Pemphigoid nodularis (non-bullous): a clinicopathological study of five cases

Hypertrophic Lichen Planus: An Up-to-Date Review and Differential Diagnosis

CONTEXT.—

Hypertrophic lichen planus (HLP) is a variant of lichen planus that can be difficult to diagnose based on histopathologic features alone. Thus, patient clinical history and clinicopathologic correlation are essential considerations to make the correct diagnosis.

OBJECTIVE.—

To discuss the clinical and histologic presentation of HLP and provide a thorough review of commonly encountered mimickers in the differential diagnosis.

DATA SOURCES.—

Data were derived from a literature review, personal clinical and research experiences, and a review of cases in the archives of a tertiary care referral center.

CONCLUSIONS.—

In general, HLP involves the lower extremities and is characterized by thickened, scaly nodules and plaques that are often pruritic and chronic in nature. HLP affects both males and females and is most common in adults 50 to 75 years of age. Unlike conventional lichen planus, HLP tends to have eosinophils and classically displays a lymphocytic infiltrate most concentrated around the tips of rete ridges. The differential diagnosis for HLP is broad and encompasses numerous entities in many different categories, including premalignant and malignant neoplasms, reactive squamoproliferative tumors, benign epidermal neoplasms, connective tissue disease, autoimmune bullous disease, infection, and drug-related reactions. Therefore, a high index of suspicion must be maintained to avoid a misdiagnosis and potential inappropriate treatments.

Generalized Nodules in an Older Adult Man

A man in his 60s presented with an 8-month history of pruritic papulonodular lesions on his extremities and trunk, with no significant improvement with steroids and antihistamines. What is your diagnosis?

Case Report: Pemphigoid Nodularis-Five Patients With Many Years of Follow-Up and Review of the Literature

Pemphigoid nodularis is a rare form of pemphigoid that joins the clinical picture of prurigo nodularis and the immunological features of bullous pemphigoid, which is therapeutically challenging. Here, we analyze five female patients with a long-lasting course of nodular pemphigoid in terms of clinical and immunological characteristics and therapy. All the patients fulfilled clinical and immunological criteria of nodular pemphigoid. We applied numerous techniques allowing the proper diagnosis: direct and indirect immunofluorescence, salt split skin, ELISA, BIOCHIP, and fluorescence overlay antigen mapping using laser scanning confocal microscopy. Our study showed that 4 of 5 patients fulfilled the clinical and immunological criteria of nodular bullous pemphigoid. Two out of 4 patients presented exclusively nodular lesions; in the other two patients, blisters and erythematous lesions preceded prurigo-like lesions by a few years. The remaining patient had clinical and immunological criteria of nodular mucous membrane pemphigoid, presenting oral erosions, scarring conjunctivitis, and numerous disseminated nodules on the skin. All the patients were treated with multiple medicines; however, it was observed that the use of clobetasol propionate on the entire body plus antidepressants best controlled the disease. Pemphigoid nodularis mainly occurs in elderly women. In cases with coexisting psychological problems, antidepressants should be considered as an important complementary therapy to the basic one with clobetasol propionate.

Spongiform pemphigoid: A case series of an uncommon histopathologic pattern

INTRODUCTION

Bullous pemphigoid is an autoimmune bullous disease characterized by subepidermal separation. We encountered cases of bullous pemphigoid confirmed by direct immunofluorescence study but demonstrating spongiotic dermatitis without subepidermal clefting. Many of them occurred in volar sites, mimicking dyshidrotic dermatitis.

METHODS

We retrospectively collected patients who were pathologically and/or immunopathologically diagnosed with bullous pemphigoid from 2002 to 2017. Patients who presented with prominent spongiosis without subepidermal clefting were included and compared with patients who were diagnosed with dyshidrotic dermatitis.

RESULTS

A total of nine cases of spongiform pemphigoid out of 385 bullous pemphigoid patients (2.3%) were identified and compared with 15 patients with dyshidrotic dermatitis. Average age of spongiform pemphigoid patients (76 years) was much older than that of the control group (34 years). Microvesicles in the mid- to lower epidermis (P < 0.001), eosinophils exocytosis (P < 0.001), and eosinophils microabscess (P < 0.001) in both the epidermis and papillary dermis were more common in spongiform pemphigoid.

