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Tešanović Perković D, Bukvić Mokos Z, Marinović B. Epidermolysis Bullosa Acquisita-Current and Emerging Treatments. J Clin Med 2023; 12:jcm12031139. [PMID: 36769788 PMCID: PMC9917799 DOI: 10.3390/jcm12031139] [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: 11/29/2022] [Revised: 01/10/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
Epidermolysis bullosa acquisita (EBA) is a rare chronic autoimmune subepidermal blistering disease of the skin and mucous membranes, usually beginning in adulthood. EBA is induced by autoantibodies to type VII collagen, a major component of anchoring fibrils in the dermal-epidermal junction (DEJ). The binding of autoantibodies to type-VII collagen subsequently leads to the detachment of the epidermis and the formation of mucocutaneous blisters. EBA has two major clinical subtypes: the mechanobullous and inflammatory variants. The classic mechanobullous variant presentation consists of skin fragility, bullae with minimal clinical or histological inflammation, erosions in acral distribution that heal with scarring, and milia formation. The inflammatory variant is challenging to differentiate from other autoimmune bullous diseases, most commonly bullous pemphigoid (BP) but also mucous membrane pemphigoid (MMP), Brunsting-Perry pemphigoid, and linear IgA dermatosis. Due to its recalcitrance conventional treatment of epidermolysis bullosa acquisita is shown to be demanding. Here we discuss novel therapeutic strategies that have emerged and which could potentially improve the quality of life in patients with EBA.
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Affiliation(s)
| | - Zrinka Bukvić Mokos
- Department of Dermatology and Venereology, School of Medicine, University Hospital Centre Zagreb, University of Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia
| | - Branka Marinović
- Department of Dermatology and Venereology, School of Medicine, University Hospital Centre Zagreb, University of Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia
- Correspondence:
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2
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Tekin B, Johnson EF, Wieland CN, Gibson LE, Camilleri MJ, Kalaaji AN, Comfere NI, Peters MS, Lehman JS. Histopathology of autoimmune bullous dermatoses: What's new? Hum Pathol 2022; 128:69-89. [PMID: 35764145 DOI: 10.1016/j.humpath.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/19/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
Abstract
Autoimmune bullous dermatoses are characterized by the presence of tissue-bound and often circulating pathogenic autoantibodies targeting structural components of the skin and/or mucous membranes. The diagnostic workup for this heterogeneous group of disorders consists of a multi-step process, of which the light microscopic examination is a crucial component. This review is organized following a classification scheme that is based on two main histopathologic features, namely level of intraepithelial split and composition of the inflammatory infiltrate. Overall, we aim to place emphasis on the histopathologic clues that can assist pathologists in differential diagnosis and review the updates in the literature.
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Affiliation(s)
- Burak Tekin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Emma F Johnson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Carilyn N Wieland
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Lawrence E Gibson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Michael J Camilleri
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Amer N Kalaaji
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Nneka I Comfere
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Margot S Peters
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Julia S Lehman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA.
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3
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Arora S, Shetty VM, Rao CR, Pai SB, Rao R. Serration pattern analysis as a practical adjunct tool for categorization of subepidermal autoimmune blistering diseases. Indian J Dermatol Venereol Leprol 2021; 87:778-786. [PMID: 34491679 DOI: 10.25259/ijdvl_1232_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Serration pattern analysis helps in the classification of subepidermal autoimmune blistering disorders; more precisely, it helps to differentiate epidermolysis bullosa acquisita from other subepidermal autoimmune blistering disorders. Most of the published reports of this tool have come from a single center. OBJECTIVES The objectives of the study were to study the utility of serration pattern analysis in classifying subepidermal autoimmune blistering disorders. METHODS Seventy five cases of subepidermal autoimmune blistering disorders were enrolled in this prospective study. A three millimeter punch biopsy was taken from the perilesional skin or mucosa for direct immunofluorescence; indirect immunofluorescence was carried out using salt-split skin. Subclassification of subepidermal autoimmune blistering disorders was done based on direct immunofluorescence, indirect immunofluorescence on salt-split skin, indirect immunofluorescence using knockout skin and serration pattern analysis findings. RESULTS Indirect immunofluorescence was positive in 68 cases; 14 cases showed a dermal staining pattern while the rest showed either an epidermal or a combined pattern. All patients with epidermal or combined staining patterns showed "n" serrated pattern on direct immunofluorescence. Nine patients with dermal staining on indirect immunofluorescence also revealed an "n" serration pattern on direct immunofluorescence indicating the diagnosis of anti-p200 pemphigoid, and the rest showed a "u" serrated pattern. Three patients with negative indirect immunofluorescence showed "u" serration on direct immunofluorescence while the rest showed "n" serration. LIMITATIONS ELISA and immunoblotting could not be performed due to resource constraints. CONCLUSION Based on indirect immunofluorescence and serration pattern analysis, classification of the majority of patients with subepidermal autoimmune blistering disorders was possible in our study. Pattern recognition is a cost-effective tool and can be easily learnt. It is recommended to be practiced in all laboratories where facilities for advanced immunological diagnosis are unavailable.
