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Karakioulaki M, Eyerich K, Patsatsi A. Advancements in Bullous Pemphigoid Treatment: A Comprehensive Pipeline Update. Am J Clin Dermatol 2024; 25:195-212. [PMID: 38157140 PMCID: PMC10866767 DOI: 10.1007/s40257-023-00832-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 01/03/2024]
Abstract
ABASTRACT Bullous pemphigoid (BP) is a common autoimmune bullous disease affecting mainly the elderly, with rising incidence due to increased life expectancy. This disease is characterized by tense bullous lesions on normal or erythematous skin, accompanied by pruritus. BP pathogenesis involves autoantibodies against hemidesmosomal proteins BP180 and BP230, leading to detachment at the dermo-epidermal junction as well as blister formation. BP is associated with coexisting comorbidities and drug exposure, and its management often requires high doses or chronic use of systemic glucocorticoids, posing risks of adverse effects. This review focuses on novel treatment options for BP, exploring therapies targeting different immune pathways. Rituximab, a CD20 monoclonal antibody, depletes B-lymphocytes and has shown efficacy in severe cases. Dupilumab, targeting interleukin (IL)-4 receptor α and thus blocking IL-4 and IL-13, downregulates type 2 helper (Th2) responses and has demonstrated promising results. Targeting eosinophil-related molecules using bertilimumab and AKST4290 has yielded positive results in clinical trials. Omalizumab, an immunoglobulin (Ig) E antibody, can reduce disease severity and allows corticosteroid tapering in a number of cases. Complement inhibitors such as nomacopan and avdoralimab are being investigated. IL-17 and IL-23 inhibitors such as secukinumab and tildrakizumab have shown potential in a limited number of case reports. Neonatal Fc receptor antagonists such as efgartigimod are under investigation. Additionally, topical therapies and Janus kinase inhibitors are being explored as potential treatments for BP. These novel therapies offer promising alternatives for managing BP, with potential to improve outcomes and reduce high cumulative doses of systemic corticosteroids and related toxicities. Further research, including controlled clinical trials, is needed to establish their efficacy, safety, and optimal dosing regimens for BP management.
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Affiliation(s)
- Meropi Karakioulaki
- Department of Dermatology and Venerology, Medical Center, University Hospital Freiburg, Freiburg, Germany
| | - Kilian Eyerich
- Department of Dermatology and Venerology, Medical Center, University Hospital Freiburg, Freiburg, Germany
| | - Aikaterini Patsatsi
- Second Department of Dermatology, School of Medicine, Papageorgiou Hospital, Aristotle University, Thessaloníki, Greece.
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Kline SN, Orlando NA, Lee AJ, Wu MJ, Zhang J, Youn C, Feller LE, Pontaza C, Dikeman D, Limjunyawong N, Williams KL, Wang Y, Cihakova D, Jacobsen EA, Durum SK, Garza LA, Dong X, Archer NK. Staphylococcus aureus proteases trigger eosinophil-mediated skin inflammation. Proc Natl Acad Sci U S A 2024; 121:e2309243121. [PMID: 38289950 PMCID: PMC10861893 DOI: 10.1073/pnas.2309243121] [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: 06/06/2023] [Accepted: 12/22/2023] [Indexed: 02/01/2024] Open
Abstract
Staphylococcus aureus skin colonization and eosinophil infiltration are associated with many inflammatory skin disorders, including atopic dermatitis, bullous pemphigoid, Netherton's syndrome, and prurigo nodularis. However, whether there is a relationship between S. aureus and eosinophils and how this interaction influences skin inflammation is largely undefined. We show in a preclinical mouse model that S. aureus epicutaneous exposure induced eosinophil-recruiting chemokines and eosinophil infiltration into the skin. Remarkably, we found that eosinophils had a comparable contribution to the skin inflammation as T cells, in a manner dependent on eosinophil-derived IL-17A and IL-17F production. Importantly, IL-36R signaling induced CCL7-mediated eosinophil recruitment to the inflamed skin. Last, S. aureus proteases induced IL-36α expression in keratinocytes, which promoted infiltration of IL-17-producing eosinophils. Collectively, we uncovered a mechanism for S. aureus proteases to trigger eosinophil-mediated skin inflammation, which has implications in the pathogenesis of inflammatory skin diseases.
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Affiliation(s)
- Sabrina N. Kline
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Nicholas A. Orlando
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Alex J. Lee
- Department of Oncology, Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD21205
| | - Meng-Jen Wu
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Jing Zhang
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Christine Youn
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Laine E. Feller
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Cristina Pontaza
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Dustin Dikeman
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Nathachit Limjunyawong
- Center of Research Excellence in Allergy and Immunology, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok10700, Thailand
| | - Kaitlin L. Williams
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Yu Wang
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Daniela Cihakova
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Elizabeth A. Jacobsen
- Division of Allergy, Asthma and Clinical Immunology, Mayo Clinic Arizona, Scottsdale, AZ85259
| | - Scott K. Durum
- Cancer Innovation Laboratory, Center for Cancer Research, National Cancer Institute, NIH, Frederick, MD21702
| | - Luis A. Garza
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
| | - Xinzhong Dong
- HHMI, Johns Hopkins University School of Medicine, Baltimore, MD21205
- Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD21205
| | - Nathan K. Archer
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD21287
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Huang R, Hu L, Jiang F. Study of cytokine-induced immunity in bullous pemphigoid: recent developments. Ann Med 2023; 55:2280991. [PMID: 38109924 PMCID: PMC10732206 DOI: 10.1080/07853890.2023.2280991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/04/2023] [Indexed: 12/20/2023] Open
Abstract
Bullous pemphigoid (BP) is an organ-specific disease. Its pathogenesis has not been clearly studied yet; However, studies in recent years have shown that its pathogenesis is related to T helper cells. The pathogenesis of BP is mainly related to Th2 and Th17-related cytokines. IL-4, IL-5 and IL-13 cause eosinophil recruitment, promote antibody production, trigger pruritus and promote blister formation and other symptoms. IL-17 and IL-23 promote the production of matrix metalloproteinase-9 (MMP-9) by related cells, which causes dermo-epidermal junction (DEJ) separation to form bullae and blisters, and can persist in BP inflammation. The serum concentrations of IL-17 and IL-23 are related to the prognosis of BP. In this paper, we focus on the role of related cytokines in the pathogenesis of bullous pemphigoid and the relationship between the related cytokine populations secreted by three major T helper cells-helper T lymphocytes 1 (Th1), Th2, and Th17. A better understanding of the biological and immunological functions of cytokines associated with BP patients will provide opportunities for therapeutic targets in BP.
