1
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Abstract
BACKGROUND AND OBJECTIVES Treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is a well-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe cases, the use of immunoglobulin is not generally based on data from randomized controlled trials usually required for evidence-based medicine. Since the indications for the use of IVIg are rare, it is unlikely that such studies will be available in the foreseeable future. Because first-line use is limited by the high costs of IVIg, the first clinical guidelines on the use of IVIg in dermatological conditions were established in 2008 and renewed in 2011. METHODS The European guidelines presented here were prepared by a panel of experts nominated by the European Dermatology Forum (EDF) and European Academy of Dermatology and Venereology (EADV). The guidelines were developed to update the indications for treatment currently considered effective and to summarize the evidence for the use of IVIg in dermatological autoimmune diseases and TEN. RESULTS AND CONCLUSION The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as a decision-making tool for the use of IVIg in dermatological diseases.
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2
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Enk A, Hadaschik E, Eming R, Fierlbeck G, French L, Girolomoni G, Hertl M, Jolles S, Karpati S, Steinbrink K, Stingl G, Volc‐Platzer B, Zillikens D. Europäische Leitlinien (S1) für die Anwendung von hochdosierten intravenösen Immunglobulinen in der Dermatologie. J Dtsch Dermatol Ges 2017; 15:227-238. [DOI: 10.1111/ddg.13013_g] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Alexander Enk
- HautklinikRuprecht‐Karls‐Universität Heidelberg Deutschland
| | - Eva Hadaschik
- HautklinikRuprecht‐Karls‐Universität Heidelberg Deutschland
| | - Rüdiger Eming
- Klinik für Dermatologie und AllergologiePhilipps‐Universität Marburg Deutschland
| | - Gerhard Fierlbeck
- Universitäts‐HautklinikEberhard‐Karls‐Universität Tübingen Deutschland
| | - Lars French
- Dermatologische KlinikUniversität Zürich Schweiz
| | | | - Michael Hertl
- Klinik für Dermatologie und AllergologiePhilipps‐Universität Marburg Deutschland
| | - Stephen Jolles
- Immundefizienz‐Zentrum für WalesUniversitätskrankenhaus Wales Cardiff GB
| | - Sarolta Karpati
- Abteilung für DermatologieSemmelweis‐Universität Budapest Ungarn
| | | | - Georg Stingl
- Universitätsklinik für DermatologieMedizinische Universität Wien Österreich
| | | | - Detlef Zillikens
- Klinik für DermatologieAllergologie und VenerologieUniversität zu Lübeck Deutschland
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3
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Enk A, Hadaschik E, Eming R, Fierlbeck G, French L, Girolomoni G, Hertl M, Jolles S, Karpati S, Steinbrink K, Stingl G, Volc-Platzer B, Zillikens D. European Guidelines (S1) on the use of high-dose intravenous immunoglobulin in dermatology. J Dtsch Dermatol Ges 2016; 15:228-241. [PMID: 28036140 DOI: 10.1111/ddg.13013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is a well-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe cases, the use of immunoglobulin is not generally based on data from randomized controlled trials usually required for evidence-based medicine. Since the indications for the use of IVIg are rare, it is unlikely that such studies will be available in the foreseeable future. Because first-line use is limited by the high costs of IVIg, the first clinical guidelines on the use of IVIg in dermatological conditions were established in 2008 and renewed in 2011. METHODS The European guidelines presented here were prepared by a panel of experts nominated by the EDF and EADV. The guidelines were developed to update the indications for treatment currently considered effective and to summarize the evidence for the use of IVIg in dermatological autoimmune diseases and TEN. RESULTS AND CONCLUSION The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as a decision-making tool for the use of IVIg in dermatological diseases.
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Affiliation(s)
- Alexander Enk
- Department of Dermatology, Ruprecht-Karls-University Heidelberg, Germany
| | - Eva Hadaschik
- Department of Dermatology, Ruprecht-Karls-University Heidelberg, Germany
| | - Rüdiger Eming
- Department of Dermatology, Philipps-University Marburg, Germany
| | - Gerhard Fierlbeck
- Department of Dermatology, Eberhard-Karls-University Tübingen, Germany
| | - Lars French
- Department of Dermatology, University of Zurich, Switzerland
| | | | - Michael Hertl
- Department of Dermatology, Philipps-University Marburg, Germany
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Sarolta Karpati
- Department of Dermatology, Semmelweis University Budapest, Hungary
| | | | - Georg Stingl
- Department of Dermatology, Medical University of Vienna, Austria
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4
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Enk AH, Hadaschik EN, Eming R, Fierlbeck G, French LE, Girolomoni G, Hertl M, Jolles S, Karpati S, Steinbrink K, Stingl G, Volc-Platzer B, Zillikens D. European Guidelines (S1) on the use of high-dose intravenous immunoglobulin in dermatology. J Eur Acad Dermatol Venereol 2016; 30:1657-1669. [PMID: 27406069 DOI: 10.1111/jdv.13725] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/09/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND The treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is a well-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe clinical cases, the use of immunoglobulin is not generally based on data from randomized controlled trials that are usually required for the practice of evidence-based medicine. Owing to the rarity of the indications for the use of IVIg, it is also unlikely that such studies will be available in the foreseeable future. Because the high costs of IVIg treatment also limit its first-line use, the first clinical guidelines on its use in dermatological conditions were established in 2008 and renewed in 2011. MATERIALS AND METHODS The European guidelines presented here were prepared by a panel of experts nominated by the EDF and the EADV. The guidelines were developed to update the indications for treatment currently considered as effective and to summarize the evidence base for the use of IVIg in dermatological autoimmune diseases and TEN. RESULTS AND CONCLUSION The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as a decision-making tool for the use of IVIg in dermatological diseases.
