Development of bullous pemphigoid during treatment of psoriatic onycho-pachydermo periostitis with ustekinumab

Development of bullous pemphigoid during treatment of psoriasis with ustekinumab: a case report and literature review

Ustekinumab is a biological therapy that has been approved for treating moderate-to-severe psoriasis. Although injection site reactions, nasopharyngitis, headaches, and infections are the common adverse events associated with ustekinumab, the development of bullous pemphigoid (BP) is also thought to be related to ustekinumab. Given that psoriasis itself can be complicated by BP, it is worthwhile to investigate the relationship between ustekinumab, psoriasis, and BP. Here we report a case of a male patient who developed BP twice after psoriasis treatment with ustekinumab. The patient's psoriasis and BP were brought under control by discontinuing ustekinumab and administering methotrexate, minocycline, and topical corticosteroids. Because of the increasing use of biologics in patients with psoriasis, BP should be considered a potential adverse event associated with ustekinumab.

Paradoxical phenomena of bullous pemphigoid induced and treated by identical biologics

Objective

This study aimed to investigate the clinical features of biologics-induced bullous pemphigoid (BP) and the therapeutic effects of those agents for BP, exploring the underlying pathophysiological mechanisms.

Methods

We searched PubMed, Web of Science, and Elsevier for studies involving pemphigoid patients treated with or induced by identical biologics published in English from January 2009 to April 2022.

Results

Seventeen cases of drug-induced BP associated with anti-tumor necrosis factor (aTNF)-α therapies, one with interleukin (IL)-17 inhibitors, and seven with IL-12/IL-23 or IL-23 inhibitors were enrolled. Time to cutaneous toxicity varied among different types of agents, and the characteristics of clinical examinations were similar to idiopathic BP. Discontinuation of the culprit drugs and initiation of topical or systemic corticosteroids were adequate in most cases. Several monoclonal antibodies above have also been reported for the treatment of refractory or recurrent BP, especially concurrent with psoriasis.

Conclusion

Biologics for immune-related diseases, including TNF-α, IL-17, and IL-12/IL-23 or IL-23 inhibitors, can both induce and treat BP, which might be associated with a helper T cells Th1/Th2 imbalance, complicated inflammatory networks, and a specific individual microenvironment, suggestive of a new perspective on the therapeutic algorithms of BP. There have been numerous reports about biologics inducing or treating BP. We have taken note of this phenomenon and focused on biologics with both pathogenetic and therapeutic effects on BP. Our review summarized the clinical characteristics of associated cases, trying to figure out the underlying mechanisms of this paradoxical phenomenon and to provide an integrated perspective and new therapeutic alternatives for BP.

Bullous Pemphigoid Associated with Erythrodermic Psoriasis: A Case Report

Psoriasis is an immune-mediated systemic disease with multiple organs involvement, such as cardiovascular, live, gut, endocrine, and so on. Bullous pemphigoid (BP) is a rare comorbidity associated with psoriasis, while BP occurring in erythrodermic psoriasis (EP) is very rare. In this case, we reported a woman with severe EP who developed BP, in whom beta hemolytic streptococcus infection was a possible triggering factor. The complicated condition of such patients needs to draw attention of the physician and study further for better treatment.

Bullous pemphigoid induced by biologic drugs in psoriasis: a systematic review

INTRODUCTION

Several therapies for psoriasis have been described as triggers of biologic-induced bullous pemphigoid (BIBP). The real incidence of BIBP in psoriatic patients is still unknown. Hence, we compilated and analyzed current literature to identify the frequency and burden of this adverse event for psoriasis patients treated with biologics.

MATERIAL AND METHOD

We systematically searched literature records involving psoriatic patients developing BIBP. Electronic searches were conducted in Pubmed, EMBASE and Scopus in April 2021. To assess the causal relationship between BP and the biologic drug, we applied the Naranjo adverse reaction probability scale and the Karch-Lasagna algorithm.