CONCLUSION

Spongiform pemphigoid mimics spongiotic dermatitis may result in a pathological diagnostic pitfall. The presence of eosinophil microabscess and exocytosis in the epidermis and papillary dermis were important clues. Immunofluorescence studies should be conducted to confirm the diagnosis of bullous pemphigoid.

Diagnostic Workup and Evaluation of Patients with Prurigo Nodularis

Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized oftentimes by symmetrically distributed, severely pruritic nodules. Currently, the pathophysiology of PN remains to be fully elucidated, but emerging evidence suggests that neuroimmune alterations play principal roles in the pathogenesis of PN. There are several associated etiologic factors thought to be associated with PN, including dermatoses, systemic, infectious, psychiatric, and neurologic conditions. We conducted a systematic literature review to evaluate the clinical presentation, diagnosis, and etiologic factors of PN. In this review, we discuss common differential diagnoses of PN and recommend an evidence-based, standardized diagnostic evaluation for those with suspected PN.

Pemphigoid nodularis - rare presentation of bullous pemphigoid: A case report and literature review

Pemphigoid nodularis (PN) is a rare clinical variant of bullous pemphigoid characterized by the presence of nodular prurigo-like lesions and pemphigoid blisters. The diagnosis is confirmed by direct immunofluorescence (DIF)/ indirect immunofluorescence (IIF) and immunoserology tests. For some patients, with long mean duration of symptoms, the correct diagnosis of PN is delayed because the disease is not recognized. We present a case and summarize the reported characteristics of PN. The search in MEDLINE database, after selection, resulted in 36 articles presenting 47 cases of PN. Between published cases a female predominance was noted (female to male ratio of 1.8:1), almost half of the reported patients were non-Caucasian, and the mean age at presentation was 66.2 years. The mean duration until the diagnosis was almost 2 years. Sixteen patients also had other autoimmune diseases. Twenty-two patients developed vesicles/bullae/urticarial plaques before or after the diagnosis. Peripheral eosinophilia and high levels of serum total IgE were reported in 10.6 and 27.2% of patients, respectively. ELISA for either BP180, BP230 or both were positive in all tested cases. DIF and IIF microscopy were positive overall in 100 and 92.3% of cases, respectively. Corticosteroids, either topical or systemic, were the most efficient therapeutic option, although many others were used. PN remains a diagnostic and therapeutic challenge in elderly patients with unexplained refractory chronic pruritus associated with papulo-nodular lesions.

Nonbullous pemphigoid: A systematic review

BACKGROUND

Bullous pemphigoid is an autoimmune disease that typically presents with tense bullae and severe pruritus. However, bullae can be lacking, a subtype termed nonbullous pemphigoid.

OBJECTIVE

To summarize the reported characteristics of nonbullous pemphigoid.

METHODS

The EMBASE and MEDLINE databases were searched using "nonbullous pemphigoid" and various synonyms. Case reports and series describing nonbullous pemphigoid were included.

RESULTS

The search identified 133 articles. After selection, 39 articles were included, presenting 132 cases. Erythematous, urticarial plaques (52.3%) and papules/nodules (20.5%) were the most reported clinical features. The mean age at presentation was 74.9 years. Histopathology was commonly nonspecific. Linear depositions of IgG and/or C3 along the basement membrane zone were found by direct immunofluorescence microscopy in 93.2%. Indirect immunofluorescence on salt-split skin was positive in 90.2%. The mean diagnostic delay was 22.6 months. A minority of patients (9.8%) developed bullae during the reported follow-up.

LIMITATIONS

Results are mainly based on case reports and small case series.

CONCLUSION

Nonbullous pemphigoid is an underdiagnosed variant of pemphigoid that most often does not evolve to bullous lesions and mimics other pruritic skin diseases. Greater awareness among physicians is needed to avoid delay in diagnosis.