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Affiliation(s)
- Sukriti Arora
- Department of Dermatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Varsha M Shetty
- Department of Dermatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Chythra R Rao
- Department of Community Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Satish B Pai
- Department of Dermatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Raghavendra Rao
- Department of Dermatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
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4
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Rashid H, Lamberts A, Diercks GFH, Pas HH, Meijer JM, Bolling MC, Horváth B. Oral Lesions in Autoimmune Bullous Diseases: An Overview of Clinical Characteristics and Diagnostic Algorithm. Am J Clin Dermatol 2019; 20:847-861. [PMID: 31313078 PMCID: PMC6872602 DOI: 10.1007/s40257-019-00461-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Autoimmune bullous diseases are a group of chronic inflammatory disorders caused by autoantibodies targeted against structural proteins of the desmosomal and hemidesmosomal plaques in the skin and mucosa, leading to intra-epithelial or subepithelial blistering. The oral mucosa is frequently affected in these diseases, in particular, in mucous membrane pemphigoid, pemphigus vulgaris, and paraneoplastic pemphigus. The clinical symptoms are heterogeneous and may present with erythema, blisters, erosions, and ulcers localized anywhere on the oral mucosa, and lead to severe complaints for the patients including pain, dysphagia, and foetor. Therefore, a quick and proper diagnosis with adequate treatment is needed. Clinical presentations of autoimmune bullous diseases often overlap and diagnosis cannot be made based on clinical features alone. Immunodiagnostic tests are of great importance in differentiating between the different diseases. Direct immunofluorescence microscopy shows depositions of autoantibodies along the epithelial basement membrane zone in mucous membrane pemphigoid subtypes, or depositions on the epithelial cell surface in pemphigus variants. Additional immunoserological tests are useful to discriminate between the different subtypes of pemphigoid, and are essential to differentiate between pemphigus and paraneoplastic pemphigus. This review gives an overview of the clinical characteristics of oral lesions and the diagnostic procedures in autoimmune blistering diseases, and provides a diagnostic algorithm for daily practice.
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Affiliation(s)
- Hanan Rashid
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Aniek Lamberts
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Gilles F H Diercks
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hendri H Pas
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Joost M Meijer
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Maria C Bolling
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Barbara Horváth
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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Harrell J, Rubio XB, Nielson C, Hsu S, Motaparthi K. Advances in the diagnosis of autoimmune bullous dermatoses. Clin Dermatol 2019; 37:692-712. [PMID: 31864451 DOI: 10.1016/j.clindermatol.2019.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Autoimmune bullous dermatoses are defined by autoantibodies directed against adhesion proteins in the epidermis or basement membrane zone, resulting in blister formation on the skin and mucosa. Diagnosis depends on lesional biopsy for histopathology and perilesional biopsy for direct immunofluorescence. Additional diagnostic methods include indirect immunofluorescence, enzyme-linked immunosorbent assay, and immunoblot (Western blot), which may be selected in specific clinical scenarios due to improved sensitivity and/or specificity. This contribution reviews the available evidence supporting the use of each method to provide a practical reference for clinicians when diagnosing autoimmune bullous disorders. Techniques and cost are reviewed, and newer diagnostic techniques with potential for clinical application are.
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Affiliation(s)
- Jane Harrell
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Colton Nielson
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sylvia Hsu
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA.