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Affiliation(s)
- Ruiting Huang
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Lingyu Hu
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Fuqiong Jiang
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
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4
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Jesenak M, Diamant Z, Simon D, Tufvesson E, Seys SF, Mukherjee M, Lacy P, Vijverberg S, Slisz T, Sediva A, Simon HU, Striz I, Plevkova J, Schwarze J, Kosturiak R, Alexis NE, Untersmayr E, Vasakova MK, Knol E, Koenderman L. Eosinophils-from cradle to grave: An EAACI task force paper on new molecular insights and clinical functions of eosinophils and the clinical effects of targeted eosinophil depletion. Allergy 2023; 78:3077-3102. [PMID: 37702095 DOI: 10.1111/all.15884] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 09/14/2023]
Abstract
Over the past years, eosinophils have become a focus of scientific interest, especially in the context of their recently uncovered functions (e.g. antiviral, anti-inflammatory, regulatory). These versatile cells display both beneficial and detrimental activities under various physiological and pathological conditions. Eosinophils are involved in the pathogenesis of many diseases which can be classified into primary (clonal) and secondary (reactive) disorders and idiopathic (hyper)eosinophilic syndromes. Depending on the biological specimen, the eosinophil count in different body compartments may serve as a biomarker reflecting the underlying pathophysiology and/or activity of distinct diseases and as a therapy-driving (predictive) and monitoring tool. Personalized selection of an appropriate therapeutic strategy directly or indirectly targeting the increased number and/or activity of eosinophils should be based on the understanding of eosinophil homeostasis including their interactions with other immune and non-immune cells within different body compartments. Hence, restoring as well as maintaining homeostasis within an individual's eosinophil pool is a goal of both specific and non-specific eosinophil-targeting therapies. Despite the overall favourable safety profile of the currently available anti-eosinophil biologics, the effect of eosinophil depletion should be monitored from the perspective of possible unwanted consequences.
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Affiliation(s)
- Milos Jesenak
- Department of Clinical Immunology and Allergology, University Teaching Hospital in Martin, Martin, Slovak Republic
- Department of Paediatrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
- Department of Pulmonology and Phthisiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
| | - Zuzana Diamant
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund University, Lund, Sweden
- Department Microbiology Immunology & Transplantation, KU Leuven, Catholic University of Leuven, Leuven, Belgium
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ellen Tufvesson
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund University, Lund, Sweden
| | - Sven F Seys
- Laboratory of Clinical Immunology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Manali Mukherjee
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- The Firestone Institute for Respiratory Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Paige Lacy
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Susanne Vijverberg
- Amsterdam UMC Location University of Amsterdam, Pulmonary Diseases, Amsterdam, The Netherlands
| | - Tomas Slisz
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, 2nd Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland
- Institute of Biochemistry, Brandenburg Medical School, Neuruppin, Germany
| | - Ilja Striz
- Department of Clinical and Transplant Immunology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jana Plevkova
- Department of Pathophysiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Jurgen Schwarze
- Child Life and Health and Centre for Inflammation Research, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Radovan Kosturiak
- Department of Paediatrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
- Outpatient Clinic for Clinical Immunology and Allergology, Nitra, Slovak Republic
| | - Neil E Alexis
- Center for Environmental Medicine, Asthma and Lung Biology, Department of Paediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Martina Koziar Vasakova
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Edward Knol
- Department Center of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department Dermatology/Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leo Koenderman
- Department Center of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department Pulmonary Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
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Chen HC, Wang CW, Toh WH, Lee HE, Chung WH, Chen CB. Advancing Treatment in Bullous Pemphigoid: A Comprehensive Review of Novel Therapeutic Targets and Approaches. Clin Rev Allergy Immunol 2023; 65:331-353. [PMID: 37897588 DOI: 10.1007/s12016-023-08973-1] [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] [Accepted: 10/15/2023] [Indexed: 10/30/2023]
Abstract
Bullous pemphigoid is one of the most common autoimmune bullous diseases occurring primarily in the elderly. Pathogenic autoantibodies against BP180 and BP230 at the dermal-epidermal junction cause subepidermal blisters, erosions, and intense pruritus, all of which adversely affect the patients' quality of life and may increase their morbidity and mortality. Current systemic treatment options for bullous pemphigoid are limited to corticosteroids and immunosuppressants, which can have substantial side effects on these vulnerable patients that even exceed their therapeutic benefits. Therefore, more precisely, targeting therapies to the pathogenic cells and molecules in bullous pemphigoid is an urgent issue. In this review, we describe the pathophysiology of bullous pemphigoid, focusing on autoantibodies, complements, eosinophils, neutrophils, proteases, and the T helper 2 and 17 axes since they are crucial in promoting proinflammatory environments. We also highlight the emerging therapeutic targets for bullous pemphigoid and their latest discoveries in clinical trials or experimental studies. Further well-designed studies are required to establish the efficacy and safety of these prospective therapeutic options.
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Affiliation(s)
- Hsuan-Chi Chen
- Department of Medical Education, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Linkou, Taipei, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
| | - Wu Han Toh
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, USA
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
- Department of Biology, Johns Hopkins University, Baltimore, MD, USA
| | - Hua-En Lee
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Linkou, Taipei, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Linkou, Taipei, Taiwan.
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan.
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan.
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China.
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan.
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan.
- Department of Dermatology, Beijing Tsinghua Chang Gung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
- Department of Dermatology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan.
| | - Chun-Bing Chen
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Linkou, Taipei, Taiwan.
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou, Taiwan.
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan.
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China.
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China.
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan.
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Tanaka A, Fujimura Y, Fuke S, Izumi K, Ujiie H. A case of bullous pemphigoid developing under treatment with benralizumab for bronchial asthma. J Dermatol 2023; 50:1199-1202. [PMID: 37122191 DOI: 10.1111/1346-8138.16811] [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: 02/06/2023] [Revised: 03/22/2023] [Accepted: 04/10/2023] [Indexed: 05/02/2023]
Abstract
Bullous pemphigoid (BP) is an autoimmune disease characterized by itchy erythema and tense blisters on the whole body. Recent reports have unveiled the pathogenic roles of eosinophils in BP (e.g., dermal-epidermal separation, generation of pruritus). Thus, eosinophils are considered a therapeutic target. Benralizumab is an anti-IL-5 receptor alpha (IL-5Rα) monoclonal antibody (mAb) that is widely used to treat severe eosinophilic asthma. By affecting IL-5Rα, benralizumab depletes eosinophils and basophils due to apoptosis through antibody-dependent cell-mediated cytotoxicity. The efficacies of benralizumab and other biologics, including bertilimumab (anti-eotaxin-1 mAb) and mepolizumab (anti-IL-5 mAb), were evaluated in several clinical trials. Also, reslizumab, an anti-IL-5 mAb, was reported as a successful treatment option in a case of BP. We present a case of severe asthma treated with benralizumab at 8-week intervals for 3 years before BP developed. Histologically, subepidermal blisters without eosinophilic infiltration were observed. Methylprednisolone pulse therapy followed by 40 mg/day (1 mg/kg/day) of oral prednisolone (PSL) was initiated, but the skin lesions worsened. Additional intravenous immunoglobulin and oral azathioprine enabled the oral PSL to be tapered. The benralizumab was discontinued after the onset of BP because the asthma did not worsen. To the best of our knowledge, there have been no reports of BP developing during anti-eosinophil therapy. BP may occur paradoxically via various pathways during treatment with drugs that are typically effective against BP.
