronic inflammatory skin diseases are atopic dermatitis, psoriasis, urticaria, lichen planus, and hidradenitis suppurativa, driven by a complex interplay of genetics and environmental factors. Autoimmunity is another important cause of chronic skin inflammation. The autoimmune response may be mainly T cell driven, such as in alopecia areata or vitiligo, or B cell driven in chronic spontaneous urticaria, pemphigus and pemphigoid diseases. Rare causes of chronic skin inflammation are autoinflammatory diseases, or rheumatic diseases, such as cutaneous lupus erythematosus or dermatomyositis. Whilst we have seen a significant improvement in diagnosis and treatment, several challenges remain. Especially for rarer causes of chronic skin inflammation, early diagnosis is often missed because of low awareness and lack of diagnostics. Systemic immunosuppression is the treatment of choice for almost all of these diseases. Adverse events due to immunosuppression, insufficient therapeutic responses and relapses remain a challenge. For atopic dermatitis and psoriasis, a broad spectrum of innovative treatments has been developed. However, treatment responses cannot be predicted so far. Hence, development of (bio)markers allowing selection of specific medications for individual patients is needed. Given the encouraging developments during the past years, we envision that many of these challenges in the diagnosis and treatment of chronic inflammatory skin diseases will be thoroughly addressed in the future.
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Affiliation(s)
- Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - David Rosmarin
- Department of Dermatology, Tufts Medical Center, Boston, MA, United States
| | - Michael P Schön
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany.,Lower Saxony Institute of Occupational Dermatology, University Medical Center Göttingen, Göttingen, Germany
| | - Sonja Ständer
- Center for Chronic Pruritus, Department of Dermatology, University Hospital Muenster, Muenster, Germany
| | - Katharina Boch
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Martin Metz
- Institute for Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Marcus Maurer
- Institute for Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Diamant Thaci
- Institute and Comprehensive Center for Inflammation Medicine, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Connor Cole
- Division of Dermatology, Rush University Medical Center, Chicago, IL, United States.,Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Kyle T Amber
- Division of Dermatology, Rush University Medical Center, Chicago, IL, United States.,Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Dario Didona
- Department of Dermatology and Allergology, Philipps-Universität, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps-Universität, Marburg, Germany
| | - Andreas Recke
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Hanna Graßhoff
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Alexander Hackel
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Anja Schumann
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Gant Sprow
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Joshua Dan
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Tanya Sezin
- Department of Dermatology, Columbia University Medical Center, New York, NY, United States
| | - Angela M Christiano
- Department of Dermatology, Columbia University Medical Center, New York, NY, United States
| | - Kerstin Wolk
- Psoriasis Research and Treatment Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Interdisciplinary Group Molecular Immunopathology, Dermatology/Medical Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Sabat
- Psoriasis Research and Treatment Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Interdisciplinary Group Molecular Immunopathology, Dermatology/Medical Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Victoria P Werth
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Ralf J Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
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11
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Sun C, Feng S. Recent developments in the pathogenesis of pruritus in bullous pemphigoid. Int J Dermatol 2021; 60:1441-1448. [PMID: 34037252 DOI: 10.1111/ijd.15589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/04/2021] [Accepted: 03/23/2021] [Indexed: 11/29/2022]
Abstract
Bullous pemphigoid (BP) is a common autoimmune bullous disease which mainly affects the elderly. The incidence of BP is gradually increasing and associated with high mortality. This disease is clinically characterized by intensely pruritic and widespread bullous lesions. Alternative therapy options for pruritus in patients with BP are limited primarily because pathophysiological mechanisms of itching in BP are still unclear. This review aims to explain crucial concepts of the pathogenesis of pruritus in BP. Vital findings in recent years will be summarized, and cofactors of the pathogenesis of pruritus will be discussed in detail. We will summarize knowledge on pathogenic factors in the immunologic level conducing to skin pruritus in BP.
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Affiliation(s)
- Chao Sun
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
| | - Suying Feng
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
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12
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Garrido PM, Queirós CS, Travassos AR, Borges-Costa J, Filipe P. Emerging treatments for bullous pemphigoid. J DERMATOL TREAT 2020; 33:649-661. [DOI: 10.1080/09546634.2020.1782325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Pedro Miguel Garrido
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
| | - Catarina Soares Queirós
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
| | - Ana Rita Travassos
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
| | - João Borges-Costa
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
- Dermatology Universitary Clinic, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Dermatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Lisbon, Portugal
| | - Paulo Filipe
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
- Dermatology Universitary Clinic, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Dermatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
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13
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Yang M, Wu H, Zhao M, Chang C, Lu Q. The pathogenesis of bullous skin diseases. J Transl Autoimmun 2019; 2:100014. [PMID: 32743502 PMCID: PMC7388362 DOI: 10.1016/j.jtauto.2019.100014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/14/2019] [Accepted: 08/21/2019] [Indexed: 01/13/2023] Open
Abstract
Bullous skin diseases are a group of dermatoses characterized by blisters and bullae in the skin and mucous membranes. The etiology and pathogenesis of bullous skin diseases are not completely clear. The most common are pemphigus and bullous pemphigoid (BP). Autoantibodies play critical roles in their pathogenesis. Abnormalities in the adhesion between keratinocytes in patients with pemphigus leads to acantholysis and formation of intra-epidermal blisters. Anti-desmoglein autoantibodies are present both in the circulation and skin lesions of patients with pemphigus. The deficient adhesion of keratinocytes to the basement membrane in BP patients gives rise to subepidermal blisters. Autoantibodies against the components of hemidesmosome can be detected in BP patients. Many novel therapeutics based on knowledge of the pathogenesis have emerged in recent years.
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Affiliation(s)
- Miao Yang
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, PR China
| | - Haijing Wu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, PR China
| | - Ming Zhao
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, PR China
| | - Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, 95616, USA
- Division of Pediatric Immunology and Allergy, Joe DiMaggio Children’s Hospital, Hollywood, FL, 33021, USA
| | - Qianjin Lu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, PR China
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14
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Messingham KN, Crowe TP, Fairley JA. The Intersection of IgE Autoantibodies and Eosinophilia in the Pathogenesis of Bullous Pemphigoid. Front Immunol 2019; 10:2331. [PMID: 31636640 PMCID: PMC6787172 DOI: 10.3389/fimmu.2019.02331] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/16/2019] [Indexed: 12/13/2022] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease characterized by autoantibodies targeting cellular adhesion molecules. While IgE autoantibodies are occasionally reported in other autoimmune blistering diseases, BP is unique in that most BP patients develop an IgE autoantibody response. It is not known why BP patients develop self-reactive IgE and the precise role of IgE in BP pathogenesis is not fully understood. However, clinical evidence suggests an association between elevated IgE antibodies and eosinophilia in BP patients. Since eosinophils are multipotent effector cells, capable cytotoxicity and immune modulation, the putative interaction between IgE and eosinophils is a primary focus in current studies aimed at understanding the key components of disease pathogenesis. In this review, we provide an overview of BP pathogenesis, highlighting clinical and experimental evidence supporting central roles for IgE and eosinophils as independent mediators of disease and via their interaction. Additionally, therapeutics targeting IgE, the Th2 axis, or eosinophils are also discussed.
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Affiliation(s)
- Kelly N Messingham
- Department of Dermatology, The University of Iowa, Iowa City, IA, United States
| | - Tyler P Crowe
- Department of Dermatology, The University of Iowa, Iowa City, IA, United States
| | - Janet A Fairley
- Department of Dermatology, The University of Iowa, Iowa City, IA, United States.,Iowa City VA Medical Center, Iowa City, IA, United States
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15
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Saschenbrecker S, Karl I, Komorowski L, Probst C, Dähnrich C, Fechner K, Stöcker W, Schlumberger W. Serological Diagnosis of Autoimmune Bullous Skin Diseases. Front Immunol 2019; 10:1974. [PMID: 31552014 PMCID: PMC6736620 DOI: 10.3389/fimmu.2019.01974] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/05/2019] [Indexed: 12/12/2022] Open
Abstract
Autoimmune bullous dermatoses (AIBD) encompass a variety of organ-specific autoimmune diseases that manifest with cutaneous and/or mucosal blisters and erosions. They are characterized by autoantibodies targeting structural proteins of the skin, which are responsible for the intercellular contact between epidermal keratinocytes and for adhesion of the basal keratinocytes to the dermis. The autoantibodies disrupt the adhesive functions, leading to splitting and blister formation. In pemphigus diseases, blisters form intraepidermally, whereas in all other disease types they occur subepidermally. Early identification of autoimmune bullous dermatoses is crucial for both treatment and prognosis, particularly as regards tumor-associated disease entities. The diagnosis is based on clinical symptoms, histopathology, direct immunofluorescence to detect antibody/complement deposits, and the determination of circulating autoantibodies. The identification of various target antigens has paved the way for the recent development of numerous specific autoantibody tests. In particular, optimized designer antigens and multiplex test formats for indirect immunofluorescence and ELISA have enhanced and refined the laboratory analysis, enabling highly efficient serodiagnosis and follow-up. This review elaborates on the current standards in the serological diagnostics for autoimmune bullous dermatoses.