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6
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Saschenbrecker S, Karl I, Komorowski L, Probst C, Dähnrich C, Fechner K, Stöcker W, Schlumberger W. Serological Diagnosis of Autoimmune Bullous Skin Diseases. Front Immunol 2019; 10:1974. [PMID: 31552014 PMCID: PMC6736620 DOI: 10.3389/fimmu.2019.01974] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/05/2019] [Indexed: 12/12/2022] Open
Abstract
Autoimmune bullous dermatoses (AIBD) encompass a variety of organ-specific autoimmune diseases that manifest with cutaneous and/or mucosal blisters and erosions. They are characterized by autoantibodies targeting structural proteins of the skin, which are responsible for the intercellular contact between epidermal keratinocytes and for adhesion of the basal keratinocytes to the dermis. The autoantibodies disrupt the adhesive functions, leading to splitting and blister formation. In pemphigus diseases, blisters form intraepidermally, whereas in all other disease types they occur subepidermally. Early identification of autoimmune bullous dermatoses is crucial for both treatment and prognosis, particularly as regards tumor-associated disease entities. The diagnosis is based on clinical symptoms, histopathology, direct immunofluorescence to detect antibody/complement deposits, and the determination of circulating autoantibodies. The identification of various target antigens has paved the way for the recent development of numerous specific autoantibody tests. In particular, optimized designer antigens and multiplex test formats for indirect immunofluorescence and ELISA have enhanced and refined the laboratory analysis, enabling highly efficient serodiagnosis and follow-up. This review elaborates on the current standards in the serological diagnostics for autoimmune bullous dermatoses.
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Affiliation(s)
| | - Ingolf Karl
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Christian Probst
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Cornelia Dähnrich
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Kai Fechner
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Winfried Stöcker
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
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7
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Epidermolysis bullosa acquisita: A comprehensive review. Autoimmun Rev 2019; 18:786-795. [DOI: 10.1016/j.autrev.2019.06.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/26/2019] [Indexed: 02/07/2023]
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8
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Lamberts A, Rashid H, Pas HH, Diercks GFH, Meijer JM, Horváth B. Pemphigoid variants affecting the skin. Clin Exp Dermatol 2019; 44:721-727. [PMID: 31099084 DOI: 10.1111/ced.13984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2019] [Indexed: 11/29/2022]
Abstract
Pemphigoid diseases are autoimmune subepidermal blistering diseases affecting the skin and mucous membranes, which are caused by autoantibodies targeting structural hemidesmosomal proteins or hemidesmosome-associated proteins. Variants of pemphigoid can be differentiated based on targeted antigens and clinical aspects. In this review, we will discuss pemphigoid variants that predominantly affect the skin, and provide clinicians with clues to diagnosis.
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Affiliation(s)
- A Lamberts
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - H Rashid
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - H H Pas
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - G F H Diercks
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - J M Meijer
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - B Horváth
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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9
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Koga H, Prost-Squarcioni C, Iwata H, Jonkman MF, Ludwig RJ, Bieber K. Epidermolysis Bullosa Acquisita: The 2019 Update. Front Med (Lausanne) 2019; 5:362. [PMID: 30687710 PMCID: PMC6335340 DOI: 10.3389/fmed.2018.00362] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 12/19/2018] [Indexed: 11/13/2022] Open
Abstract
Epidermolysis bullosa acquisita (EBA) is an orphan autoimmune disease. Patients with EBA suffer from chronic inflammation as well as blistering and scarring of the skin and mucous membranes. Current treatment options rely on non-specific immunosuppression, which in many cases, does not lead to a remission of treatment. Hence, novel treatment options are urgently needed for the care of EBA patients. During the past decade, decisive clinical observations, and frequent use of pre-clinical model systems have tremendously increased our understanding of EBA pathogenesis. Herein, we review all of the aspects of EBA, starting with a detailed description of epidemiology, clinical presentation, diagnosis, and current treatment options. Of note, pattern analysis via direct immunofluorescence microscopy of a perilesional skin lesion and novel serological test systems have significantly facilitated diagnosis of the disease. Next, a state-of the art review of the current understanding of EBA pathogenesis, emerging treatments and future perspectives is provided. Based on pre-clinical model systems, cytokines and kinases are among the most promising therapeutic targets, whereas high doses of IgG (IVIG) and the anti-CD20 antibody rituximab are among the most promising "established" EBA therapeutics. We also aim to raise awareness of EBA, as well as initiate basic and clinical research in this field, to further improve the already improved but still unsatisfactory conditions for those diagnosed with this condition.