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Affiliation(s)
- Arisa Tanaka
- Department of Dermatology, KKR Sapporo Medical Center, Sapporo, Japan
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yu Fujimura
- Department of Dermatology, KKR Sapporo Medical Center, Sapporo, Japan
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Satoshi Fuke
- Department of Respiratory Medicine, KKR Sapporo Medical Center, Sapporo, Japan
| | - Kentaro Izumi
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Singh S, Kirtschig G, Anchan VN, Chi CC, Taghipour K, Boyle RJ, Murrell DF. Interventions for bullous pemphigoid. Cochrane Database Syst Rev 2023; 8:CD002292. [PMID: 37572360 PMCID: PMC10421473 DOI: 10.1002/14651858.cd002292.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common autoimmune blistering disease. Oral steroids are the standard treatment. We have updated this review, which was first published in 2002, because several new treatments have since been tried. OBJECTIVES To assess the effects of treatments for bullous pemphigoid. SEARCH METHODS We updated searches of the following databases to November 2021: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched five trial databases to January 2022, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA RCTs of treatments for immunofluorescence-confirmed bullous pemphigoid. DATA COLLECTION AND ANALYSIS At least two review authors, working independently, evaluated the studies against the review's inclusion criteria and extracted data from included studies. Using GRADE methodology, we assessed the certainty of the evidence for each outcome in each comparison. Our primary outcomes were healing of skin lesions and mortality. MAIN RESULTS We identified 14 RCTs (1442 participants). The main treatment modalities assessed were oral steroids, topical steroids, and the oral anti-inflammatory antibiotic doxycycline. Most studies reported mortality but adverse events and quality of life were not well reported. We decided to look at the primary outcomes 'disease control' and 'mortality'. Almost all studies investigated different comparisons; two studies were placebo-controlled. The results are therefore based on a single study for each comparison except azathioprine. Most studies involved only small numbers of participants. We assessed the risk of bias for all key outcomes as having 'some concerns' or high risk, due to missing data, inappropriate analysis, or insufficient information. Clobetasol propionate cream versus oral prednisone Compared to oral prednisone, clobetasol propionate cream applied over the whole body probably increases skin healing at day 21 (risk ratio (RR 1.08, 95% confidence interval (CI) 1.03 to 1.13; 1 study, 341 participants; moderate-certainty evidence). Skin healing at 21 days was seen in 99.8% of participants assigned to clobetasol and 92.4% of participants assigned to prednisone. Clobetasol propionate cream applied over the whole body compared to oral prednisone may reduce mortality at one year (RR 0.73, 95% CI 0.53 to 1.01; 1 study, 341 participants; low-certainty evidence). Death occurred in 26.5% (45/170) of participants assigned to clobetasol and 36.3% (62/171) of participants assigned to oral prednisone. This study did not measure quality of life. Clobetasol propionate cream may reduce risk of severe complications by day 21 compared with oral prednisone (RR 0.65, 95% CI 0.50 to 0.86; 1 study, 341 participants; low-certainty evidence). Mild clobetasol propionate cream regimen (10 to 30 g/day) versus standard clobetasol propionate cream regimen (40 g/day) A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen probably does not change skin healing at day 21 (RR 1.00, 95% CI 0.97 to 1.03; 1 study, 312 participants; moderate-certainty evidence). Both groups showed complete healing of lesions at day 21 in 98% participants. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change mortality at one year (RR 1.00, 95% CI 0.75 to 1.32; 1 study, 312 participants; low-certainty evidence), which occurred in 118/312 (37.9%) participants. This study did not measure quality of life. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change adverse events at one year (RR 0.94, 95% CI 0.78 to 1.14; 1 study, 309 participants; low-certainty evidence). Doxycycline versus prednisolone Compared to prednisolone (0.5 mg/kg/day), doxycycline (200 mg/day) induces less skin healing at six weeks (RR 0.81, 95% CI 0.72 to 0.92; 1 study, 213 participants; high-certainty evidence). Complete skin healing was reported in 73.8% of participants assigned to doxycycline and 91.1% assigned to prednisolone. Doxycycline compared to prednisolone probably decreases mortality at one year (RR 0.25, 95% CI 0.07 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 14; 1 study, 234 participants; moderate-certainty evidence). Mortality occurred in 2.4% (3/132) of participants with doxycycline and 9.7% (11/121) with prednisolone. Compared to prednisolone, doxycycline improved quality of life at one year (mean difference 1.8 points lower, which is more favourable on the Dermatology Life Quality Index, 95% CI 1.02 to 2.58 lower; 1 study, 234 participants; high-certainty evidence). Doxycycline compared to prednisolone probably reduces severe or life-threatening treatment-related adverse events at one year (RR 0.59, 95% CI 0.35 to 0.99; 1 study, 234 participants; moderate-certainty evidence). Prednisone plus azathioprine versus prednisone It is unclear whether azathioprine plus prednisone compared to prednisone alone affects skin healing or mortality because there was only very low-certainty evidence from two trials (98 participants). These studies did not measure quality of life. Adverse events were reported in a total of 20/48 (42%) participants assigned to azathioprine plus prednisone and 15/44 (34%) participants assigned to prednisone. Nicotinamide plus tetracycline versus prednisone It is unclear whether nicotinamide plus tetracycline compared to prednisone affects skin healing or mortality because there was only very low-certainty evidence from one trial (18 participants). This study did not measure quality of life. Fewer adverse events were reported in the nicotinamide group. Methylprednisolone plus azathioprine versus methylprednisolone plus dapsone It is unclear whether azathioprine plus methylprednisolone compared to dapsone plus methylprednisolone affects skin healing or mortality because there was only very low-certainty evidence from one trial (54 participants). This study did not measure quality of life. A total of 18 adverse events were reported in the azathioprine group and 13 in the dapsone group. AUTHORS' CONCLUSIONS Clobetasol propionate cream applied over the whole body is probably similarly effective as, and may cause less mortality than, oral prednisone for treating bullous pemphigoid. Lower-dose clobetasol propionate cream applied over the whole body is probably similarly effective as standard-dose clobetasol propionate cream and has similar mortality. Doxycycline is less effective but causes less mortality than prednisolone for treating bullous pemphigoid. Other treatments need further investigation.