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Affiliation(s)
| | - Ingolf Karl
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Christian Probst
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Cornelia Dähnrich
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Kai Fechner
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Winfried Stöcker
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
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16
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Seyed Jafari SM, Gadaldi K, Feldmeyer L, Yawalkar N, Borradori L, Schlapbach C. Effects of Omalizumab on FcεRI and IgE Expression in Lesional Skin of Bullous Pemphigoid. Front Immunol 2019; 10:1919. [PMID: 31474990 PMCID: PMC6702353 DOI: 10.3389/fimmu.2019.01919] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 07/29/2019] [Indexed: 11/26/2022] Open
Abstract
Recent studies suggest an important role of immunoglobulin E (IgE) as an alternative pathogenic pathway in the development of bullous pemphigoid (BP), as the most frequent subepidermal blistering disease of the skin Use of IgE targeted therapies, such as omalizumab, has been shown promising in recent studies. The aim of this study was to assess the effect of omalizumab on FcεRI and IgE expression on circulating basophils and on lesional intradermal cells in BP to generate insight into the immunological effects of omalizumab in BP. We report two cases of BP patients treated with omalizumab. Efficacy of treatment was assessed clinically 4 months after initiation of the therapy. Lesional and non-lesional skin biopsies where taken before and 4 weeks after initiation of omalizumab therapy. In addition, FcεRI expression on circulating cells and IgE levels in serum and in the skin samples, as well as anti-BP180 and anti-BP230 in serum and eosinophils and basophils counts in blood were assessed before and during treatment. Both patients showed a marked improvement after 4 months, with no adverse effects. Down-regulation of FcεRI, IgE in lesional skin and on circulating basophils were observed in parallel with clinical improvement. The current case study supports the role of omalizumab in the treatment of a subset of BP patients. Our observations suggest that omalizumab represents a valuable therapeutic option in the management of BP patients. Its efficacy might be related to reduction in FcεRI+ and IgE+ basophils and intradermal cells.
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Affiliation(s)
| | | | | | | | | | - Christoph Schlapbach
- Department of Dermatology, Inselspital-Bern University Hospital, University of Bern, Bern, Switzerland
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17
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Amber KT, Maglie R, Solimani F, Eming R, Hertl M. Targeted Therapies for Autoimmune Bullous Diseases: Current Status. Drugs 2019; 78:1527-1548. [PMID: 30238396 DOI: 10.1007/s40265-018-0976-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Autoimmune bullous skin disorders are rare but meaningful chronic inflammatory diseases, many of which had a poor or devastating prognosis prior to the advent of immunosuppressive drugs such as systemic corticosteroids, which down-regulate the immune pathogenesis in these disorders. Glucocorticoids and adjuvant immunosuppressive drugs have been of major benefit for the fast control of most of these disorders, but their long-term use is limited by major side effects such as blood cytopenia, osteoporosis, diabetes mellitus, hypertension, and gastrointestinal ulcers. In recent years, major efforts were made to identify key elements in the pathogenesis of autoimmune bullous disorders, leading to the identification of their autoantigens, which are mainly located in desmosomes (pemphigus) and the basement membrane zone (pemphigoids). In the majority of cases, immunoglobulin G, and to a lesser extent, immunoglobulin A autoantibodies directed against distinct cutaneous adhesion molecules are directly responsible for the loss of cell-cell and cell-basement membrane adhesion, which is clinically related to the formation of blisters and/or erosions of the skin and mucous membranes. We describe and discuss novel therapeutic strategies that directly interfere with the production and regulation of pathogenic autoantibodies (rituximab), their catabolism (intravenous immunoglobulins), and their presence in the circulation and extravascular tissues such as the skin (immunoadsorption), leading to a significant amelioration of disease. Moreover, we show that these novel therapies have pleiotropic effects on various proinflammatory cells and cytokines. Recent studies in bullous pemphigoid suggest that targeting of immunoglobulin E autoantibodies (omalizumab) may be also beneficial. In summary, the introduction of targeted therapies in pemphigus and pemphigoid holds major promise because of the high efficacy and fewer side effects compared with conventional global immunosuppressive therapy.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of Illinois at Chicago, 808 Wood St. Room 377, Chicago, IL, 60612, USA.
| | - Roberto Maglie
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany.,Department of Surgery and Translational Medicine, Section of Dermatology, University of Florence, Florence, Italy
| | - Farzan Solimani
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany
| | - Rüdiger Eming
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany.
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18
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Genovese G, Di Zenzo G, Cozzani E, Berti E, Cugno M, Marzano AV. New Insights Into the Pathogenesis of Bullous Pemphigoid: 2019 Update. Front Immunol 2019; 10:1506. [PMID: 31312206 PMCID: PMC6614376 DOI: 10.3389/fimmu.2019.01506] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/17/2019] [Indexed: 12/19/2022] Open
Abstract
There are several lines of evidence indicating that the physiopathological bases of bullous pemphigoid (BP), the most common subepidermal autoimmune bullous disease, are hallmarked by the production of autoantibodies directed against the hemidesmosomal anchoring proteins BP180 and BP230. In contrast to the robustness of the latter assumption, the multifaceted complexity of upstream and downstream mechanisms implied in the pathogenesis of BP remains an area of intense speculation. So far, an imbalance between T regulatory cells and autoreactive T helper (Th) cells has been regarded as the main pathogenic factor triggering the autoimmune response in BP patients. However, the contributory role of signaling pathways fostering the B cell stimulation, such as Toll-like receptor activation, as well as that of ancillary inflammatory mechanisms responsible for blister formation, such as Th17 axis stimulation and the activation of the coagulation cascade, are still a matter of debate. In the same way, the pathomechanisms implied in the loss of dermal-epidermal adhesion secondary to autoantibodies binding are not fully understood. Herein, we review in detail the current concepts and controversies on the complex pathogenesis of BP, shedding light on the most recent theories emerging from the literature.
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Affiliation(s)
- Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Di Zenzo
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell'Immacolata (IDI) IRCCS, Rome, Italy
| | - Emanuele Cozzani
- DISSAL Section of Dermatology, Università degli Studi di Genova, Genoa, Italy
| | - Emilio Berti
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Massimo Cugno
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Internal Medicine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
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19
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Giusti D, Le Jan S, Gatouillat G, Bernard P, Pham BN, Antonicelli F. Biomarkers related to bullous pemphigoid activity and outcome. Exp Dermatol 2018; 26:1240-1247. [PMID: 29105148 DOI: 10.1111/exd.13459] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2017] [Indexed: 12/11/2022]
Abstract
Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease of the skin. Investigation of the BP-associated pathophysiological processes during the last decades showed that the generation of autoantibodies directed against the hemidesmosome proteins BP180 and BP230, a hallmark of the BP-associated autoimmune response, leads to the recruitment of inflammatory immune cells at the dermal-epidermal junction, and subsequently to the release of a large amount of inflammatory molecules involved in blister formation. Analysis in transversal and longitudinal studies of autoantibodies and inflammatory molecules production both at the time of diagnosis and under treatment was mainly performed within the serum but also in the blister fluid. Some autoimmune or inflammatory molecules expression was related to the presence of clinical signs, while others were mere bystanders. In this review, we focused on the autoimmune and inflammatory molecules that have been identified as potential biomarkers of BP development and outcome.
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Affiliation(s)
- Delphine Giusti
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Sébastien Le Jan
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France
| | - Gregory Gatouillat
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Philippe Bernard
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Bach Nga Pham
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims Champagne-Ardenne, Reims, France
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20
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James T, Salman S, Stevenson B, Bundell C, Kelly G, Nolan D, John M. IgE blockade in autoimmunity: Omalizumab induced remission of bullous pemphigoid. Clin Immunol 2018; 198:54-56. [PMID: 30557620 DOI: 10.1016/j.clim.2018.12.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 11/04/2018] [Accepted: 12/12/2018] [Indexed: 12/16/2022]
Abstract
Bullous pemphigoid (BP) is a blistering dermopathy and a prototypic antibody-mediated autoimmune disease. Detection of IgG autoantibodies against hemidesmosomal proteins BP180 and/or BP230 are diagnostic and levels can correlate with disease activity. Therapies include corticosteroids and oral immunosuppressants, while intravenous immunoglobulin and rituximab are reserved for treatment resistant cases. Here we describe a patient with severe BP which was refractory to standard first line therapy, intravenous immunoglobulin and rituximab induced depletion of peripheral B cells. Use of the monoclonal anti-IgE antibody omalizumab resulted in rapid resolution of blistering despite ongoing high levels of anti-skin IgG antibodies. To our knowledge this is the first case of BP responsive to omalizumab after failure of rituximab to be reported. This case adds to emerging data on omalizumab as a novel BP treatment as well as providing new evidence of an independent role for autoreactive IgE-mediated inflammation in the formation of BP skin lesions.