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Affiliation(s)
- Hiroshi Koga
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Fukuoka, Japan
| | - Catherine Prost-Squarcioni
- Department of Dermatology, APHP, Avicenne Hospital, Referral Center for Autoimmune Bullous Diseases, Bobigny, France
| | - Hiroaki Iwata
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Marcel F Jonkman
- Department of Dermatology, Center for Blistering Diseases, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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10
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Koga H, Teye K, Yamashita K, Ishii N, Tsuruta D, Nakama T. Detection of anti-type VII collagen IgE antibodies in epidermolysis bullosa acquisita. Br J Dermatol 2018; 180:1107-1113. [PMID: 30311191 DOI: 10.1111/bjd.17310] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Epidermolysis bullosa acquisita (EBA) is a rare pemphigoid disease involving autoantibodies to type VII collagen (COL7), a major structural component of anchoring fibrils. IgE autoantibodies to type XVII collagen (BP180) have been identified in bullous pemphigoid (BP), the prototype of pemphigoid diseases. Although the pathogenic relevance of IgG anti-COL7 has been investigated, that of IgE in EBA remains unclear. OBJECTIVES To reveal the presence and pathogenic relevance of IgE anti-COL7 in EBA. METHODS We examined IgE antibodies in 109 patients with EBA by indirect immunofluorescence (IIF) and enzyme-linked immunosorbent assay (ELISA). RESULTS IIF with normal human skin revealed IgE reactivity in the basement membrane zone in 29 (26·6%) cases. To verify whether the IgE antibodies were specific to COL7, we performed IIF with 21 clearly positive cases and the skin of a patient with dystrophic EBA, which does not involve COL7. All cases showed negative results, indicating that IgE antibodies were specific to COL7. In a modified IgG COL7 ELISA for IgE, 16 (14·7%) cases were positive (three and 13 cases were negative and positive on IIF, respectively). We compared anti-COL7 IgG and IgE, and found a weak but significant correlation (r = 0·459, P < 0·001). EBA is clinically divided into a mechanobullous (MB; noninflammatory) type and an inflammatory (INF) type resembling BP. Of the IIF-positive cases, 11 of 30 (37%) had INF and nine of 48 (19%) had MB. CONCLUSIONS This study is the first to demonstrate the presence of circulating anti-COL7 IgE in patients with EBA, which may correlate with the clinical phenotype.
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Affiliation(s)
- H Koga
- Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan
| | - K Teye
- Kurume University Institute of Cutaneous Cell Biology, Fukuoka, Japan
| | - K Yamashita
- Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan
| | - N Ishii
- Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan
| | - D Tsuruta
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - T Nakama
- Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan
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11
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Amber KT, Murrell DF, Schmidt E, Joly P, Borradori L. Autoimmune Subepidermal Bullous Diseases of the Skin and Mucosae: Clinical Features, Diagnosis, and Management. Clin Rev Allergy Immunol 2018; 54:26-51. [PMID: 28779299 DOI: 10.1007/s12016-017-8633-4] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Autoimmune subepidermal blistering diseases of the skin and mucosae constitute a large group of sometimes devastating diseases, encompassing bullous pemphigoid, gestational pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, and anti-p200 pemphigoid. Their clinical presentation is polymorphic. These autoimmune blistering diseases are associated with autoantibodies that target distinct components of the basement membrane zone of stratified epithelia. These autoantigens represent structural proteins important for maintenance of dermo-epidermal integrity. Bullous pemphigoid (BP) is the most common subepidermal autoimmune blistering disease of the skin and mucosae. Although the disease typically presents with a generalized blistering eruption associated with itch, atypical variants with either localized bullous lesions or "non-bullous" presentations are observed in approximately 20% of patients. A peculiar form of BP typically associated with pregnancy is pemphigoid gestationis. In anti-p200 pemphigoid, patients present with tense blisters on erythematosus or normal skin resembling BP, with a predilection for acral surfaces. These patients have antibodies targeting the 200-kDa basement membrane protein. Epidermolysis bullosa is a rare autoimmune blistering disease associated with autoantibodies against type VII collagen that can have several phenotypes including a classical form mimicking dystrophic epidermolysis bullosa, an inflammatory presentation mimicking BP, or mucous membrane pemphigoid-like lesions. Mucous membrane pemphigoid (MMP) is the term agreed upon by international consensus for an autoimmune blistering disorder, which affects one or more mucous membrane and may involve the skin. The condition involves a number of different autoantigens in the basement membrane zone. It may result in severe complications from scarring, such as blindness and strictures. Diagnosis of these diseases relies on direct immunofluorescence microscopy studies and immunoserological assays. Management of affected patients is often challenging. We will here review the clinical and immunopathological features as well as the pathophysiology of this group of organ-specific autoimmune diseases. Finally, we will discuss the diagnostic approach and the principles of management in clinical practice.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of California Irvine Health, 118 Med Surg 1, Irvine, CA, 92697, USA.