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Affiliation(s)
- Sanjay Singh
- Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Vinayak N Anchan
- Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ching-Chi Chi
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Kathy Taghipour
- Department of Dermatology, Whittington Health NHS Trust, London, UK
| | - Robert J Boyle
- National Heart & Lung Institute, Section of Inflammation and Repair, Imperial College London, London, UK
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital & University of New South Wales, Sydney, Australia
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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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Yan T, Xie Y, Liu Y, Shan Y, Wu X, Wang J, Zuo YG, Zhang Z. Dupilumab effectively and rapidly treats bullous pemphigoid by inhibiting the activities of multiple cell types. Front Immunol 2023; 14:1194088. [PMID: 37575240 PMCID: PMC10421662 DOI: 10.3389/fimmu.2023.1194088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Background Bullous pemphigoid (BP) is an autoimmune skin-blistering disease. Systemic corticosteroids remain the first line treatment for moderate-to-severe BP with the potential for severe adverse events. Dupilumab has emerged as an alternative option for BP patients. Objective We evaluated the efficiency and safety of dupilumab on BP treatment and explored a mode of drug action in depth. Methods and results A multicenter retrospective cohort included 20 BP patients who received dupilumab with or without systemic corticosteroid in dupilumab group, and 20 matched BP patients who received corticosteroid alone in conventional group. Serum samples were collected from 20 patients (10 from dupilumab group and 10 from conventional group) at baseline and week 4. Compared to systemic corticosteroid alone, dupilumab with or without systemic corticosteroid was similarly efficacious in clinical remission at week4 (complete remission plus partial remission: 100%) and week24 (complete remission plus partial remission:100%), but allowing significant decreases in the cumulative doses of corticosteroids with reducing the incidence of adverse events. However, dupilumab did not decrease BP180 antibody despite an obvious clinical improvement. Comparative plasma proteomic analysis performed before and after treatment in 3 BP patients from dupilumab group revealed that drug use was associated with 30 differentially expressed proteins, including 26 down-regulated and 4 up-regulated proteins. The former consisted of immune related proteins involved in T/B cell interactions (inducible T-cell co-stimulator ligand, ICOSL) and in the activation of eosinophils (PRG2), mast cells (S100A12), and complement (CR2). TARC and ICOSL levels correlated with BP severity in patients who received either dupilumab or conventional treatment. Conclusion Dupilumab has similar efficacy in treating BP as conventional drugs, by inhibiting the activities of many types of immune cells and complement, and regulating the interactions between T and B cells.
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Affiliation(s)
- Tianmeng Yan
- Department of Dermatology, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Department of Dermatology, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Yinghan Xie
- Department of Dermatology, Peking Union Medical College Hospital, Beijing, China
| | - Yuhua Liu
- Department of Dermatology, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Ying Shan
- Department of Dermatology, Peking Union Medical College Hospital, Beijing, China
| | - Xiaoyan Wu
- Department of Dermatology, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Jing Wang
- Department of Dermatology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Ya-Gang Zuo
- Department of Dermatology, Peking Union Medical College Hospital, Beijing, China
| | - Zhenying Zhang
- Department of Dermatology, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Department of Dermatology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
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Wang SH, Shan Y, Li SZ, Zuo YG. Anti-interleukin 4 receptor α antibody for the treatment of Chinese bullous pemphigoid patients with diverse comorbidities and a 1-year follow-up: a monocentric real-world study. Front Immunol 2023; 14:1165106. [PMID: 37545503 PMCID: PMC10399451 DOI: 10.3389/fimmu.2023.1165106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Background Bullous pemphigoid (BP) is a common subepidermal bullous disorder that lacks adequate treatment alternatives. Dupilumab, an anti-interleukin (IL) 4 receptor α antibody blocking Th2 molecules IL-4 and 13, has been used off-label and shown to be effective in refractory BP cases. Methods BP patients with various disease severities and comorbidities were included in this case series. All patients received dupilumab alone or in combination with immunosuppressants in a real-world setting. Complete remission (CR) was defined as the absence of pruritus symptoms and previous BP eruptions, with only hyperpigmentation patches and without newly occurring lesions for at least 4 weeks. Disease relapse was classified as the appearance of three or more new lesions within 1 month or at least one large urticarial or eczematous lesion that did not resolve within a week. Findings Ten individuals were enrolled in this case series. Pruritus symptoms and BP eruptions improved significantly in nine patients (90%). Seven patients (70%) attained CR, including all mild-to-moderate (100%) cases and three of six (50%) severe BP cases. At the dupilumab monotherapy stage, eosinophilia was observed in two severe cases. One patient out of seven (14.3%) relapsed after 1 year of follow-up after CR. Conclusion Treatment of BP with diverse comorbidities with anti-IL-4 receptor α antibody provides further credentials to a prospective randomized study. More impressive efficacy and safety profiles were observed in patients with mild-to-moderate disease after 1 year of follow-up. Eosinophilia may occur in patients receiving dupilumab monotherapy.
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Affiliation(s)
- Si-Hang Wang
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Shan
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Dermatology, Hebei North University, Zhangjiakou, Hebei, China
| | - Si-Zhe Li
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ya-Gang Zuo
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Gasparini G, Amber KT, Cozzani E, Parodi A. Editorial: Autoimmune blistering diseases: advances in the understanding of pathogenesis and new therapeutic horizons. Front Med (Lausanne) 2023; 10:1243878. [PMID: 37502359 PMCID: PMC10369339 DOI: 10.3389/fmed.2023.1243878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/03/2023] [Indexed: 07/29/2023] Open
Affiliation(s)
- Giulia Gasparini
- Section of Dermatology, Dipartimento di Scienze della Salute (DISSAL), University of Genoa, Genoa, Italy
- Dermatology Unit, Ospedale Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genoa, Italy
| | - Kyle T. Amber
- Department of Dermatology, Rush University Medical Center, Chicago, IL, United States
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Emanuele Cozzani
- Section of Dermatology, Dipartimento di Scienze della Salute (DISSAL), University of Genoa, Genoa, Italy
- Dermatology Unit, Ospedale Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genoa, Italy
| | - Aurora Parodi
- Section of Dermatology, Dipartimento di Scienze della Salute (DISSAL), University of Genoa, Genoa, Italy
- Dermatology Unit, Ospedale Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genoa, Italy
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Olbrich H, Sadik CD, Schmidt E. Autoimmune blistering diseases: promising agents in clinical trials. Expert Opin Investig Drugs 2023; 32:615-623. [PMID: 37526503 DOI: 10.1080/13543784.2023.2242778] [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: 05/22/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Treatment options for autoimmune bullous diseases (AIBD) are currently limited to corticosteroids and traditional immunomodulants and immunosuppressants that are associated with unfavorable adverse effect profiles. The most frequent AIBDs, i.e. bullous pemphigoid, pemphigus vulgaris, and mucous membrane pemphigoid, impose a high disease burden onto affected patients and can be detrimental due to infections, exsiccosis, and impaired food intake. Significant progress has been made in elucidating disease mechanisms and key mediators by in vivo and in vitro models, thus identifying a multifaceted range of possible drug targets. However, except for rituximab for pemphigus vulgaris, no new drugs have been approved for the treatment of AIBDs in the last decades. AREAS COVERED This review covers new drug developments and includes ongoing or completed phase 2 and 3 clinical trials. Studies were identified by querying the registries of ClinicalTrials.gov and Cochrane Library. EXPERT OPINION Promising results were shown for a variety of new agents including nomacopan, efgartigimod, omalizumab, dupilumab, as well as chimeric autoantibody receptor T cells. Clinical translation in the field of AIBDs is highly active, and we anticipate significant advances in the treatment landscape.