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Affiliation(s)
- Talia James
- Department of Clinical Immunology, Royal Perth Hospital, Perth, WA 6000, Australia.
| | - Sam Salman
- Department of Clinical Immunology, Royal Perth Hospital, Perth, WA 6000, Australia; Department of Immunology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, WA 6009, Australia; Medical School, University of Western Australia, Perth, WA 6009, Australia
| | - Brittany Stevenson
- Department of Clinical Immunology, Royal Perth Hospital, Perth, WA 6000, Australia; Department of Immunology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, WA 6009, Australia
| | - Christine Bundell
- Department of Immunology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, WA 6009, Australia
| | - Gavin Kelly
- Department of Clinical Immunology, Royal Perth Hospital, Perth, WA 6000, Australia
| | - David Nolan
- Department of Clinical Immunology, Royal Perth Hospital, Perth, WA 6000, Australia
| | - Mina John
- Department of Clinical Immunology, Royal Perth Hospital, Perth, WA 6000, Australia; Institute of Immunology and Infectious Diseases (IIID), Murdoch University, Murdoch, WA 6150, Australia.
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21
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Corti L, Fanoni D, Venegoni L, Muratori S, Recalcati S, Berti E. Detection of IgE autoantibodies in mucous membrane pemphigoid and their association with disease severity. GIORN ITAL DERMAT V 2018; 155:754-759. [PMID: 30298707 DOI: 10.23736/s0392-0488.18.06167-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Mucous membrane pemphigoid (MMP) is an autoimmune disease characterized by scarring lesions at mucosal sites. Although the pathogenic role of specific IgG and/or IgA has been already demonstrated and the detection of these immunoglobulins is a criterion in the diagnosis of MMP, little is known about IgE role in this disease. Therefore, the main purpose of this study was to assess the presence of circulating and tissue bound IgE in patients with MMP and their possible correlations with clinical presentation and disease course. METHODS We conducted a retrospective study on 29 patients affected by MMP, recruited from a single center. Direct and indirect immunofluorescence studies were assessed to analyze the presence of specific IgE directed against the basal membrane zone. For each patient, fluorescence data were compared to clinical features. RESULTS Linear deposits of C3, IgG and IgA were present in 86.2%, 62% and 37.9% of cases respectively, while IgE linear deposits were detected in 17 out of 29 patients (58.6%) including one case with isolated IgE positivity. Circulating IgE and IgA anti-BMZ were present in 7 (24.1%) and 5 (17.2%) patients, respectively. Both the presence of circulating IgA and of tissue bound IgE deposits correlated with disease activity index (P<0.014). CONCLUSIONS Our results demonstrated the presence of IgE autoantibodies in MMP, particularly in more severe cases. Thus, IgE detection may represent an additional useful diagnostic tool in this disease.
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Affiliation(s)
- Laura Corti
- Unit of Dermatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Fanoni
- Department of Medical-Surgical Physiopathology and of Transplants, University of Milan, Milan, Italy -
| | - Luigia Venegoni
- Department of Medical-Surgical Physiopathology and of Transplants, University of Milan, Milan, Italy
| | - Simona Muratori
- Unit of Dermatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sebastiano Recalcati
- Unit of Dermatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emilio Berti
- Unit of Dermatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Medical-Surgical Physiopathology and of Transplants, University of Milan, Milan, Italy
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22
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Amber KT, Valdebran M, Kridin K, Grando SA. The Role of Eosinophils in Bullous Pemphigoid: A Developing Model of Eosinophil Pathogenicity in Mucocutaneous Disease. Front Med (Lausanne) 2018; 5:201. [PMID: 30042946 PMCID: PMC6048777 DOI: 10.3389/fmed.2018.00201] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease which carries a significant mortality and morbidity. While historically BP has been characterized as an IgG driven disease mediated by anti-BP180 and BP230 IgG autoantibodies, developments in recent years have further elucidated the role of eosinophils and IgE autoantibodies. In fact, eosinophil infiltration and eosinophilic spongiosis are prominent features in BP. Several observations support a pathogenic role of eosinophils in BP: IL-5, eotaxin, and eosinophil-colony stimulating factor are present in blister fluid; eosinophils line the dermo-epidermal junction (DEJ) in the presence of BP serum, metalloprotease-9 is released by eosinophils at the site of blisters; eosinophil degranulation proteins are found on the affected basement membrane zone as well as in serum corresponding with clinical disease; eosinophil extracellular DNA traps directed against the basement membrane zone are present, IL-5 activated eosinophils cause separation of the DEJ in the presence of BP serum; and eosinophils are the necessary cell required to drive anti-BP180 IgE mediated skin blistering. Still, it is likely that eosinophils contribute to the pathogenesis of BP in numerous other ways that have yet to be explored based on the known biology of eosinophils. We herein will review the role of eosinophils in BP and provide a framework for understanding eosinophil pathogenic mechanisms in mucocutaneous disease.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of California, Irvine, Irvine, CA, United States
| | - Manuel Valdebran
- Department of Dermatology, University of California, Irvine, Irvine, CA, United States
| | - Khalaf Kridin
- Department of Dermatology, Rambam Healthcare Campus, Haifa, Israel
| | - Sergei A Grando
- Department of Dermatology, University of California, Irvine, Irvine, CA, United States.,Departments of Dermatology and Biological Chemistry, Institute for Immunology, University of California, Irvine, Irvine, CA, United States
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23
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Lin L, Hwang BJ, Culton DA, Li N, Burette S, Koller BH, Messingham KA, Fairley JA, Lee JJ, Hall RP, An L, Diaz LA, Liu Z. Eosinophils Mediate Tissue Injury in the Autoimmune Skin Disease Bullous Pemphigoid. J Invest Dermatol 2018; 138:1032-1043. [PMID: 29246800 PMCID: PMC7531612 DOI: 10.1016/j.jid.2017.11.031] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 11/03/2017] [Accepted: 11/14/2017] [Indexed: 01/21/2023]
Abstract
Eosinophils are typically associated with unique inflammatory settings, including allergic inflammation and helminth infections. However, new information suggests that eosinophils contribute more broadly to inflammatory responses and participate in local immune regulation and the tissue remodeling/repair events linked with a variety of diseases. Eosinophilic infiltration has long been a histologic hallmark of bullous pemphigoid (BP), a subepidermal autoimmune blistering disease characterized by autoantibodies directed against basement membrane protein BP180. However, the exact role of eosinophils in disease pathogenesis remains largely unknown. We show here that eosinophils are necessary for IgE autoantibody-mediated BP blister formation in a humanized IgE receptor mouse model of BP. Disease severity is IgE dose dependent and correlates with the degree of eosinophil infiltration in the skin. Furthermore, IgE autoantibodies fail to induce BP in eosinophil-deficient mice, confirming that eosinophils are required for IgE-mediated tissue injury. Thus, eosinophils provide the cellular link between IgE autoantibodies and skin blistering in this murine model of BP. These findings suggest a role for eosinophils in autoimmune disease and have important implications for the treatment of BP and other antibody-mediated inflammatory and autoimmune diseases.