RESULTS

Our systematic review identified 586 records through the three electronic databases. We identified 15 case reports of BIBP. These cases implicated two cases induced by adalimumab, three by efalizumab, three by etanercept, six by ustekinumab, and one case by secukinumab. Mean period of latency until the BIBP developed was time 5.12 ± 3.44 weeks for TNF-α blockers, and 28.66 ± 26.27 weeks for ustekinumab (p = .09). Most of the cases were assessed as "probable" consistently in both the Naranjo scale and the Karch-Lasagna algorithm.

CONCLUSION

This work presents an accurate estimation on the frequency and burden of BIBP. Ustekinumab presents with the largest evidence of BIBP, especially in patients with previous failure to TNF-α agents. Distinct patterns in the cytokinic pathways and clinical course exist between the BP induced by TNF-α blockers and ustekinumab. A close monitoring of skin condition is highly advisable in patients receiving biologic therapies for psoriasis. Knowledge of BIBP is of great importance to determine the preventive measures and select optimal treatment options.What's already known about this topic?The widespread use of biologic drugs has led dermatologists to encounter increasing situations of biologic-induced BP (BIBP).A lack of data exists on the real incidence of BIBP in psoriatic patients.BIBP is an important adverse event to know when managing patients with psoriasis using biologics.What does this study add?This work presents an accurate estimation on the raised burden of BIBP.Ustekinumab presents with the largest evidence of BIBP, especially in patients with previous failure to TNF-α agents.Mean period of latency until the BIBP developed was time 5.12 ± 3.44 weeks for TNF-α blockers, and 28.66 ± 26.27 weeks for ustekinumab.Distinct patterns in the cytokine pathways and clinical course exist between the BP induced by TNF-α blockers and ustekinumab.A careful screening of previous history of bullous diseases and a baseline immunologic study in psoriatic patients should be advisable prior to commencing any biologic therapy.A close monitoring of skin condition is highly advisable in patients receiving biologic therapies for psoriasis.

Pemphigus and Pemphigoid: From Disease Mechanisms to Druggable Pathways

Pemphigus and pemphigoid are paradigms for understanding the mechanisms of antibody-mediated autoimmune disease in humans. In pemphigus, IgG4-predominant autoantibodies cause intraepidermal blistering by direct interference with desmoglein interactions and subsequent disruption of desmosomes and signaling pathways. In pemphigoid, IgG1, IgG4, and IgE autoantibodies against basement membrane zone antigens directly interfere with hemidesmosomal adhesion, activating complement and Fc receptor‒mediated effector pathways. Unraveling disease mechanisms in pemphigus and pemphigoid has identified numerous opportunities for clinical trials, which hold promise to identify safer and more effective therapies for these potentially life-threatening diseases.

Guselkumab-associated bullous pemphigoid in a psoriasis patient: A case report and review of the literature

Drug‐induced bullous pemphigoid (DBP) associated to biologics administered for psoriasis is rare. DBP has been described especially in association with anti‐TNF‐α drugs and anti‐IL12 and 23, but never in relation to guselkumab (anti‐IL23). We report the case of a 76‐year‐old male patient with severe psoriasis (PASI 20), presenting with generalized tense bullae and erosions after being recently switched to guselkumab therapy. Histology and direct immunofluorescence confirmed the suspect of bullous pemphigoid (BP). Guselkumab administration was interrupted, low‐dose oral corticosteroid therapy was introduced and after only 1‐month remission was obtained with no new lesions appearing. As outlined in the presented case, DBP's onset typically follows the introduction of a new drug in patients taking polypharmacy. In addition, DBP may spontaneously regress after discontinuation of the triggering drug and it responds very rapidly to steroid therapy. Up to date, DBP has been described after biological therapy for psoriasis in 11 patients, following administration of ustekinumab, efalizumab, etanercept, secukinumab, and adalimumab. Conversely, DBP after guselkumab therapy for psoriasis has never been reported in published studies. We highlight the need to face and document increasing, though rare, side effects of biologic therapies, as new biologic molecules are being constantly developed and administered to psoriatic patients, to promptly interrupt treatment when needed.