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Affiliation(s)
- Henning Olbrich
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | | | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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Kwon HJ, Kim KH, Yoon JH. Refractory Bullous Pemphigoid Successfully Treated with Reslizumab: A Possible Novel Therapeutic Modality. Ann Dermatol 2023; 35:S103-S106. [PMID: 37853878 PMCID: PMC10608355 DOI: 10.5021/ad.21.177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/25/2021] [Accepted: 11/04/2021] [Indexed: 10/20/2023] Open
Abstract
Bullous pemphigoid (BP) is a chronic, autoimmune blistering disease that has concerning morbidity and mortality rates. Recently, several studies have focused on eosinophils due to their significant role in the pathogenesis of BP, considering that they are ubiquitous in the serum, tissue, and blister fluids of patients with BP. With this context, precision therapy that targets mediators of eosinophil activity could be a possible novel therapeutic strategy. Interleukin (IL)-5 is crucial for B-cell maturation, which consequently results in immunoglobulin production, and promotes eosinophil differentiation, proliferation, and activation. To our best knowledge, reslizumab has not yet been reported to treat BP. Herein, we report a case of steroid- and omalizumab-resistant BP treated successfully using reslizumab. Our data suggest that IL-5 could be a novel specific biologic target within the entire immunopathogenesis of BP, and reslizumab would be a novel therapeutic modality.
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Affiliation(s)
- Hyeok-Jin Kwon
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Korea
| | - Ki-Ho Kim
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Korea
| | - Jung-Ho Yoon
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Korea.
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BAUM S, ENGLER MARKOWITZ M, LYAKHOVITSKY A, GERSHON R, AVIV H, SEGAL Z, BARZILAI A. Skin Eosinophil Counts in Bullous Pemphigoid as a Prognostic Factor for Disease Severity and Treatment Response. Acta Derm Venereol 2023; 103:adv00850. [PMID: 36250732 PMCID: PMC9885287 DOI: 10.2340/actadv.v102.2938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/17/2022] [Indexed: 01/11/2023] Open
Abstract
Dermal infiltration of eosinophils and eosinophilic spongiosis are prominent features of bullous pemphigoid lesions. Although several observations support the pathogenic role of eosinophils in bullous pemphigoid, few studies have examined the impact of skin eosinophil counts on disease severity and treatment response. This retrospective study assessed the association between eosinophil counts in skin biopsy samples of 137 patients with bullous pemphigoid and their demographic characteristics, comorbidities, disease severity, and treatment response. There was no relationship between eosinophil count and age, sex, or disease severity at disease onset. There was a positive relationship between eosinophil counts and neurological comorbidity and a negative relationship between eosinophil counts and treatment response. At all follow-up points patients with no tissue eosinophils had a better response to treatment than patients with any tissue eosinophil count. In conclusion, skin eosinophil counts in patients with bullous pemphigoid are not correlated with disease severity at onset, but can serve as a negative prognostic marker for treatment response.
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Affiliation(s)
- Sharon BAUM
- Department of Dermatology, Sheba Medical Center, Tel HaShomer,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Anna LYAKHOVITSKY
- Department of Dermatology, Sheba Medical Center, Tel HaShomer,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rotem GERSHON
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hannah AVIV
- Department of Dermatology, Sheba Medical Center, Tel HaShomer
| | - Zvi SEGAL
- Department of Dermatology, Sheba Medical Center, Tel HaShomer,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviv BARZILAI
- Department of Dermatology, Sheba Medical Center, Tel HaShomer,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Institute of Pathology, Sheba Medical Center, Tel HaShomer
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15
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Zhang L, Chen Z, Wang L, Luo X. Bullous pemphigoid: The role of type 2 inflammation in its pathogenesis and the prospect of targeted therapy. Front Immunol 2023; 14:1115083. [PMID: 36875098 PMCID: PMC9978795 DOI: 10.3389/fimmu.2023.1115083] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 02/06/2023] [Indexed: 02/18/2023] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune disease that mainly occurs in the elderly, severely affecting their health and life quality. Traditional therapy for BP is mainly based on the systemic use of corticosteroids, but long-term use of corticosteroids results in a series of side effects. Type 2 inflammation is an immune response largely mediated by group 2 innate lymphoid cells, type 2 T helper cells, eosinophils, and inflammatory cytokines, such as interleukin (IL)-4, IL-5 and IL-13. Among patients with BP, the levels of immunoglobulin E and eosinophils are significantly increased in the peripheral blood and skin lesions, suggesting that the pathogenesis is tightly related to type 2 inflammation. To date, various targeted drugs have been developed to treat type 2 inflammatory diseases. In this review, we summarize the general process of type 2 inflammation, its role in the pathogenesis of BP and potential therapeutic targets and medications related to type 2 inflammation. The content of this review may contribute to the development of more effective drugs with fewer side effects for the treatment of BP.
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Affiliation(s)
- Luyao Zhang
- Department of Allergy and Immunology, Huashan Hospital, Fudan University, Shanghai, China
| | - Zihua Chen
- Department of Allergy and Immunology, Huashan Hospital, Fudan University, Shanghai, China
| | - Lanting Wang
- Department of Allergy and Immunology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoqun Luo
- Department of Allergy and Immunology, Huashan Hospital, Fudan University, Shanghai, China
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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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[Artículo traducido] Asociación entre eosinófilos de sangre periférica y cutáneos con la gravedad del penfigoide ampolloso y los resultados terapéuticos. ACTAS DERMO-SIFILIOGRAFICAS 2022. [DOI: 10.1016/j.ad.2022.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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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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Current and Innovated Managements for Autoimmune Bullous Skin Disorders: An Overview. J Clin Med 2022; 11:jcm11123528. [PMID: 35743598 PMCID: PMC9224787 DOI: 10.3390/jcm11123528] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
Autoimmune bullous skin disorders are a group of disorders characterized by the formation of numerous blisters and erosions on the skin and/or the mucosal membrane, arising from autoantibodies against the intercellular adhesion molecules and the structural proteins. They can be classified into intraepithelial or subepithelial autoimmune bullous dermatoses based on the location of the targeted antigens. These dermatoses are extremely debilitating and fatal in certain cases, depending on the degree of cutaneous and mucosal involvement. Effective treatments should be implemented promptly. Glucocorticoids serve as the first-line approach due to their rapid onset of therapeutic effects and remission of the acute phase. Nonetheless, long-term applications may lead to major adverse effects that outweigh the benefits. Hence, other adjuvant therapies are mandatory to minimize the potential harm and ameliorate the quality of life. Herein, we summarize the current therapeutic strategies and introduce promising therapies for intractable autoimmune bullous diseases.