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Affiliation(s)
- Lan Lin
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; School of Life Science and Biotechnology, Dalian University of Technology, Dalian, Liaoning, People's Republic of China
| | - Bin-Jin Hwang
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Donna A Culton
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ning Li
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan Burette
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Beverly H Koller
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Janet A Fairley
- Department of Dermatology, University of Iowa, Iowa City, Iowa, USA
| | - James J Lee
- Mayo Clinic Arizona, Department of Biochemistry and Molecular Biology, Scottsdale, Arizona, USA
| | - Russell P Hall
- Department of Dermatology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lijia An
- School of Life Science and Biotechnology, Dalian University of Technology, Dalian, Liaoning, People's Republic of China
| | - Luis A Diaz
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Zhi Liu
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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24
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Freire P, Muñoz C, Stingl G. IgE autoreactivity in bullous pemphigoid: eosinophils and mast cells as major targets of pathogenic immune reactants. Br J Dermatol 2017; 177:1644-1653. [PMID: 28868796 PMCID: PMC5814899 DOI: 10.1111/bjd.15924] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune disease characterized by tense blisters that are usually preceded by urticarial eruptions. Affected patients exhibit IgG and/or IgE autoantibodies against BP180 and/or BP230. Their relative importance in disease pathogenesis has not been fully elucidated. OBJECTIVES The aim of this study was to provide a better characterization of the circulating and tissue-resident IgE in patients with BP at the serological, structural and functional levels. METHODS Sera (n = 19) and skin (n = 33) from patients with BP were analysed via enzyme-linked immunosorbent assay (ELISA) and immunofluorescence, respectively. RESULTS The results obtained show that many patients with BP exhibit elevated IgE levels in the serum and in the skin. In the skin, it is very rarely and only sparsely found along the basement membrane zone, but is prominently present on mast cells and eosinophils. At least a portion of these IgE antibodies are BP-specific, as evidenced by serum ELISA and by the colocalization of BP180 and FcεRI-bound IgE on mast cells and/or eosinophils. An important role of these immune reactants can be inferred from our additional finding that cross-linking of IgE, derived from BP sera, on FcεRI-expressing rat basophils with BP180 results in robust degranulation of these cells. CONCLUSIONS We propose the existence of a disease pathway alternative to IgG and complement that may well be responsible for some of the clinical features of this autoimmune disease.
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Affiliation(s)
- P.C. Freire
- Department of DermatologyDivision of Immunology, Allergy and Infectious DiseasesMedical University of ViennaVienna1090Austria
| | - C.H. Muñoz
- Department of DermatologyDivision of Immunology, Allergy and Infectious DiseasesMedical University of ViennaVienna1090Austria
| | - G. Stingl
- Department of DermatologyDivision of Immunology, Allergy and Infectious DiseasesMedical University of ViennaVienna1090Austria
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25
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Simon D, Borradori L, Simon HU. Eosinophils as putative therapeutic targets in bullous pemphigoid. Exp Dermatol 2017; 26:1187-1192. [PMID: 28833620 DOI: 10.1111/exd.13416] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2017] [Indexed: 12/14/2022]
Abstract
Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering skin disease and is characterized by the presence of autoantibodies directed against the hemidesmosomal proteins BP180 and BP230 that can be detected in the skin and serum of BP patients. Histologically, the dermal infiltration of eosinophils is obvious. The objective of this review was to present evidence that eosinophils play a key role in the pathogenesis of BP. Eosinophils, together with cytokines and chemokines regulating their production, recruitment and activation, are abundantly present in lesional skin, in blisters and in peripheral blood of patients with BP. Recently, using a cryosection model, eosinophils were demonstrated to induce dermal-epidermal separation in the presence of BP antibodies. Thus, eosinophils and their products, as well as mediators regulating their function, present promising targets for the treatment of BP.
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Affiliation(s)
- Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luca Borradori
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland
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26
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IgE autoantibodies and their association with the disease activity and phenotype in bullous pemphigoid: a systematic review. Arch Dermatol Res 2017; 310:11-28. [PMID: 29071428 PMCID: PMC5754504 DOI: 10.1007/s00403-017-1789-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 10/01/2017] [Accepted: 10/16/2017] [Indexed: 12/13/2022]
Abstract
Bullous pemphigoid (BP) is the most common autoimmune skin disease of blistering character. The underlying pathophysiological mechanism involves an immune attack, usually by IgG class autoantibodies, on the autoantigen BP 180/BPAg2, which is a type XVII collagen (COL17) protein acting as the adhesion molecule between the epidermis and the basement membrane of the dermis. About 40 years ago, following consistent findings of elevated total serum IgE levels in BP patients, it was hypothesized that IgE may be involved in the pathophysiology of BP. Our objective was to determine whether there is strong evidence for an association between IgE class autoantibodies and the clinical severity or phenotype of BP. Three databases were searched for relevant studies and appropriate exclusion and inclusion criteria were applied. Data was extracted and assessed in relation to the study questions concerning the clinical significance of IgE autoantibodies in BP. Nine studies found that anti-BP180 autoantibodies of IgE class are associated with increased severity of BP, whereas two studies did not find such an association. The number of studies which found an association between higher IgE autoantibody levels and the erythematous urticarial phenotype of BP (5) was equal in number to the studies which found no such association (5). In conclusion, higher serum IgE autoantibody levels are associated with more severe clinical manifestations of BP. There is insufficient evidence to support higher IgE autoantibody levels being associated with specific clinical phenotypes of BP.
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27
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Hashimoto T, Ohzono A, Teye K, Numata S, Hiroyasu S, Tsuruta D, Hachiya T, Kuroda K, Hashiguchi M, Kawakami T, Ishii N. Detection of IgE autoantibodies to BP180 and BP230 and their relationship to clinical features in bullous pemphigoid. Br J Dermatol 2017; 177:141-151. [PMID: 27716903 DOI: 10.1111/bjd.15114] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND IgE autoantibodies are considered to be involved in the pathogenesis of bullous pemphigoid (BP), particularly inflammatory and erythematous phenotypes. OBJECTIVES To develop reliable enzyme-linked immunosorbent assays (ELISAs) for the detection of IgE autoantibodies to both BP180 and BP230 in BP sera, and to compare the ELISA results with clinical features. METHODS We used commercially available IgG ELISAs to develop IgE ELISAs for both BP180 and BP230. To determine the influence of excess amounts of IgG autoantibodies, all normal and BP sera were tested before and after IgG adsorption. The results of the IgE ELISAs were statistically compared with various ELISAs and various clinical parameters, including our own severity scores and BP phenotypes. RESULTS IgG adsorption generally showed no changes in sensitivity and specificity for IgE ELISAs, although slight cross-reactivity of anti-IgE secondary antibody to IgG and interference of excess amounts of IgG autoantibodies to IgE reactivity were suggested. IgE autoantibodies to BP180 were found in 21 of 36 BP sera and IgE autoantibodies to BP230 were found in 18 of 36 BP sera. The results of IgG and IgE ELISAs for both BP180 and BP230 were well correlated. IgG and IgE anti-BP180 antibodies correlated with disease activity but IgG and IgE anti-BP230 autoantibodies did not. IgE anti-BP230 autoantibodies correlated with nodular phenotype but not erythematous phenotype. CONCLUSIONS The results of this study indicated that IgE autoantibodies to both BP180 and BP230 are frequently detected in BP sera. IgE anti-BP180 autoantibodies seemed to be pathogenic, while an association between IgE autoantibodies and inflammatory BP phenotype was not indicated.
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Affiliation(s)
- T Hashimoto
- Department of Dermatology, Kurume University School of Medicine and Kurume University Institute of Cutaneous Cell Biology, Kurume, Fukuoka, Japan
| | - A Ohzono
- Department of Dermatology, Kurume University School of Medicine and Kurume University Institute of Cutaneous Cell Biology, Kurume, Fukuoka, Japan
| | - K Teye
- Department of Dermatology, Kurume University School of Medicine and Kurume University Institute of Cutaneous Cell Biology, Kurume, Fukuoka, Japan
| | - S Numata
- Department of Dermatology, Kurume University School of Medicine and Kurume University Institute of Cutaneous Cell Biology, Kurume, Fukuoka, Japan
| | - S Hiroyasu
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - D Tsuruta
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - T Hachiya
- Research and Development Division, Medical and Biological Laboratories Co. Ltd., Nagoya, Aichi, Japan
| | - K Kuroda
- IVD Development Department, Medical and Biological Laboratories Co. Ltd., Nagoya, Aichi, Japan
| | - M Hashiguchi
- Sales & Marketing Division, Medical and Biological Laboratories Co. Ltd., Nagoya, Aichi, Japan
| | - T Kawakami
- Department of Dermatology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - N Ishii
- Department of Dermatology, Kurume University School of Medicine and Kurume University Institute of Cutaneous Cell Biology, Kurume, Fukuoka, Japan
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28
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Bağcı IS, Horváth ON, Ruzicka T, Sárdy M. Bullous pemphigoid. Autoimmun Rev 2017; 16:445-455. [DOI: 10.1016/j.autrev.2017.03.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 11/27/2022]
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29
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Qian Y, Culton DA, Jeong JS, Trupiano N, Valenzuela JG, Diaz LA. Non-infectious environmental antigens as a trigger for the initiation of an autoimmune skin disease. Autoimmun Rev 2016; 15:923-30. [PMID: 27396816 DOI: 10.1016/j.autrev.2016.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 06/13/2016] [Indexed: 12/20/2022]
Abstract
Pemphigus represents a group of organ specific autoimmune blistering disorders of the skin mediated by pathogenic autoantibodies with well-defined antigenic targets. While most of these diseases are sporadic, endemic forms of disease do exist. The endemic form of pemphigus foliaceus (also known as fogo selvagem, FS) exhibits epidemiological features that suggest exposure to hematophagous insect bites are a possible precipitating factor of this autoimmune disease, and provides a unique opportunity to study how environmental factors contribute to autoimmune disease development. FS patients and healthy individuals from endemic regions show an autoreactive IgM response that starts in early childhood and becomes restricted to IgG4 autoantibodies in FS patients. In searching for triggering environmental antigens, we have found that IgG4 and IgE autoantibodies from FS patients cross-react with a salivary antigen from sand flies. The presence of these cross-reactive antibodies and antibody genetic analysis confirming that these antibodies evolve from the same naïve B cells provides compelling evidence that this non-infectious environmental antigen could be the initial target of the autoantibody response in FS. Consequently, FS serves as an ideal model to study the impact of environmental antigens in the development of autoimmune disease.