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Affiliation(s)
- A H Enk
- Department of Dermatology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany.
| | - E N Hadaschik
- Department of Dermatology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - R Eming
- Department of Dermatology, Philipps-University Marburg, Marburg, Germany
| | - G Fierlbeck
- Department of Dermatology, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - L E French
- Department of Dermatology, University of Zurich, Zurich, Switzerland
| | - G Girolomoni
- Department of Dermatology, University of Verona, Verona, Italy
| | - M Hertl
- Department of Dermatology, Philipps-University Marburg, Marburg, Germany
| | - S Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - S Karpati
- Department of Dermatology, Semmelweis University Budapest, Budapest, Hungary
| | - K Steinbrink
- Department of Dermatology, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - G Stingl
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - B Volc-Platzer
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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5
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Schmidt E. [Optimizing therapy in patients with severe autoimmune blistering skin diseases]. Hautarzt 2009; 60:633-40. [PMID: 19536513 DOI: 10.1007/s00105-008-1680-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Autoimmune bullous diseases are a heterogeneous group of disorders that can be subdivided according to the level of split formation in the intraepidermal blistering pemphigus diseases and subepidermal bullous disorders, latter including pemphigoid diseases, epidermolysis bullosa acquisita (EBA), and dermatitis herpetiformis. In the majority of autoimmune bullous disorders, disease activity can be sufficiently controlled by systemic corticosteroids in combination with further immunsuppressants/-modulants such as dapsone, doxycycline, azathioprine, mycophenolate mofetil, or methotrexate. In contrast, in pemphigus, mucous membrane pemphigoid, and EBA, treatment is challenging and conventional immunosuppressive therapy induces clinical remission only in a minority of patients. Until recently, only cyclosphosphamide and high-dose intravenous immunoglobulin (IVIG) were available as potent second-line therapies. Meanwhile, immunoadsorption and the monoclonal anti-CD20 antibody rituximab have been established as further therapeutic options. The present review focuses on efficacy, adverse events, treatment protocols, and mechanisms of action of IVIG, immunoadsorption, and rituximab in the treatment of severe and/or refractory patients with bullous autoimmune diseases.
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Affiliation(s)
- E Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck, Ratzeburger Allee 160, 23538 Lübeck.
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6
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Enk A, Fierlbeck G, French L, Hertl M, Messer G, Meurer M, Steinbrink K, Stingl G, Volc-Platzer B, Zillikens D. Use of high-dose immunoglobulins in dermatology. J Dtsch Dermatol Ges 2009; 7:806-812. [DOI: 10.1111/j.1610-0387.2009.07118.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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7
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Abstract
Autoimmune bullous disorders pose a clinical challenge based on their potentially lethal course and limited therapeutic options. The currently employed immunosuppressive treatments are accompanied by a plethora of side effects. Therefore, our group has sought for many years to dissect the molecular mechanisms of the immune pathogenesis of pemphigus and the pemphigoids allowing for a more specific treatment of these disorders. We have extensively characterized the role of autoaggressive T cells and potential regulatory networks in both disorders and have contributed several tools for more refined serological and T cell-based disease parameters. The ultimate therapeutic goal is anergy induction in these autoaggressive T cells which inititate and perpetuate the B cell-driven immune pathogenesis of pemphigus and the pemphigoids.
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Affiliation(s)
- Michael Hertl
- Department of Dermatology and Allergy, University of Marburg, Germany.
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8
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Staubach-Renz P, von Stebut E, Bräuninger W, Maurer M, Steinbrink K. [Hypocomplementemic urticarial vasculitis syndrome. Successful therapy with intravenous immunoglobulins]. Hautarzt 2008; 58:693-7. [PMID: 17453168 DOI: 10.1007/s00105-007-1301-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Autoimmune diseases can initially present as chronic urticaria. We describe the course of a patient with hypocomplementemic urticarial vasculitis syndrome (HUVS) as well as his successful treatment with high-dose intravenous immunoglobulins (IVIG). HUVS was diagnosed clinically and confirmed by histology and laboratory studies. After only one cycle with IVIG (2 g/kg) all HUVS symptoms were significantly decreased.
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MESH Headings
- Adult
- Angioedema/diagnosis
- Angioedema/drug therapy
- Angioedema/immunology
- Angioedema/pathology
- Autoimmune Diseases/diagnosis
- Autoimmune Diseases/drug therapy
- Autoimmune Diseases/immunology
- Autoimmune Diseases/pathology
- Biopsy
- Complement C1q/deficiency
- Complement C3/deficiency
- Complement C4/deficiency
- Diagnosis, Differential
- Follow-Up Studies
- Humans
- Immunoglobulins, Intravenous/administration & dosage
- Infusions, Intravenous
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/drug therapy
- Lupus Erythematosus, Systemic/immunology
- Lupus Erythematosus, Systemic/pathology
- Male
- Skin/pathology
- Vasculitis, Leukocytoclastic, Cutaneous/diagnosis
- Vasculitis, Leukocytoclastic, Cutaneous/drug therapy
- Vasculitis, Leukocytoclastic, Cutaneous/immunology
- Vasculitis, Leukocytoclastic, Cutaneous/pathology
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Affiliation(s)
- P Staubach-Renz
- Universitäts-Hautklinik Mainz, Langenbeckstrasse 1, 55101 Mainz, Deutschland.
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