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Association of Peripheral Blood and Cutaneous Eosinophils With Bullous Pemphigoid Disease Severity and Treatment Outcomes. ACTAS DERMO-SIFILIOGRAFICAS 2022; 113:881-887. [DOI: 10.1016/j.ad.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/05/2022] [Accepted: 05/29/2022] [Indexed: 11/20/2022] Open
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A Review of the Immunologic Pathways Involved in Bullous Pemphigoid and Novel Therapeutic Targets. J Clin Med 2022; 11:jcm11102856. [PMID: 35628982 PMCID: PMC9146139 DOI: 10.3390/jcm11102856] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 02/01/2023] Open
Abstract
Bullous pemphigoid (BP) is a rare, chronic antibody-mediated autoimmune blistering disease primarily affecting the elderly, with an age of onset over 60. Current treatment options are limited and involve the use of corticosteroids and immunosuppressants, but their long-term use is associated with significant morbidity and mortality. In Japan, human intravenous immunoglobin is approved for the treatment of corticosteroid-refractory BP. However, no treatment option is approved by the Food and Drug Administration for the management of BP. Therefore, developing effective therapies free of debilitating side effects is imperative. In this review, we summarize the main immunologic pathways involved in the pathogenesis of BP, with an emphasis on the role of eosinophils, immunoglobulins, cytokines such as the interleukin (IL)-4 and IL-5, and complements. We further discuss the latest advances with novel therapeutic targets tested for the management of BP. Ongoing efforts are needed to run well-designed controlled trials and test the efficacy and safety of investigational drugs while providing much-needed access to these medications for refractory patients who will not otherwise be able to afford them as off-label prescriptions.
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Dellon ES, Simon D, Wechsler ME. Controversies in Allergy: The Potential Role of Biologics as First-Line Therapy in Eosinophilic Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1169-1176. [PMID: 35167955 PMCID: PMC9086115 DOI: 10.1016/j.jaip.2022.01.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/17/2022] [Accepted: 01/28/2022] [Indexed: 01/11/2023]
Abstract
With advances in understanding the role of eosinophils in disease pathogenesis, particularly in the airways, gastrointestinal tract, and skin, targeting eosinophils or the cytokines that lead to their production, activation, and survival has become an increasingly pursued therapeutic approach. Newly developed biologic agents target eosinophils directly, other cells interacting with or activating eosinophils, or cytokines in the type 2 inflammatory pathway with specific antibodies. Current treatment paradigms reserve therapy with biologics for patients refractory to or intolerant of corticosteroids or immunosuppressants. Given accumulating data for safety and efficacy of these biologics, however, there is the question of whether targeted treatments should be used earlier in the treatment algorithm. In this article, we discuss the pros and cons of using biologics as first-line therapy for eosinophilic diseases of the airways, gastrointestinal tract, and skin. We highlight emerging biologic agents and future directions for research, as well as a rationale for the early use of some biologics to prevent tissue damage, disease progression, and organ dysfunction in selected conditions.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Diseases, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael E Wechsler
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colo
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Ellebrecht CT, Maseda D, Payne AS. Pemphigus and Pemphigoid: From Disease Mechanisms to Druggable Pathways. J Invest Dermatol 2022; 142:907-914. [PMID: 34756581 PMCID: PMC8860856 DOI: 10.1016/j.jid.2021.04.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/06/2021] [Accepted: 04/18/2021] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
| | - Damian Maseda
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Aimee S. Payne
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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Wu T, Tang L, Feng Y, Jia Y, Li F. Eosinophils and associated parameters in different types of skin diseases related to elevated eosinophil levels. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:73. [PMID: 35282056 PMCID: PMC8848371 DOI: 10.21037/atm-22-99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/14/2022] [Indexed: 11/06/2022]
Abstract
Background Eosinophils, basophils, white blood cells (WBC), and immunoglobulin E (IgE) play major roles in the pathogenesis of atopic dermatitis (AD), bullous pemphigoid (BP), drug reaction with eosinophilia and systemic symptoms (DRESS), and hypereosinophilic syndrome (HES). This study aimed to describe these parameters in different skin diseases and provide further information concerning the underlying pathogenesis. Methods A cross-sectional study of blood test results, including WBC count, peripheral eosinophil count, peripheral basophil/WBC percentage, and IgE level, from 115 cases of AD, 75 cases of BP, 55 cases of DRESS, 119 cases of HES, and 621 healthy volunteers was performed in China. Data from before and after treatment and the population distribution of different diseases were compared and described. Results All participants showed increased peripheral eosinophil counts, eosinophil/WBC ratios, IgE levels, and decreased peripheral basophil counts, with variance among the different disease groups. Peripheral eosinophil counts in HES patients and IgE level in AD patients increased the most prominently. No significant correlation existed among eosinophils, basophils, and IgE. An obvious decrease in eosinophil count was demonstrated after treatment in all 4 diseases. Conclusions Eosinophils, basophils, and IgE exert functions in diverse skin diseases, presenting altered peripheral blood test results. In some cases, these changes are demonstrated only in the skin and not in the blood. Compared with the other parameters considered in this study, eosinophils seemed to be a better biomarker for treatment effects, regardless of the disease type.
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Affiliation(s)
- Tong Wu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Luyan Tang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yang Feng
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yanjing Jia
- Department of Nursing, Huashan Hospital, Fudan University, Shanghai, China
| | - Fei Li
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China.,Department of Dermatology, Huashan Hospital Baoshan, Fudan University, Shanghai, China
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Rhyou HI, Han SH, Nam YH. Successful induction treatment of bullous pemphigoid using reslizumab: a case report. Allergy Asthma Clin Immunol 2021; 17:117. [PMID: 34784964 PMCID: PMC8596938 DOI: 10.1186/s13223-021-00619-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/21/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Bullous pemphigoid (BP) is a potentially life-threatening autoimmune blistering disease which is characterized by autoantibodies against hemidesmosomal proteins of the skin and mucous membranes. In recent years, the role of eosinophil and immunoglobulin E autoantibodies have been further elucidated in BP, and have been considered potential therapeutic targets.
Case presentations
A 67-year-old male presented with erythematous bullous eruption. The skin eruption was located on whole body, and suggested BP. Peripheral blood eosinophil count and total immunoglobulin E markedly elevated in initial laboratory findings. Topical and systemic steroid (methylprednisolone 2 mg/kg/day) treatment was started, and his skin symptoms worsened repeatedly, whenever systemic steroid were reduced. On admission day 29, reslizumab (anti-interleukin-5) 3.5 mg/kg was administered intravenously to the patients. The bullous skin lesion began to improve rapidly, and methylprednisolone (8 mg/day) was reduced without any worsening of symptoms during two doses of reslizumab.
Conclusions
We report a case of successful treatment response to reslizumab administration in a patient with BP. Further studies are needed to confirm the role of anti-interleukin-5 as a treatment for BP in the future.
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Radonjic-Hoesli S, Brüggen MC, Feldmeyer L, Simon HU, Simon D. Eosinophils in skin diseases. Semin Immunopathol 2021; 43:393-409. [PMID: 34097126 PMCID: PMC8241748 DOI: 10.1007/s00281-021-00868-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/06/2021] [Indexed: 02/06/2023]
Abstract
Eosinophil infiltration is a common finding in a broad spectrum of skin diseases, despite the fact that the skin is devoid of eosinophils under physiologic conditions. Although cutaneous eosinophilia is reactive, cytokine-mediated in most cases, diseases with an intrinsic mutation-mediated clonal expansion of eosinophils can also manifest on the skin. As eosinophils are involved in host defense, regulate immune responses, generate pruritus, induce remodeling and fibrosis, and can cause tissue damage, they have the capacity to actively contribute to the pathogenesis of diseases. Recent research provided deeper insights in the mechanisms, e.g., bacterial and viral clearance, blister formation, recruitment of cytotoxic T cells, and generation of pruritus, by which eosinophils might come into action. This review aims at providing an overview on the clinical presentations of eosinophil-associated dermatoses and the current understanding of their pathogenic role in these diseases. Further, we discuss the effects of therapies targeting eosinophils.