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Affiliation(s)
- Ye Qian
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Donna A Culton
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Joseph S Jeong
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Nicole Trupiano
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Jesus G Valenzuela
- Vector Molecular Biology Section, LMVR, National Institute of Allergy and Infectious Diseases, NIH, Rockville, MD 20852, USA
| | - Luis A Diaz
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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30
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Balakirski G, Alkhateeb A, Merk H, Leverkus M, Megahed M. Successful treatment of bullous pemphigoid with omalizumab as corticosteroid-sparing agent: report of two cases and review of literature. J Eur Acad Dermatol Venereol 2016; 30:1778-1782. [DOI: 10.1111/jdv.13758] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 03/31/2016] [Indexed: 11/28/2022]
Affiliation(s)
- G. Balakirski
- Department of Dermatology and Allergology; Universitiy Hospital of Aachen; Aachen Germany
| | - A. Alkhateeb
- Department of Dermatology and Allergology; Universitiy Hospital of Aachen; Aachen Germany
| | - H.F. Merk
- Department of Dermatology and Allergology; Universitiy Hospital of Aachen; Aachen Germany
| | - M. Leverkus
- Department of Dermatology and Allergology; Universitiy Hospital of Aachen; Aachen Germany
| | - M. Megahed
- Department of Dermatology and Allergology; Universitiy Hospital of Aachen; Aachen Germany
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31
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Hammers CM, Stanley JR. Mechanisms of Disease: Pemphigus and Bullous Pemphigoid. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2016; 11:175-97. [PMID: 26907530 DOI: 10.1146/annurev-pathol-012615-044313] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pemphigus and bullous pemphigoid are autoantibody-mediated blistering skin diseases. In pemphigus, keratinocytes in epidermis and mucous membranes lose cell-cell adhesion, and in pemphigoid, the basal keratinocytes lose adhesion to the basement membrane. Pemphigus lesions are mediated directly by the autoantibodies, whereas the autoantibodies in pemphigoid fix complement and mediate inflammation. In both diseases, the autoantigens have been cloned and characterized; pemphigus antigens are desmogleins (cell adhesion molecules in desmosomes), and pemphigoid antigens are found in hemidesmosomes (which mediate adhesion to the basement membrane). This knowledge has enabled diagnostic testing for these diseases by enzyme-linked immunosorbent assays and dissection of various pathophysiological mechanisms, including direct inhibition of cell adhesion, antibody-induced internalization of antigen, and cell signaling. Understanding these mechanisms of disease has led to rational targeted therapeutic strategies.
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Affiliation(s)
- Christoph M Hammers
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania 19104; .,Department of Dermatology, University of Luebeck, D-23562 Luebeck, Germany;
| | - John R Stanley
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania 19104;
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32
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Mersmann M, Dworschak J, Ebermann K, Komorowski L, Schlumberger W, Stöcker W, Zillikens D, Probst C, Schmidt E. Immunoadsorber for specific apheresis of autoantibodies in the treatment of bullous pemphigoid. Arch Dermatol Res 2016; 308:31-8. [PMID: 26498290 DOI: 10.1007/s00403-015-1606-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 09/29/2015] [Accepted: 10/14/2015] [Indexed: 01/28/2023]
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering skin disease associated with autoantibodies against two hemidesmosomal proteins, BP180 (type XVII collagen) and BP230. As the pathogenic relevance of antibodies against the immunodominant NC16A domain of BP180 has been clearly demonstrated, specific removal of these antibodies should be a rational therapeutic approach. Here, we evaluated three recombinant forms of bacterially produced BP180 NC16A, a monomer, trimer, and tetramer, together with different matrices for their efficacy to specifically adsorb autoantibodies from BP plasma samples. An adsorber consisting of NC16A-trimer coupled to NHS-activated Sepharose 4 Fast Flow revealed satisfying adsorption rates and a high specificity. The NC16A-trimer adsorber was regenerable and autoclavable. It has the potential to be used for specific immunoadsorption to treat severe and refractory BP and other pemphigoid diseases associated with BP180 NC16A reactivity.
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Affiliation(s)
- Michael Mersmann
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany.
| | - Jenny Dworschak
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Kristin Ebermann
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Lars Komorowski
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Wolfgang Schlumberger
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Winfried Stöcker
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Christian Probst
- Institute of Experimental Immunology, Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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33
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van Beek N, Schulze FS, Zillikens D, Schmidt E. IgE-mediated mechanisms in bullous pemphigoid and other autoimmune bullous diseases. Expert Rev Clin Immunol 2015; 12:267-77. [PMID: 26588556 DOI: 10.1586/1744666x.2016.1123092] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Autoimmune bullous diseases (AIBDs) are characterized by autoantibodies against structural proteins of the dermal-epidermal junction (in pemphigoid diseases) and the epidermal/ epithelial desmosomes (in pemphigus diseases). By far, the most common AIBD is bullous pemphigoid, which is immunopathologically characterized by autoantibodies against BP180 (type XVII collagen) and BP230. IgG and, to a lesser extent, IgA autoantibodies are the major autoantibody isotypes in these disorders. IgE autoantibodies are increasingly reported in particular in bullous pemphigoid. The development of specific and sensitive anti-BP180 IgE ELISA systems, the report of two experimental murine models employing IgE autoantibodies against BP180, and the successful treatment of bullous pemphigoid with the anti-IgE antibody omalizumab have raised interest in the role of IgE autoantibodies and the modulation of their production in AIBDs. Here, the relevance of IgE autoantibodies in the diagnosis, pathophysiology, and treatment decisions of AIBDs, with a focus on bullous pemphigoid, is reviewed.
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Affiliation(s)
- Nina van Beek
- a Department of Dermatology , University of Lübeck , Lübeck , Germany
| | - Franziska S Schulze
- b Lübeck Institute of Experimental Dermatology (LIED) , University of Lübeck , Lübeck , Germany
| | - Detlef Zillikens
- a Department of Dermatology , University of Lübeck , Lübeck , Germany
| | - Enno Schmidt
- a Department of Dermatology , University of Lübeck , Lübeck , Germany
- b Lübeck Institute of Experimental Dermatology (LIED) , University of Lübeck , Lübeck , Germany
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34
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Zuo Y. Is anti-BP180 IgE associated with clinical phenotype? Reply to the letter to the editor. Arch Dermatol Res 2015; 308:67-8. [PMID: 26596575 DOI: 10.1007/s00403-015-1610-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/05/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Yagang Zuo
- Peking Union Medical College Hospital, Beijing, China.