Alternative uses of ustekinumab for non-indicated dermatological conditions: a systematic review

Ustekinumab is approved for the treatment of psoriasis and Crohn's disease. Because many dermatological conditions are due to immune-mediated development, ustekinumab may be effective in other conditions. A systematic review of the off-label uses of ustekinumab, as well as on-label adverse effect, was performed, reporting on clinical improvement. MEDLINE, Embase, Web of Science, and Cochrane databases were searched for studies regarding ustekinumab treatment of rativa (HS), lichen planus (LP), pyoderma gangrenosum (PG), pityriasis rubra pilaris (PRP), cutalopecia areata (AA), atopic dermatitis (AD), Bechet's disease, bullous pemphigoid (BP), hidradenitis suppuaneous sarcoidosis, cutaneous systemic lupus erythematosus (SLE), and vitiligo. Descriptive statistics were performed. 74 articles of 4596 screened were included, and reported on 212 patients receiving ustekinumab treatment. Across all studies, ustekinumab showed promise in treating patients: AA (10/12 patients; 83.3% improvement), AD (28/74 patients; 37.8% improvement), HS (42/52 patients; 80.8% improvement), and PRP (25/27 patients; 92.6% improvement), among others. Adverse events were noted with the use of ustekinumab, including development of AA (four patients), AD (three patients), and BP (four patients), among others. Ustekinumab can be a promising option for patients with dermatological conditions refractory to traditional therapies. Adverse events must be monitored in certain patients.

Bullous pemphigoid induced by ustekinumab: a case report

A possible case of bullous pemphigoid (BP) that developed during treatment with ustekinumab is reported. Ustekinumab is a human monoclonal antibody found in pathologies such as psoriasis, which works by inhibiting the activity of interleukin-12 and interleukin-23. We describe the case of a 75-year-old woman who presented with new onset of erythematous and bullous lesions 5 days after receiving a fifth dose of ustekinumab. The patient was treated with corticosteroids and dapsone, whereupon the lesions disappeared. Ustekinumab was withdrawn. Currently the patient remains asymptomatic. In addition, the histopathological and immunofluorescence findings confirmed the diagnosis of BP. Three causality algorithms were applied and revealed a probable causal relationship. There may be a causal relationship between the use of ustekinumab and BP. This association should be taken into account by physicians when prescribing and reviewing drug therapies.

Autoimmune blistering diseases provoked during the treatment of chronic inflammatory disease with biologic agents: a systematic review

BACKGROUND

To investigate the clinical course of autoimmune blistering diseases (AIBDs) following treatment with biologic agents (BAs) for chronic inflammatory diseases.

METHODS

A comprehensive review of available, published literature was performed using PubMed and CINAHL search engines. Diagnostic criteria of AIBD included positive direct immunofluorescence studies and/or positive serology with clinically suggestive features.

RESULTS

A total of 22 cases of AIBDs provoked by the use of BAs were found. The most commonly implicated agents were tumor necrosis factor-alpha inhibitors (n = 14). The mean age of onset of AIBD was 59.4 years (median 61.5 years, range 31-82). Average time to onset of AIBD following initiation of the suspected BA was 33.7 ± 43.8 weeks (range 3 days to 152 weeks). Psoriasis was the most common associated condition for which the BA was prescribed (n = 11), followed by rheumatoid arthritis (n = 6) and ulcerative colitis (n = 5). Of the 21 cases reporting AIBD outcome, 17 reported remission or complete resolution upon stopping treatment with the involved BA. Four cases reported continued bullae formation without worsening of disease following cessation of the BA or systemic corticosteroids used to treat the AIBD. Five cases rechallenged the patient with the involved BA and four of the five reported recurrence, often with quicker onset and more severe symptoms.