| | - Dedee F Murrell
- Department of Dermatology, St. George Hospital, Gray Street, Kogarah, Sydney, NSW, Australia
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Pascal Joly
- Department of Dermatology, INSERM U901, University of Rouen, Rouen, France
| | - Luca Borradori
- Department of Dermatology, University of Bern, Bern, Switzerland
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12
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Prost-Squarcioni C, Caux F, Schmidt E, Jonkman MF, Vassileva S, Kim SC, Iranzo P, Daneshpazhooh M, Terra J, Bauer J, Fairley J, Hall R, Hertl M, Lehman JS, Marinovic B, Patsatsi A, Zillikens D, Werth V, Woodley DT, Murrell DF. International Bullous Diseases Group: consensus on diagnostic criteria for epidermolysis bullosa acquisita. Br J Dermatol 2018; 179:30-41. [PMID: 29165796 DOI: 10.1111/bjd.16138] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Epidermolysis bullosa acquisita (EBA) is a complex autoimmune bullous disease disease with variable clinical presentations and multiple possible diagnostic tests, making an international consensus on the diagnosis of EBA essential. OBJECTIVES To obtain an international consensus on the clinical and diagnostic criteria for EBA. METHODS The International Bullous Diseases Group (IBDG) met three times to discuss the clinical and diagnostic criteria for EBA. For the final voting exercise, 22 experts from 14 different countries voted on 50 different items. When > 30% disagreed with a proposal, a discussion was held and re-voting carried out. RESULTS In total, 48 of 50 proposals achieved consensus after discussion. This included nine diagnostic criteria, which are summarized in a flow chart. The IBDG was unable to determine one procedure that would be applicable worldwide. A limitation of the study is that differential diagnosis of bullous systemic lupus erythematosus has not been addressed. CONCLUSIONS This first international consensus conference established generally agreed-upon clinical and laboratory criteria defining the clinical classification of and diagnostic testing for EBA. Holding these voting exercises in person with the possibility of discussion prior to voting has advantages in reaching consensus over Delphi exercises with remote voting.
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Affiliation(s)
- C Prost-Squarcioni
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, APHP, Avicenne Hospital, Bobigny, France.,Department of Histology, UFR Léonard de Vinci, University Paris 13, Bobigny, France.,Department of Pathology, APHP, Avicenne Hospital, Bobigny, France
| | - F Caux
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, APHP, Avicenne Hospital, Bobigny, France
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - M F Jonkman
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - S Vassileva
- Department of Dermatology, Medical University of Sofia, Sofia, Bulgaria
| | - S C Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - P Iranzo
- Department of Dermatology, Hospital Clinic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - M Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - J Terra
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - J Bauer
- Division of Molecular Dermatology, Department of Dermatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - J Fairley
- Department of Dermatology, University of Iowa and Department of Veterans Affairs Medical Center, Iowa City, IA, U.S.A
| | - R Hall
- Department of Dermatology, Duke Medical Center, Durham, NC, U.S.A
| | - M Hertl
- Department of Dermatology, University Hospital, Marburg, Germany
| | - J S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, MN, U.S.A
| | - B Marinovic
- Department of Dermatology and Venereology, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - A Patsatsi
- Second University Dermatology Department, Aristotle University School of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | | | - V Werth
- Department of Dermatology, University of Pennsylvania and Philadelphia Department of Veterans Affairs Medical Center, Philadelphia, PA, U.S.A
| | - D T Woodley
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, U.S.A