Nodular Subtype of Bullous Pemphigoid

INTRODUCTION

Itching nodules and papules are common findings. A rare but important differential diagnosis is the nodular subtype of bullous pemphigoid.

METHODS AND RESULTS

The investigators report a female patient presenting with strongly itching papules disseminated over her extremities and trunk. Physical examination revealed multiple erythematous, mostly excoriated papules and nodules on her back, abdomen, and extremities. Histology showed changes compatible with prurigo lesion, and immunofluorescence showed positive results for BP180 and BP230. Considering these clinical, histologic, and immunofluorescence findings, the diagnosis of a nodular subtype of bullous pemphigoid was made. The patient showed healing of lesions under a combination therapy with systemic psoralen and ultraviolet A, topical application of corticosteroids, and systemic therapy with azathioprine and prednisolone.

DISCUSSION

Pemphigoid nodularis represents the rare prurigo variant of bullous pemphigoid. Typically, lesions show the same immunopathologic and histologic features as in common bullous pemphigoid but mostly without the characteristic clinical finding of bullae.

Pemphigoid Nodularis

Background

Pemphigoid nodularis is a rare clinical variant of bullous pemphigoid characterized by overlapping clinical features of both prurigo nodularis lesions and bullous pemphigoid blisters. The condition appears to be more common in females and is often resistant to treatment.

Objective

To raise awareness of this rare variant of bullous pemphigoid.

Methods

Case report. Results and Conclusion Dermatologists should include this variant in differential diagnosis of prurigo nodularis because early recognition can lead to an effective treatment for the prurigo component.

BP180- and BP230-specific IgG autoantibodies in pruritic disorders of the elderly: a preclinical stage of bullous pemphigoid?

Pruritus increasingly occurs in the elderly population and is associated with a variety of dermatoses of mixed aetiology. Clinical and experimental evidence suggests that senile pruritus may be linked to autoimmune events initiated by loss of self-tolerance against cutaneous autoantigens, which is facilitated by immune ageing processes. T-cell immunity, which underpins the production of pathogenic autoantibodies in autoimmune diseases, is deregulated by immune senescence thereby leading to autoimmune disorders such as bullous pemphigoid (BP). High mortality rates of BP combined with steadily increasing incidence emphasize the need for an effective diagnostic strategy at an early stage. We summarize here the current understanding of immunological alterations during the ageing process, thereby focusing on aberrant T-cell responses against the basement membrane antigens BP180 and BP230, which may eventually lead to the clinical outcome of BP.

Juvenile pemphigoid nodularis: Report of a rare case

Bullous pemphigoid is an autoimmune blistering disease that is rare in childhood. Pemphigoid nodularis is a variant of BP that is exceedingly rare in children. Pemphigoid nodularis is characterized by overlapping clinical features of both prurigo nodularis and BP. We report here a case of pemphigoid nodularis in an 11-year-old boy.

Molecular diagnosis in autoimmune skin blistering conditions

Blister formation in skin and mucous membranes results from a loss of cell-cell or cell-matrix adhesion and is a common outcome of pathological events in a variety of conditions, including autoimmune and genetic diseases, viral and bacterial infections, or injury by physical and chemical factors. Autoantibodies against structural components maintaining cell-cell and cell-matrix adhesion induce tissue damage in autoimmune blistering diseases. Detection of these autoantibodies either tissue-bound or circulating in serum is essential to diagnose the autoimmune nature of disease. Various immunofluorescence methods as well as molecular immunoassays, including enzyme-linked immunosorbent assay and immunoblotting, belong to the modern diagnostic algorithms for these disorders. There is still a considerable need to increase awareness of the rare autoimmune blistering diseases, which often show a severe, chronic-relapsing course, among physicians and the public. This review article describes the immunopathological features of autoimmune bullous diseases and the molecular immunoassays currently available for their diagnosis and monitoring.