CONCLUSIONS

BAs may be suspected in patients developing AIBD while being treated for chronic inflammatory diseases. A majority of cases resolve upon cessation of the offending agent.

Psoriasis is associated with increased risk of bullous pemphigoid: A nationwide population-based cohort study in Taiwan

Psoriasis may coexist with bullous pemphigoid (BP); however, no cohort studies have investigated the relationship between psoriasis and the risk of BP. This study aims to investigate the relationship between psoriasis and the risk of BP in Taiwan. This cohort study consists of 109 777 psoriatic patients and 109 777 matched non-exposed controls. Psoriatic patients diagnosed between 2002 and 2012 were identified from the Taiwan National Health Insurance Research Database. The age-, sex- and index date-matched non-exposed group was selected from the same database. The relationship between psoriasis and the risk of BP was investigated using Cox proportional hazards analyses. Psoriasis was significantly associated with an increased risk of BP (hazard ratio, 3.05; 95% confidence interval, 2.10-4.43; P < 0.001). The mean interval between the diagnoses of psoriasis and BP was 2.86 years, with the highest occurrence in the first year after psoriasis diagnosis, and gradually decreasing with each year of observation. Psoriatic patients with BP were significantly younger than BP patients in the non-exposed group (71.6 ± 13.9 vs 76.6 ± 7.7 years, respectively; P = 0.030). A higher proportion of patients with coexisting psoriasis and BP received phototherapy (20%). In conclusion, psoriasis was independently associated with a 3.05-fold increased risk of BP, and psoriatic patients with BP were younger, with over one-third of BP cases diagnosed in the first year after incident psoriasis. Therefore, clinicians treating patients with psoriasis may be aware of the possibility of the development of BP.

Interaction of Psoriasis and Bullous Diseases

Patients with psoriasis are frequently complicated with autoimmune bullous diseases, especially, pemphigoid diseases. It has been known that one-third cases of anti-laminin gamma1 pemphigoid, formerly anti-p200 pemphigoid, are associated with psoriasis whereas bullous pemphigoid is the most frequently associated bullous disease in psoriasis cases regardless of the lack of detectable levels of the accompanying anti-laminin gamma1 autoantibodies. Despite several suggestions, however, the definitive reason of the striking association of psoriasis and these autoimmune bullous diseases remains elusive. In this review, we look over the epidemiological evidence of the association of psoriasis and autoimmune bullous diseases and the information of genetic susceptibilities of each disease, and discuss the possible mechanisms of their complication with reference to the recent understandings of each pathogenesis.

Bullous Pemphigoid: A Review of its Diagnosis, Associations and Treatment

Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease in Western countries, and typically affects the elderly. BP is immunologically characterized by tissue-bound and circulating autoantibodies directed against either the BP antigen 180 (BP180, or BPAG2) or the BP antigen 230 (BP230, or BPAG1e), or even both, which are components of hemidesmosomes involved in the dermal-epidermal cohesion. Risk factors for BP include old age, neurologic diseases (dementia, Parkinson's disease, cerebrovascular disease), and some particular drugs, including loop diuretics, spironolactone and neuroleptics. The spectrum of clinical presentations is extremely broad. Clinically, BP is an intensely pruritic erythematous eruption with widespread blister formation. In the early stages, or in atypical, non-bullous variants of the disease, only excoriated, eczematous or urticarial lesions (either localized or generalized) are present. The diagnosis of BP relies on immunopathologic findings, especially based on both direct and indirect immunofluorescence microscopy observations, as well as on anti-BP180/BP230 enzyme-linked immunosorbent assays (ELISAs). BP is usually a chronic disease, with spontaneous exacerbations and remissions, which may be accompanied by significant morbidity. In the past decade, potent topical corticosteroids have emerged as an effective and safe first-line treatment for BP, but their long-term feasibility is still controversial. Newer therapeutic agents targeting molecules involved in the inflammatory cascade associated with BP represent future alternatives to classical immunosuppressant drugs for maintenance therapy.