| | - D F Murrell
- Department of Dermatology at St George Hospital, University of New South Wales, Sydney, Australia
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Jonkman M, Meijer J, Diercks G, Pas H. Response to ‘Serological diagnostics in the detection of IgG autoantibodies against human collagen VII in epidermolysis bullosa acquisita: a multicentre analysis’. Br J Dermatol 2018; 178:573. [DOI: 10.1111/bjd.16023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M.F. Jonkman
- Department of Dermatology; Center for Blistering Diseases; University of Groningen; University Medical Center Groningen; Groningen the Netherlands
| | - J.M. Meijer
- Department of Dermatology; Center for Blistering Diseases; University of Groningen; University Medical Center Groningen; Groningen the Netherlands
| | - G.F.H. Diercks
- Department of Dermatology; Center for Blistering Diseases; University of Groningen; University Medical Center Groningen; Groningen the Netherlands
| | - H.H. Pas
- Department of Dermatology; Center for Blistering Diseases; University of Groningen; University Medical Center Groningen; Groningen the Netherlands
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Hertl M, Hashimoto T. Response to ‘Serological diagnostics in the detection of IgG autoantibodies against human collagen VII in epidermolysis bullosa acquisita: a multicentre analysis': reply from authors. Br J Dermatol 2018; 178:573-574. [DOI: 10.1111/bjd.16169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M. Hertl
- Department of Dermatology and Allergology; Philipps University; Marburg Germany
| | - T. Hashimoto
- Department of Dermatology; Osaka City University Graduate School of Medicine; Osaka Japan
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15
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Schmidt T, Hoch M, Lotfi Jad SS, Solimani F, Di Zenzo G, Marzano AV, Goebeler M, Cozzani E, Kern JS, Sitaru C, Lakoš Jukić I, Sárdy M, Uzun S, Jedlickova H, Gläser R, Kaneda M, Eming R, Göpel G, Ishii N, Greene B, Hashimoto T, Hertl M. Serological diagnostics in the detection of IgG autoantibodies against human collagen VII in epidermolysis bullosa acquisita: a multicentre analysis. Br J Dermatol 2017; 177:1683-1692. [PMID: 28703393 DOI: 10.1111/bjd.15800] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Epidermolysis bullosa acquisita (EBA) is a rare, potentially devastating autoimmune disease of the skin. IgG autoantibodies directed against type VII collagen (Col7), the major component of anchoring fibrils, induce skin fragility leading to cutaneous and mucocutaneous blister formation, which is mostly of a scarring phenotype. Thus, powerful and reproducible diagnostic assays are critical to establish the diagnosis of EBA early to avoid irreversible sequelae. OBJECTIVES The present international, retrospective multicentre study included a large cohort of patients with EBA and evaluated the diagnostic power of four different diagnostic assays for the detection of anti-Col7 IgG autoantibodies. METHODS Overall, 95 EBA sera and 200 control sera consisting of 100 bullous pemphigoid sera, 50 pemphigus vulgaris sera and 50 sera of healthy controls were tested for anti-Col7 IgG autoantibodies using indirect immunofluorescence (IIF), two commercial enzyme-linked immunosorbent assay (ELISA) systems and Western blot (WB) analysis. EBA sera were taken from patients with positive direct immunofluorescence and IgG reactivity in at least one of the immunoserological assays (IIF, ELISA, WB). RESULTS A Col7-NC1/NC2 ELISA (MBL, Nagoya, Japan) showed the highest sensitivity (97·9%), followed by a Col7-NC1 ELISA (Euroimmun, Lübeck, Germany) (89·5%), WB with Col7-NC1 (85·3%), and IIF on saline-split human skin (74·7%). The specificities of both ELISA systems were comparable (NC1 98·7%, NC1/NC2 99·3%). Furthermore, WB was more sensitive than IIF, which was more specific. CONCLUSIONS The two commercially available ELISA systems allow for a highly sensitive and specific diagnosis of EBA. The sensitivity of the Col7-NC1/NC2 ELISA is significantly higher compared with the ELISA based on the Col7-NC1 domain only.