Combination therapy of fexofenadine and montelukast is effective in prurigo nodularis and pemphigoid nodularis

In this study, we report on the efficacy of combination therapy of second-generation antihistamine antagonist, fexofenadine hydrochloride, and leukotriene receptor inhibitor, montelukast sodium, for the treatment of 15 prurigo nodularis or pemphigoid nodularis patients, in whom conventional therapy was ineffective. All patients received 10 mg montelukast once a day and 240 mg fexofenadine twice a day for 4 weeks in addition to other medications they had been taking. We assessed the manifestations of the lesions and itching intensity before and after the therapy, and we evaluated each patient as (i) markedly improved, (ii) improved, (iii) slightly improved, (iv) no change, (v) worse. Two patients (13.3%) were evaluated as markedly improved, and the lesions of one patient completely disappeared. Three patients (20.0%) were evaluated as improved, and six patients (40.0%) as slightly improved. Thus, 11 of 15 cases (73.3%) improved by combination therapy of fexofenadine and montelukast, in which nine cases (75.0%) of prurigo nodularis and two cases (66.7%) of pemphigoid nodularis were involved. No patients revealed any side effects. This study revealed that combination therapy of fexofenadine and montelukast was effective for some patients with conventional therapy-resistant prurigo nodularis and pemphigoid nodularis.

Bullous pemphigoid in younger adults: three case reports

Bullous pemphigoid is an autoimmune subepidermal bullous dermatosis more commonly observed in the elderly (over 70 years old). Autoantibodies are produced for specific antigens of the epidermal basement membrane zone: BP 180 and BP 230 (hemidesmosome proteins). We report three cases of bullous pemphigoid in adults younger than 50 years old, discussing the clinical characteristics of the disease in younger patients.

IgG autoantibody reactivity against bullous pemphigoid (BP) 180 and BP230 in elderly patients with pruritic dermatoses

BACKGROUND

Pruritic dermatoses of the elderly often pose a diagnostic and therapeutic challenge. Specifically, a prodromal phase of bullous pemphigoid (BP) has to be considered in patients with pruritic lesions of polymorphic appearance. These conditions frequently do not fulfil all the clinical, histological and immunopathological criteria for establishing the diagnosis of BP.

OBJECTIVES

To investigate IgG reactivity against the autoantigens of BP, BP180 and BP230, by enzyme-linked immunosorbent assay, in elderly patients affected with various pruritic disorders who had never experienced clinically apparent blisters.

METHODS

The sera of 15 elderly patients with pruritic disorders (group I) were tested for IgG reactivity against BP180 and BP230. Also included were 30 patients with full-blown BP (group II) and 25 age-matched patients with immediate-type allergic reactions (group III).

RESULTS

Thirty-three per cent of the patients with pruritic disorders (group I) showed IgG against BP230 and/or BP180: four of 15 patients had IgG against BP230 while two of the 15 group I patients were BP180 reactive. All the BP sera (group II) showed IgG reactivity against BP180 and/or BP230. Notably, two of 25 control sera (group III) showed IgG reactivity against either BP180 or BP230.

CONCLUSIONS

The present findings suggest that IgG reactivity against BP230 (i.e. the COOH terminus), and to a lesser extent against BP180, is a common finding in pruritic disorders of the elderly with a wide clinical spectrum. IgG-mediated autoimmunity against the intracellular BP230 may facilitate a chronic, inflammatory response eventually leading to full-blown BP which is presumably associated with IgG against BP180.

Immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) associated with pemphigoid nodularis: a case report and review of the literature

The immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) is a rare disorder caused by mutations of the FOXP3 gene. The FOXP3 gene encodes a DNA-binding protein of the forkhead/winged-helix family and is the central controller of the development of CD4+CD25+ regulatory T cells. CD4+CD25+ regulatory T cells help prevent autoimmune disease; a deficiency of these cells causes increased immunologic reactivity and autoimmunity. We describe a 14-year-old boy with IPEX syndrome confirmed by mutation analysis of the FOXP3 gene. The patient had chronic dermatitis and later developed bullous pemphigoid. He subsequently formed diffuse prurigo nodularis-like lesions resistant to multiple topical and systemic immunosuppressive medications. These lesions were confirmed by biopsy, direct immunofluorescence, and enzyme-linked immunosorbent assay of the 180 kd bullous pemphigoid antigen to be pemphigoid nodularis. He recently responded to rituximab, allowing discontinuation of his oral prednisone.