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35
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Messingham KN, Wang JW, Holahan HM, Srikantha R, Aust SC, Fairley JA. Eosinophil localization to the basement membrane zone is autoantibody- and complement-dependent in a human cryosection model of bullous pemphigoid. Exp Dermatol 2015; 25:50-5. [PMID: 26475989 DOI: 10.1111/exd.12883] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2015] [Indexed: 01/21/2023]
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease characterized by antibodies (IgG and IgE) targeting cell-substrate adhesion proteins. A variety of BP models suggest that autoantibody-dependent neutrophil degranulation is essential for blister formation. However, lesional biopsies reveal a predominance of eosinophils and few neutrophils. Our goal was to evaluate the role of antibodies and complement in eosinophil localization, degranulation and split formation at the dermo-epidermal junction (DEJ) utilizing a human skin cryosection model of BP paired with a human eosinophilic cell line, 15HL-60. Expression of receptors for IgG (FcγRII), IgE (FcεRI) and complement (CR1 and CR3) was confirmed on 15HL-60 cells using flow cytometry. 15HL-60 expression of granule protein [eosinophil derived neurotoxin (EDN) and eosinophil peroxidase (EPO)] mRNA and their degranulation in vitro was confirmed using RT-PCR and ELISA, respectively. For cryosection experiments, BP or control sera or IgG and IgE antibodies purified from BP sera were utilized in combination with 15HL-60 cells ± fresh complement. Both BP serum and fresh complement were required for localization of 15-HL60 cells to the DEJ. Interestingly, eosinophil localization to the DEJ was dependent on IgG, but not IgE, and complement. However, no subepidermal split was observed. Additionally, the 15HL-60 cells did not degranulate under any experimental conditions and direct application of cell lysate to cryosections did not result in a split. Our observation that eosinophil localization to the DEJ is dependent on IgG mediated complement fixation provides additional insight into the sequence of events during the development of BP lesions.
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Affiliation(s)
| | - Jeffrey W Wang
- Department of Dermatology, University of Iowa, Iowa City, IA, USA
| | | | | | - Samantha C Aust
- Department of Dermatology, University of Iowa, Iowa City, IA, USA
| | - Janet A Fairley
- Department of Dermatology, University of Iowa, Iowa City, IA, USA.,Veterans Administration Medical Center, Iowa City, IA, USA
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Amber KT. Is anti-BP180 IgE associated with clinical phenotype? A reply to 'Levels of anti-BP180 NC16A IgE do not correlate with severity of disease in the early stages of bullous pemphigoid'. Arch Dermatol Res 2015; 308:65-6. [PMID: 26590973 DOI: 10.1007/s00403-015-1609-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 11/05/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of California Irvine, Irvine, CA, USA. .,, 118 Med Surg 1, Irvine, CA, 92697-2400, USA.
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Bing L, Xiping Z, Li L, Jun P, Yi-Xia W, Min Y, Qing L, Qiu-Ning S, Hong-Zhong J, Ya-Gang Z. Levels of anti-BP180 NC16A IgE do not correlate with severity of disease in the early stages of bullous pemphigoid. Arch Dermatol Res 2015; 307:849-54. [PMID: 26404084 DOI: 10.1007/s00403-015-1598-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 08/16/2015] [Accepted: 09/07/2015] [Indexed: 10/23/2022]
Abstract
Bullous pemphigoid (BP), a common autoimmune skin disease, is associated with IgG autoantibodies against the hemidesmosomal proteins, BP180 and BP230. In addition to IgG, IgE has been shown to play a role in the disease. However, the association between disease activity and IgE specific to the NC16A domain of BP180 in blister fluid remains unclear. Our objective was to evaluate the correlation between BP disease activity and BP180 NC16A-specific IgE sera and blister fluid titers, and to analyze changes during treatment. We evaluated the levels of anti-BP180 IgE autoantibodies in the sera and blister fluids of 37 BP patients using an Enzyme-linked immunosorbent assay. We also observed changes in the levels of these antibodies in 2 BP patients at 4 or 5 different time points (day 0 when the patient first visited our hospital, day 5, day 14, day 39 and day 62 for patient 1; day 0, day 4, day 8 and day 17 for patient 2). We also collected extra serum samples from the 2 patients when the disease was controlled (blister disappeared) (day 85, day 104 and day 146 for patient 1 and day 123, day 158 and day 189 for the other patient). IgE anti-BP180 antibodies were detected in the serum of 72.97 % of the patients. There was no correlation between disease activity scores and BP180 NC16A IgE titers in serum (r = -0.077, p > 0.05) or in blister fluid (r = 0.262, p > 0.05). The levels of the autoantibody in serum were positively correlated with that in blister fluid (r = 0.6651, p < 0.001); however, the levels continued to rise despite effective control of the disease in the initial two to 6 weeks of diagnosis. The level of this autoantibody reached a peak on day 39 for patient 1 and on day 17 for patient 2 although the systemic and topical medication of steroid had controlled the disease process effectively. We conclude that levels of anti-BP180 NC16A IgE are higher in the sera than blister fluids. These levels could generally reflect disease severity throughout the course of the disease, but not in the early stages of medication.
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Affiliation(s)
- Liu Bing
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No 1 Shuaifuyuan Hutong, Dongcheng District, Beijing, 100730, China
| | - Zhou Xiping
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No 1 Shuaifuyuan Hutong, Dongcheng District, Beijing, 100730, China
| | - Li Li
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No 1 Shuaifuyuan Hutong, Dongcheng District, Beijing, 100730, China
| | - Peng Jun
- Department of Dermatology, Cangzhou People's Hospital, Cangzhou, Hebei Province, China
| | - Wang Yi-Xia
- Department of Dermatology, Air Force General Hospital, Beijing, China
| | - Yang Min
- Department of Dermatology, Beijing Hospital, Beijing, China
| | - Liu Qing
- Department of Dermatology, Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Sun Qiu-Ning
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No 1 Shuaifuyuan Hutong, Dongcheng District, Beijing, 100730, China
| | - Jin Hong-Zhong
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No 1 Shuaifuyuan Hutong, Dongcheng District, Beijing, 100730, China
| | - Zuo Ya-Gang
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No 1 Shuaifuyuan Hutong, Dongcheng District, Beijing, 100730, China.
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Ujiie H. IgE autoantibodies in bullous pemphigoid: supporting role, or leading player? J Dermatol Sci 2015; 78:5-10. [PMID: 25797172 DOI: 10.1016/j.jdermsci.2015.03.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 02/26/2015] [Accepted: 03/02/2015] [Indexed: 11/16/2022]
Abstract
Bullous pemphigoid (BP) is a common autoimmune blistering skin disease in which two hemidesmosomal components--the transmembrane collagen XVII (BP180 or BPAG2) and the plakin family protein BP230 (BPAG1)--are targeted by autoimmunity. Of these, collagen XVII (COL17) is thought to be a major autoantigen, and vital roles of IgG autoantibodies in blister formation have been elucidated. However, BP shows distinct features, including pruritic urticarial erythema and eosinophilic infiltration, which may be independent of IgG-mediated autoimmunity. Recently, it has been revealed that sera from certain patients with BP contain IgE autoantibodies to COL17 and that IgE autoantibodies bind to peri-lesional dermal-epidermal junctions. Mouse models have demonstrated that IgE antibodies to COL17 induce erythema and eosinophilic infiltration in skin. In addition, the successful treatment of severe BP with omalizumab, a humanized monoclonal antibody targeting IgE, has been reported. These findings suggest that both IgG and IgE autoantibodies to COL17 may be involved in the BP pathogenesis. This article summarizes IgE-mediated autoimmunity to COL17 in BP.
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Affiliation(s)
- Hideyuki Ujiie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, N15W7, Kita-Ku, Sapporo 060-8638, Japan.
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39
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Moriuchi R, Nishie W, Ujiie H, Natsuga K, Shimizu H. In vivo analysis of IgE autoantibodies in bullous pemphigoid: a study of 100 cases. J Dermatol Sci 2015; 78:21-5. [PMID: 25724363 DOI: 10.1016/j.jdermsci.2015.01.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 01/22/2015] [Accepted: 01/26/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is an acquired autoimmune blistering disease characterized by subepidermal blister formation, in vivo linear deposition of immunoglobulin G (IgG) and complements at the dermal-epidermal junction (DEJ). The circulating IgG autoantibodies are directed against two epidermal hemidesmosomal glycoproteins: BP180, also known as type XVII collagen (COL17), and BP230. In addition, recent studies have shown that IgE autoantibodies may be involved in the pathogenesis of BP, although in vivo IgE deposition in lesional skin has not been fully characterized in large numbers of BP patients. OBJECTIVE This study investigated the incidence of in vivo deposition of IgE autoantibodies at the DEJ in lesional skin from a large number of BP patients. METHODS Peri-lesional skin samples from 100 patients who met the clinical and histopathological criteria for BP were investigated by direct immunofluorescence for the deposition of autoantibodies and complement. Patients' sera were also investigated by enzyme-linked immunosorbent assay and indirect immunofluorescence. RESULTS 18% of BP patients were found to show IgE deposition at the DEJ. Disease severity, clinical course and outcome did not differ between IgE-positive and IgE-negative patients. In 3 IgE-positive cases, IgG was undetectable in vivo, and these cases showed atypical manifestations. CONCLUSION The results of in vivo IgE deposition may not be useful in predicting the disease course of BP, although predominant IgE deposition could alter the pattern of clinical manifestations.