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Affiliation(s)
- Susanne Radonjic-Hoesli
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marie-Charlotte Brüggen
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Department of Dermatology, Hochgebirgsklinik Davos, Davos, Switzerland
| | - Laurence Feldmeyer
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland
- Department of Clinical Immunology and Allergology, Sechenov University, Moscow, Russia
- Laboratory of Molecular Immunology, Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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27
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Jacobsen EA, Jackson DJ, Heffler E, Mathur SK, Bredenoord AJ, Pavord ID, Akuthota P, Roufosse F, Rothenberg ME. Eosinophil Knockout Humans: Uncovering the Role of Eosinophils Through Eosinophil-Directed Biological Therapies. Annu Rev Immunol 2021; 39:719-757. [PMID: 33646859 PMCID: PMC8317994 DOI: 10.1146/annurev-immunol-093019-125918] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The enigmatic eosinophil has emerged as an exciting component of the immune system, involved in a plethora of homeostatic and inflammatory responses. Substantial progress has been achieved through experimental systems manipulating eosinophils in vivo, initially in mice and more recently in humans. Researchers using eosinophil knockout mice have identified a contributory role for eosinophils in basal and inflammatory processes and protective immunity. Primarily fueled by the purported proinflammatory role of eosinophils in eosinophil-associated diseases, a series of anti-eosinophil therapeutics have emerged as a new class of drugs. These agents, which dramatically deplete eosinophils, provide a valuable opportunity to characterize the consequences of eosinophil knockout humans. Herein, we comparatively describe mouse and human eosinophil knockouts. We put forth the view that human eosinophils negatively contribute to a variety of diseases and, unlike mouse eosinophils, do not yet have an identified role in physiological health; thus, clarifying all roles of eosinophils remains an ongoing pursuit.
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Affiliation(s)
- Elizabeth A Jacobsen
- Division of Allergy, Asthma and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona 85259, USA;
| | - David J Jackson
- Guy's and St Thomas' Hospitals, London WC2R 2LS, United Kingdom;
- Department of Immunobiology, King's College London, London WC2R 2LS, United Kingdom
| | - Enrico Heffler
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
- Personalized Medicine, Asthma and Allergy Unit, Humanitas Clinical and Research Center IRCCS, 20089 Milan, Italy;
| | - Sameer K Mathur
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin 53792, USA;
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
| | - Ian D Pavord
- Respiratory Medicine Unit, Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, Oxford OX3 9DU, United Kingdom;
| | - Praveen Akuthota
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, California 92093, USA;
| | - Florence Roufosse
- Médecine Interne, Hôpital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio 45229, USA;
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28
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Lessons learned from targeting eosinophils in human disease. Semin Immunopathol 2021; 43:459-475. [PMID: 33891135 DOI: 10.1007/s00281-021-00849-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/02/2021] [Indexed: 02/08/2023]
Abstract
Eosinophils are a minor subset of the granulocyte lineage distinguished by their unique morphology, phenotype, cytoplasmic contents, and function. Evolutionarily, these are ancient cells whose existence has been conserved within vertebrates for millions of years, suggesting that their contribution to innate immunity and other pathologic and homeostatic responses are important to the host. Knowledge regarding the role of eosinophils in health and disease took a leap forward in 2004 with the creation of mouse strains deficient in eosinophils. This advance was paralleled in humans using pharmacology, namely, with the development of drugs capable of selectively reducing and sometimes even eliminating human eosinophils in those receiving these agents. As a result, a more definitive picture of what eosinophils do, and do not do, is emerging. This review will summarize recent advances in our understanding of the role of eosinophils in human disease by focusing mainly on data from clinical studies with anti-eosinophil therapies, even though the first of such agents, mepolizumab, was only approved in the USA in November 2015. Information regarding both efficacy and safety will be highlighted, and where relevant, intriguing data from animal models will also be mentioned, especially if there are conflicting effects seen in humans.
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29
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Gore Karaali M, Koku Aksu AE, Cin M, Leblebici C, Kara Polat A, Gurel MS. Tissue eosinophil levels as a marker of disease severity in bullous pemphigoid. Australas J Dermatol 2021; 62:e236-e241. [PMID: 33748980 DOI: 10.1111/ajd.13547] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/05/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Eosinophils play an important role in bullous pemphigoid (BP) pathogenesis. Although tissue infiltration with eosinophils has been known for a long time, there is a lack of knowledge about the relationship between tissue eosinophil levels and disease severity and clinical characteristics of the patients. METHODS Fifty-nine patients diagnosed with BP between January 2008 and December 2018 were reviewed. Haematoxylin-Eosin (H&E)-stained preparations were re-evaluated in terms of tissue eosinophil levels. For disease severity, Bullous Pemphigoid Disease Area Index (BPDAI) was used. The relationship between tissue eosinophil levels and disease severity and clinical features were evaluated. RESULTS Erosion/blister and urticaria/erythema BPDAI scores were higher in the group with high tissue eosinophil level than the group with low tissue eosinophil level. Tissue and peripheral blood eosinophil count were correlated with total urticaria/erythema BPDAI scores. There was no correlation between blood and tissue eosinophil count. The mortality rate was 64.7% vs 44.0% in the high vs low tissue eosinophil groups. Tissue eosinophil levels were high in patients with BP accompanying neurological disease. CONCLUSIONS Tissue eosinophil count and peripheral blood eosinophil count were correlated with disease severity in BP. Tissue eosinophil levels were also high in patients with BP accompanying neurological disease.
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Affiliation(s)
- Muge Gore Karaali
- Department of Dermatology, Mengücek Gazi Training and Research Hospital, Erzincan Binali Yıldırım University, Erzincan, Turkey
| | - Ayse Esra Koku Aksu
- Department of Dermatology, University of Health Science (HSU) Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Merve Cin
- Department of Pathology, University of Health Science (HSU) Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Cem Leblebici
- Department of Pathology, University of Health Science (HSU) Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Asude Kara Polat
- Department of Dermatology, University of Health Science (HSU) Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Salih Gurel
- Department of Dermatology, Göztepe Training and Research Hospital, Medeniyet University, Istanbul, Turkey
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30
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Kridin K, Ludwig RJ, Tzur Bitan D, Cohen AD. A History of Asthma Increases the Risk of Bullous Pemphigoid: Insights from a Large Population-Based Study. Dermatology 2021; 237:921-928. [PMID: 33640889 DOI: 10.1159/000512917] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 11/10/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bullous pemphigoid (BP) and asthma both share a pathogenic role of eosinophils and immunoglobulin E (IgE) and favorable response for corticosteroids and omalizumab. However, the association between these conditions is yet to be investigated. We sought to estimate the risk of having BP among patients previously diagnosed with asthma and to characterize patients with coexistent BP and asthma. METHODS Utilizing the dataset of Clalit Health Services, a population-based case-control study was conducted comparing BP patients (n = 3,924) with age-, sex-, and ethnicity-matched control subjects (n = 19,280) regarding the presence of asthma. Logistic regression models were utilized for univariate and multivariate analyses. RESULTS The prevalence of preceding asthma was higher in patients with BP than in control subjects (11.1 vs. 7.9%, respectively; p < 0.001). A history of asthma was associated with a 50% increase in the risk of BP (OR 1.45; 95% CI 1.30-1.62). The association was not altered greatly after adjusting for demographics (adjusted OR 1.43; 95% CI 1.28-1.61) as well as for demographics and comorbidities (adjusted OR 1.40; 95% CI 1.25-1.57). The average (SD) latency between the diagnosis of asthma and the development of BP was 12.5 (14.7) years. When compared with other patients with BP, those with a dual diagnosis of BP and asthma were older, had higher BMI, and were more frequently managed by corticosteroids and immunosuppressive and immunomodulatory adjuvants. CONCLUSIONS Asthma confers a predisposition to the development of BP. Awareness of this association may be of help for physicians managing patients with BP and asthma. Further research is required to elucidate the mechanism underlying this observation.