Pemphigoid nodularis ausgehend von einem Hypereosinophilie-Syndrom?

Pemphigoid nodularis (PN) is a rare clinical variant of pemphigoid characterized by prurigo-like skin lesions and antibodies against BP180 and BP230 characteristic for bullous pemphigoid. Interestingly, most PN patients never develop blisters. This condition is often resistant to treatment. We describe a female patient who was initially diagnosed with hypereosinophilic dermatitis. Later on, in the presence of eosinophilic infiltrations in the gastrointestinal tract, obstructive ventilation disorder, pericardial and pleural effusions, the diagnosis of idiopathic hypereosinophilic syndrome was made. During the following 3 years she developed recalcitrant PN.

Sulfamethoxypyridazine-responsive pemphigoid nodularis: a report of two cases

Pemphigoid nodularis is a chronic and uncommon variant of bullous pemphigoid. The condition is characterized by the presence of prurigo nodularis-like lesions, possible history of blistering, and immunohistochemical findings of bullous pemphigoid. These patients are often unresponsive to conventional therapy with potent topical and systemic steroids and different immunosuppressive agents used alone or in combination. We describe two cases of pemphigoid nodularis treated successfully with sulfamethoxypyridazine without any adverse effects.

Bullous Pemphigoid

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

Prurigo: diagnosis and management

Prurigo is a condition of nodular cutaneous lesions that itch (pruire) intensely. Although the acute form can be caused by insect stings, most of the subacute and chronic forms appear to be idiopathic. Toxic agents deposited in the skin by exogenous factors such as parasites, bacteria, or topically or orally administered drugs can induce itch. In susceptible individuals, physical mechanisms such as UV light can induce changes in epidermal innervation that result both in itch generally and in prurigo lesions. Prurigo is sometimes associated with atopy, pregnancy, internal diseases, malabsorption, or malignancy. Some forms of prurigo may be secondary to scratching. Emotional factors can also influence the perception of itch and induce prurigo by provoking scratching. These are the various specialized forms of prurigo, and there are certain others, such as prurigo pigmentosa, that have some ethnic preference. Topical treatments by corticosteroids, coal tar, bath photochemotherapy, UVB, cryotherapy, or capsaicin, as well as systemic regimens involving use of psoralen + UVA (PUVA), erythromycin, arotinoid acid, cyclosporine, chloroquine, dapsone, minocycline, naltrexone, azathioprine or thalidomide are used for the treatment of this condition. Psychotherapeutic agents to treat problems of mood that deteriorate prurigo are also prescribed. Combined sequential treatments for generalized, therapy-resistant cases need to be tailored to the exacerbations that occur and to provide maintenance treatment in order to enable the patient to withstand the intolerable itch.

Lichen planus pemphigoides evolving into pemphigoid nodularis

Lichen planus pemphigoides (LPP) and pemphigoid nodularis are rare clinical variants of bullous pemphigoid (BP), which are characterized by histological findings of lichen planus (LP) and nodular prurigo, respectively, and the finding of linear deposits of IgG and/or C3 at the basement membrane zone in perilesional skin. In both cases bullae may arise at the site of pre-existing LP-like or nodular prurigo-like eruptions, and clinically uninvolved skin. The disease spectrum of LPP and pemphigoid nodularis differs from that of classical BP phenotype, and their presentations are often indolent. LPP may predominantly affect a younger age group and is responsive to standard treatments used in acquired autoimmune bullous diseases, while pemphigoid nodularis is more common in elderly women and is relatively resistant to therapy. We describe a patient who had LPP for nearly two decades and subsequently developed a nodular eruption with a concurrently detected antibullous pemphigoid antigen 2 (BP180) autoantibody. His overall clinicopathological features were indicative of LPP evolving into another BP variant, pemphigoid nodularis.