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Affiliation(s)
- Reine Moriuchi
- Department of Dermatology, Hokkaido University Graduate School of Medicine, N15W7, Kita-ku, Sapporo 060-8638, Japan.
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, N15W7, Kita-ku, Sapporo 060-8638, Japan.
| | - Hideyuki Ujiie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, N15W7, Kita-ku, Sapporo 060-8638, Japan.
| | - Ken Natsuga
- Department of Dermatology, Hokkaido University Graduate School of Medicine, N15W7, Kita-ku, Sapporo 060-8638, Japan.
| | - Hiroshi Shimizu
- Department of Dermatology, Hokkaido University Graduate School of Medicine, N15W7, Kita-ku, Sapporo 060-8638, Japan.
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40
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Patel F, Wilken R, Patel FB, Sultani H, Bustos I, Duong C, Zone JJ, Raychaudhuri SP, Maverakis E. Pathophysiology of Autoimmune Bullous Diseases: Nature Versus Nurture. Indian J Dermatol 2015; 62:262-267. [PMID: 28584368 PMCID: PMC5448260 DOI: 10.4103/0019-5154.159620] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Pemphigus and pemphigoid are the prototypical immunobullous diseases. Although it has been well established that they are caused by deposition of autoreactive antibodies directed against adherence proteins within the skin, the specific genetic and environmental factors leading to development of these diseases continue to be an area of investigation. Herein, we discuss several of the potential environmental triggers that may induce patients to develop immunobullous diseases including medications, viral infections, UV exposure or other radiation injury and dietary factors. In addition, the potential genetic and immunologic mechanisms contributing to the pathogenesis of pemphigus and pemphigoid will be reviewed. The multifactorial nature of these diseases contributes to their complexity and highlights the importance of a detailed personal and family history when caring for these patients.
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Affiliation(s)
- Forum Patel
- Department of Dermatology, University of California Davis, Sacramento, CA, USA
| | - Reason Wilken
- Department of Dermatology, University of California Davis, Sacramento, CA, USA
| | - Falin B Patel
- Department of Dermatology, University of California Davis, Sacramento, CA, USA
| | - Hawa Sultani
- Department of Dermatology, University of California Davis, Sacramento, CA, USA
| | - Itzel Bustos
- Department of Dermatology, University of California Davis, Sacramento, CA, USA
| | - Christopher Duong
- Department of Dermatology, University of California Davis, Sacramento, CA, USA
| | - John J Zone
- Department of Dermatology, University of Utah, Salt Lake City, UT
| | - Siba P Raychaudhuri
- Department of Rheumatology, VA Northern California Medical Center, Mather, CA, USA.,Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Emanual Maverakis
- Department of Dermatology, University of California Davis, Sacramento, CA, USA
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41
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Messingham KN, Holahan HM, Frydman AS, Fullenkamp C, Srikantha R, Fairley JA. Human eosinophils express the high affinity IgE receptor, FcεRI, in bullous pemphigoid. PLoS One 2014; 9:e107725. [PMID: 25255430 PMCID: PMC4177878 DOI: 10.1371/journal.pone.0107725] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 08/17/2014] [Indexed: 01/21/2023] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease mediated by autoantibodies targeting BP180 (type XVII collagen). Patient sera and tissues typically have IgG and IgE autoantibodies and elevated eosinophil numbers. Although the pathogenicity of the IgE autoantibodies is established in BP, their contribution to the disease process is not well understood. Our aims were two-fold: 1) To establish the clinical relationships between total and BP180-specific IgE, eosinophilia and other markers of disease activity; and 2) To determine if eosinophils from BP patients express the high affinity IgE receptor, FcεRI, as a potential mechanism of action for IgE in BP. Our analysis of 48 untreated BP patients revealed a correlation between BP180 IgG and both BP180 IgE and peripheral eosinophil count. Additionally, we established a correlation between total IgE concentration and both BP180 IgE levels and eosinophil count. When only sera from patients (n = 16) with total IgE ≥ 400 IU/ml were analyzed, BP180 IgG levels correlated with disease severity, BP230 IgG, total circulating IgE and BP180 IgE. Finally, peripheral eosinophil count correlated more strongly with levels of BP180 IgE then with BP180 IgG. Next, eosinophil FcεRI expression was investigated in the blood and skin using several methods. Peripheral eosinophils from BP patients expressed mRNA for all three chains (α, β and γ) of the FcεRI. Surface expression of the FcεRIα was confirmed on both peripheral and tissue eosinophils from most BP patients by immunostaining. Furthermore, using a proximity ligation assay, interaction of the α- and β-chains of the FcεRI was observed in some biopsy specimens, suggesting tissue expression of the trimeric receptor form in some patients. These studies provide clinical support for the relevance of IgE in BP disease and provide one mechanism of action of these antibodies, via binding to the FcεRI on eosinophils.
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Affiliation(s)
- Kelly N. Messingham
- Department of Dermatology, University of Iowa, Iowa City, Iowa, United States of America
| | - Heather M. Holahan
- Department of Dermatology, University of Iowa, Iowa City, Iowa, United States of America
| | - Alexandra S. Frydman
- Department of Dermatology, University of Iowa, Iowa City, Iowa, United States of America
| | - Colleen Fullenkamp
- Department of Dermatology, University of Iowa, Iowa City, Iowa, United States of America
| | - Rupasree Srikantha
- Department of Dermatology, University of Iowa, Iowa City, Iowa, United States of America
| | - Janet A. Fairley
- Department of Dermatology, University of Iowa, Iowa City, Iowa, United States of America
- Veterans Administration Medical Center, Iowa City, Iowa, United States of America
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42
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Schulze FS, Beckmann T, Nimmerjahn F, Ishiko A, Collin M, Köhl J, Goletz S, Zillikens D, Ludwig R, Schmidt E. Fcγ receptors III and IV mediate tissue destruction in a novel adult mouse model of bullous pemphigoid. THE AMERICAN JOURNAL OF PATHOLOGY 2014; 184:2185-96. [PMID: 25043618 DOI: 10.1016/j.ajpath.2014.05.007] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 04/11/2014] [Accepted: 05/13/2014] [Indexed: 12/18/2022]
Abstract
Bullous pemphigoid (BP) and epidermolysis bullosa acquisita are subepidermal autoimmune blistering diseases mediated by autoantibodies against type XVII collagen (Col17) and Col7, respectively. For blister formation, Fc-mediated events, such as infiltration of inflammatory cells in the skin, complement activation, and release of proteases at the dermal-epidermal junction, are essential. Although in the neonatal passive transfer mouse model of BP, tissue destruction is mediated by Fcγ receptors (FcγRs) I and III, the passive transfer model of epidermolysis bullosa acquisita completely depends on FcγRIV. To clarify this discrepancy, we developed a novel experimental model for BP using adult mice. Lesion formation was Fc mediated because γ-chain-deficient mice and mice treated with anti-Col17 IgG, depleted from its sugar moiety at the Fc portion, were resistant to disease induction. By the use of various FcγR-deficient mouse strains, tissue destruction was shown to be mediated by FcγRIV, FcγRIII, and FcγRIIB, whereas FcγRI was not essential. Furthermore, anti-inflammatory mediators in already clinically diseased mice can be explored in the novel BP model, because the pharmacological inhibition of FcγRIV and depletion of granulocytes abolished skin blisters. Herein, we extended our knowledge about the importance of FcγRs in experimental BP and established a novel BP mouse model suitable to study disease development over a longer time period and explore novel treatment strategies in a quasi-therapeutic setting.
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Affiliation(s)
| | - Tina Beckmann
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Falk Nimmerjahn
- Department of Biology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Akira Ishiko
- Department of Dermatology, Toho University School of Medicine, Tokyo, Japan
| | - Mattias Collin
- Division of Infection Medicine, Department of Clinical Science, Lund University, Lund, Sweden
| | - Jörg Köhl
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Stephanie Goletz
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Ralf Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.
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43
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Messingham KAN, Holahan HM, Fairley JA. Unraveling the significance of IgE autoantibodies in organ-specific autoimmunity: lessons learned from bullous pemphigoid. Immunol Res 2014; 59:273-8. [PMID: 24845463 DOI: 10.1007/s12026-014-8547-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Bullous pemphigoid (BP), a cutaneous autoimmune blistering disease, has provided a useful model to elucidate a role for IgE in autoimmunity. IgE antibodies specific for the BP180 autoantigen are detected in sera and biopsy samples from the majority of BP patients. In BP biopsies, both IgE and BP180 antigen localize to the surface of mast cells, and incubation of circulating basophils from these patients with BP180 protein triggered degranulation. The in vivo pathogenicity of BP180-specific IgE was confirmed in mouse models, where injection of purified BP IgE into human skin grafted onto nu/nu mice replicated the early phase of lesion development, including mast cell degranulation, eosinophil infiltration and development of urticarial plaques. In addition, IgE antibodies from patient sera bind to BP180 on basal keratinocytes, resulting in internalization of BP180, production of inflammatory cytokines, IL-6 and IL-8, and a decrease in the number of hemidesmosomes at the basement membrane zone. These findings have led to therapeutic trials of the anti-IgE monoclonal antibody omalizumab in BP, resulting in substantial improvement in the patients' disease. Overall, the work in BP provides the first evidence for a pathogenic role for IgE in autoimmunity.