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Affiliation(s)
- Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany, .,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel,
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Dana Tzur Bitan
- Department of Behavioral Sciences, Ariel University, Ariel, Israel
| | - Arnon D Cohen
- Clalit Health Services, Tel-Aviv, Israel.,Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
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31
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Abstract
Eosinophilic dermatoses encompass a broad spectrum of diseases of different etiologies hallmarked by eosinophilic infiltration of the skin and/or mucous membranes, with or without associated blood eosinophilia. The wide range of dermatological manifestations of this spectrum, including nodules and plaques, pustules, blisters, ulcers, and urticarial lesions, is reflected in a non-univocal classification system. We identified six groups of eosinophilic dermatoses based on the predominant anatomic level of involvement: (1) epidermal; (2) of the dermal-epidermal junction; (3) dermal; (4) of the hypodermis and muscle fascia; (5) of the pilosebaceous unit; and (6) vascular/perivascular. We review clinicopathologic features and management of diseases belonging to each group, particularly: (1) pemphigus herpetiformis and atopic dermatitis as prototypes of the epidermal group; (2) bullous pemphigoid as prototypic eosinophilic dermatosis of the dermal-epidermal junction; (3) eosinophilic cellulitis (Wells syndrome), hypereosinophilic syndromes, Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome, eosinophilic dermatosis of hematologic malignancy and chronic spontaneous urticaria as paradigmatic dermal eosinophilic dermatoses; (4) eosinophilic fasciitis as an eosinophilic dermatosis with predominant involvement of the hypodermis and muscle fascia; (5) eosinophilic pustular folliculitis as a model of the pilosebaceous unit involvement; and (6) granuloma faciale, angiolymphoid hyperplasia with eosinophilia, and eosinophilic granulomatosis with polyangiitis, belonging to the vascular/perivascular group.
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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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Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disorder with substantial morbidity and mortality. BP is regarded as a disorder driven by IgG due to BP180 and BP230 IgG autoantibodies, yet, new advances highlight the function of eosinophils and IgE autoantibodies in BP. Evidence supports that eosinophils are involved in BP pathogenesis, notably, these include the presence of IL-5, eotaxin, and eosinophil-colony stimulating factor in blister fluid, peripheral blood eosinophilia is present in nearly 50% of affected patients, eosinophils are found against the dermo-epidermal junction (DEJ) when BP serum is present, metalloprotease-9 is secreted by eosinophils at blister sites, blister fluid of BP patients contains eosinophil granule proteins which are located along the lamina lucida of the BMZ in patients with BP and correspond with disease clinically, eosinophil extracellular traps (EET) have been linked to DEJ splitting, IL-5 activated eosinophils cause DEJ separation when BP serum is present, and eosinophils are requisite to drive anti-BP180 IgE mediated blistering of the skin. Yet, the mechanism whereby eosinophils contribute to the pathogenesis of BP remains to be explored. In this review, we examine the role of eosinophils in BP while offering a basis to explain the pathomechanisms of eosinophils in BP.
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Affiliation(s)
- Virginia A Jones
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA
| | - Payal M Patel
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA
| | - Kyle T Amber
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA -
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34
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Liu Y, Wang Y, Chen X, Jin H, Li L. Factors associated with the activity and severity of bullous pemphigoid: a review. Ann Med 2020; 52:55-62. [PMID: 32163298 PMCID: PMC7877946 DOI: 10.1080/07853890.2020.1742367] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 01/01/2023] Open
Abstract
Bullous pemphigoid (BP) is the most common subepidermal autoimmune blistering disease. It usually affects people older than 70 years of age. The two main autoantigens are BP180 and BP230, both of which are components of hemidesmosomes. Immunoglobulin (Ig)G and IgE autoantibodies to BP180 detected by the enzyme-linked immunoassay (ELISA) show close associations with the activity and severity of BP. In addition, inflammatory cells (eosinophils, neutrophils and mast cells) and cytokines (e.g. interleukins and CC chemokine ligands) play an important part in the pathogenesis, activity and severity of BP. We summarized the potential contribution of each factor postulated to be associated with the activity and severity of BP, and provide guidance for clinicians to pay timely and close attention to such parameters. This review may also promote the development of novel therapies for BP.Key MessagesBullous Pemphigoid Disease Area Index (BPDAI) is a scoring system which can reflect the extent of clinical involvement of BP patients.The titres of IgE autoantibodies and IgG autoantibodies against the NC16A domain of BP180 are closely correlated with the activity and severity of BP.Many inflammatory cells and molecules, such as eosinophils and interleukins, can also reflect the activity and severity of BP.
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Affiliation(s)
- Yangchun Liu
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Yiman Wang
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Xinyi Chen
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Hongzhong Jin
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Li Li
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
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35
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Cole EF, Sami N, Feldman RJ. Updates on diagnosis and management of autoimmune blistering diseases. GIORN ITAL DERMAT V 2019; 155:46-64. [PMID: 31804056 DOI: 10.23736/s0392-0488.19.06517-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the last several decades, advances in the understanding of the pathogenesis of autoimmune blistering diseases has resulted in significant improvements in diagnosis and management. These improvements include new diagnostic assays and therapies targeted at specific disease mediators. Furthermore, the abundance of new therapies in clinic trials for autoimmune blistering diseases will translate to an enhanced therapeutic armamentarium for clinicians. The aim of this article is to review new developments in the understanding of autoimmune blistering diseases and to summarize advancements in their diagnosis and management.
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Affiliation(s)
- Emily F Cole
- Emory Autoimmune Blistering Disease Clinic, Emory Department of Dermatology, Atlanta, GA, USA
| | - Naveed Sami
- Department of Dermatology, University of Central Florida, Orlando, FL, USA -
| | - Ron J Feldman
- Emory Autoimmune Blistering Disease Clinic, Emory Department of Dermatology, Atlanta, GA, USA
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36
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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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