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Affiliation(s)
- K A N Messingham
- Department of Dermatology, University of Iowa College of Medicine, 200 Hawkins Drive, Iowa City, IA, 52242, USA
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44
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Yu KK, Crew AB, Messingham KAN, Fairley JA, Woodley DT. Omalizumab therapy for bullous pemphigoid. J Am Acad Dermatol 2014; 71:468-74. [PMID: 24954907 DOI: 10.1016/j.jaad.2014.04.053] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 04/17/2014] [Accepted: 04/21/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) responds to a variety of immunosuppressive agents and usually controls, but does not cure, the disease. Omalizumab, Food and Drug Administration-approved for asthma, selectively suppresses the activity of IgE, an important immunoglobulin in the pathogenesis of BP. OBJECTIVE We wished to determine if systemic omalizumab would have a therapeutic effect in patients with BP. METHODS We treated 6 patients with BP using omalizumab and followed up their disease for up to 42 months. RESULTS Although variable, 5 of the 6 patients with BP received therapeutic benefit from systemic omalizumab (the sixth terminated treatment because of intercurrent illness) with less use of other immunosuppressants, inhibition of new bullae, less pruritus, and dramatic decreases in eosinophil counts. None of the patients had untoward side effects from omalizumab. LIMITATIONS This was an open, uncontrolled study. CONCLUSIONS Omalizumab neutralizes the activity of IgE in patients with BP and improves the control of their disease activity.
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Affiliation(s)
- Kenneth K Yu
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ashley B Crew
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Janet A Fairley
- Carver College of Medicine, University of Iowa, Iowa City, Iowa; Department of Veterans Affairs Medical Center, Iowa City, Iowa
| | - David T Woodley
- Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Veterans Affairs Medical Center, Los Angeles, California.
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Fuertes de Vega I, Iranzo-Fernández P, Mascaró-Galy J. Penfigoide ampolloso: guía de manejo práctico. ACTAS DERMO-SIFILIOGRAFICAS 2014; 105:328-46. [DOI: 10.1016/j.ad.2012.10.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 10/10/2012] [Accepted: 10/28/2012] [Indexed: 11/17/2022] Open
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46
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Fuertes de Vega I, Iranzo-Fernández P, Mascaró-Galy J. Bullous Pemphigoid: Clinical Practice Guidelines. ACTAS DERMO-SIFILIOGRAFICAS 2014. [DOI: 10.1016/j.adengl.2012.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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47
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Sodemoto K, Yamahana J, Echigo T, Nishijima C, Shimada Y, Inaoki M. Development of bullous pemphigoid after change of dialysis membrane. Hemodial Int 2013; 18:525-8. [DOI: 10.1111/hdi.12104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Kinuyo Sodemoto
- Department of Dermatology; National Hospital Organization; Kanazawa Medical Center; Kanazawa Japan
- Department of Dermatology; Kanazawa University Graduate School of Medical Science; Kanazawa Japan
| | - Junya Yamahana
- Department of Internal Medicine; Moriyama Koshino Hospital; Kanazawa Japan
- Department of Internal Medicine; Toyama Prefectural Central Hospital; Toyama Japan
| | - Takeshi Echigo
- Department of Dermatology; Kanazawa University Graduate School of Medical Science; Kanazawa Japan
| | - Chihiro Nishijima
- Department of Dermatology; National Hospital Organization; Kanazawa Medical Center; Kanazawa Japan
| | - Yuka Shimada
- Department of Dermatology; National Hospital Organization; Kanazawa Medical Center; Kanazawa Japan
| | - Makoto Inaoki
- Department of Dermatology; National Hospital Organization; Kanazawa Medical Center; Kanazawa Japan
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48
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Iwata H, Kitajima Y. Bullous pemphigoid: role of complement and mechanisms for blister formation within the lamina lucida. Exp Dermatol 2013; 22:381-5. [PMID: 23651418 DOI: 10.1111/exd.12146] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2013] [Indexed: 01/15/2023]
Abstract
Bullous pemphigoid (BP), an autoimmune subepidermal blistering skin disease, demonstrates tense blisters with or without widespread erythema, blistering along the lamina lucida, immunoglobulin G and/or complement deposits at the basement membrane zone, and the presence of circulating autoantibodies against hemidesmosomal molecules. These autoantibodies usually react against 180-kDa and/or 230-kDa proteins, designated as BP180 and BP230, respectively. The precise blistering mechanisms after autoantibodies bind to antigens are not fully understood. Immune complexes are thought to initially activate the complement cascade, which may induce activation of proteases and/or cytokines and cause dermal-epidermal separation. However, why does separation run specifically within the lamina lucida in a space as narrow as 500 nm wide? This review mainly focuses on the possible mechanisms of BP-specific blistering and how separation occurs along the lamina lucida, based on existing evidence.
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Affiliation(s)
- Hiroaki Iwata
- Department of Dermatology, University of Lübeck, Lübeck, Germany.
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49
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Pomponi D, Di Zenzo G, Zennaro D, Calabresi V, Eming R, Zuzzi S, Bernardi ML, Scala E, Mari A. Detection of IgG and IgE reactivity to BP180 using the ISAC® microarray system. Br J Dermatol 2013; 168:1205-14. [PMID: 23252883 DOI: 10.1111/bjd.12161] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune skin disease in which patient autoantibodies react with BP180 and BP230 proteins. In addition to IgG, IgE has been shown to play a role in the disease. OBJECTIVES To evaluate the feasibility of detecting IgE and IgG against the immunodominant BP180 NC16A domain (BP180) using a microarray system. METHODS BP180 was immobilized on an experimental version of the ISAC(®) microarray (Exp96). The BP study group and the controls were all tested on the commercial ISAC 103 version and on the Exp96. IgG and IgE were measured in a single run. BP180 IgG and IgE results were compared with those using an enzyme-linked immunosorbent assay (ELISA). RESULTS All results obtained using the IgG ELISA on the 31 patients with BP were replicated with the ISAC IgG. Five of eight BP sera tested by ELISA showed similar results with ISAC IgE. Twenty-nine (94%) and 19 (61%) of the 31 patients with BP were IgG and IgE positive to BP180, respectively, whereas four (3%) and six (4%) of 138 normal donors were IgG and IgE positive, respectively. Interestingly, the levels of IgG against BP180 detected using the ISAC system were related to the disease severity. Patients with BP showed a peculiar profile of IgE recognition toward some groups of allergens, which was absent in a group of allergic individuals. A significant, higher prevalence of hen's egg recognition was observed in patients with BP who had specific IgE to BP180. CONCLUSIONS The present preliminary study indicates that the ISAC microarray system is suitable for detecting IgG and IgE autoantibodies in patients with BP. Notably, this system allows the assessment of IgE and IgG autoantibodies at the same time, could be employed for the detection of autoantibodies to other autoantigens, and allows profiling for specific IgE to allergens.
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Affiliation(s)
- D Pomponi
- Center for Molecular Allergology, IDI-IRCCS, Via dei Monti di Creta 104, 00167 Rome, Italy
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50
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Abstract
Pemphigoid diseases are a group of well defined autoimmune disorders that are characterised by autoantibodies against structural proteins of the dermal-epidermal junction and, clinically, by tense blisters and erosions on skin or mucous membranes close to the skin surface. The most common of these diseases is bullous pemphigoid, which mainly affects older people and the reported incidence of which in Europe has more than doubled in the past decade. Prognosis and treatments vary substantially between the different disorders and, since clinical criteria are usually not sufficient, direct immunofluorescence microscopy of a perilesional biopsy specimen or serological tests are needed for exact diagnosis. In eight pemphigoid diseases the target antigens have been identified molecularly, which has allowed the development of standard diagnostic assays for detection of serum autoantibodies-some of which are commercially available. In this Seminar we discuss the clinical range, diagnostic criteria, diagnostic assay systems, and treatment options for this group of diseases.
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Affiliation(s)
- Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.
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