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Affiliation(s)
- T Schmidt
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - M Hoch
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - S S Lotfi Jad
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - F Solimani
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - G Di Zenzo
- Istituto Dermopatico dell'Immacolata, Rome, Italy
| | - A V Marzano
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano - Unità Operativa di Dermatologia, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - M Goebeler
- Department of Dermatology, Venereology and Allergology, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - E Cozzani
- Dermatology, IRCCS AOU San Martino Di.S.Sal., Genoa, Italy
| | - J S Kern
- Department of Dermatology, Medical Center, University of Freiburg, Freiburg, Germany
| | - C Sitaru
- Department of Dermatology, Medical Center, University of Freiburg, Freiburg, Germany
| | - I Lakoš Jukić
- Department of Dermatovenerology, University of Zagreb, Zagreb, Croatia
| | - M Sárdy
- München, Department of Dermatology and Allergology, Ludwig Maximilians University Munich, Munich, Germany
| | - S Uzun
- Department of Dermatology and Venereology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - H Jedlickova
- Department of Dermatovenereology, St. Anna University Hospital, Masaryk University, Brno, Czech Republic
| | - R Gläser
- Department of Dermatology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - M Kaneda
- Medical and Biological Laboratories, Co. Ltd, Nagoya, Japan
| | - R Eming
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - G Göpel
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
| | - N Ishii
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - B Greene
- Institute of Biometry and Statistics, Philipps-University Marburg, D-35043, Marburg, Germany
| | - T Hashimoto
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - M Hertl
- Department of Dermatology and Allergology, Philipps-University, Marburg, D-35043, Germany
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Meijer JM, Atefi I, Diercks GFH, Vorobyev A, Zuiderveen J, Meijer HJ, Pas HH, Zillikens D, Schmidt E, Jonkman MF. Serration pattern analysis for differentiating epidermolysis bullosa acquisita from other pemphigoid diseases. J Am Acad Dermatol 2017; 78:754-759.e6. [PMID: 29154993 DOI: 10.1016/j.jaad.2017.11.029] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 10/24/2017] [Accepted: 11/01/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Direct immunofluorescence (DIF) microscopy of a skin biopsy specimen is the reference standard for the diagnosis of pemphigoid diseases (PDs). Serration pattern analysis enables the differentiation of epidermolysis bullosa acquisita (EBA) from other PDs using DIF microscopy alone. However, practice gaps need to be addressed in order to implement this technique in the routine diagnostic procedure. OBJECTIVE We sought to determine and optimize the technical requirements for serration pattern analysis of DIF microscopy and determine interrater conformity of serration pattern analysis. METHODS We compared serration pattern analysis of routine DIF microscopy from laboratories in Groningen, The Netherlands and Lübeck, Germany with 4 blinded observers. Skin biopsy specimens from 20 patients with EBA and other PDs were exchanged and analyzed. Various factors were evaluated, including section thickness, transport medium, and biopsy specimen processing. RESULTS The interrater conformity of our 4 observers was 95.7%. Recognition of serration patterns was comparable in samples transported in saline and in Michel's medium and with section thicknesses of 4, 6, and 8 μm. LIMITATIONS Limitations include our small sample size and the availability of 20 samples that were compared retrospectively. CONCLUSION DIF serration pattern analysis is not restricted by variation in laboratory procedures, transport medium, or experience of observers. This learnable technique can be implemented as a routine diagnostic method as an extension of DIF microscopy for subtyping PD.
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Affiliation(s)
- Joost M Meijer
- Department of Dermatology, Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ingeborg Atefi
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Gilles F H Diercks
- Department of Dermatology, Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Artem Vorobyev
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Janny Zuiderveen
- Department of Dermatology, Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hillegonda J Meijer
- Department of Dermatology, Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hendri H Pas
- Department of Dermatology, Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Detlef Zillikens
- 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
| | - Marcel F Jonkman
- Department of Dermatology, Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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17
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Stockinger T, Richter L, Kanzler M, Melichart-Kotik M, Pas H, Derfler K, Schmidt E, Rappersberger K. [Systemic lupus erythematosus : Unusual cutaneous manifestations]. Hautarzt 2017; 67:970-981. [PMID: 27878308 DOI: 10.1007/s00105-016-3893-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Various different mucocutaneous symptoms may affect up to 80 % of systemic lupus erythematosus (SLE) patients. OBJECTIVES To investigate, various unspecific, but otherwise typical clinical symptoms of skin and mucous membranes that arise in SLE patients other than those defined as SLE criteria such as butterfly rash, chronic cutaneous lupus erythematosus, oral ulcers, and increased photosensitivity. MATERIALS AND METHODS Extensive search of peer-reviewed scientific articles was performed, medical histories of several SLE patients seen in our department were analyzed, and the rare disease courses in three SLE patients are presented. RESULTS Here we present a variety of unspecific but typical mucocutaneous manifestations in SLE patients: periungual erythema, periungual telangiectasia and periungual splinter hemorrhage, papules on the dorsum of the hands, scaling erythema, sometimes associated with necrosis, especially of the ears, along with complement deficiency, and the bizarre necroses of antiphospholipid syndrome. Furthermore, we show the typical clinico-histological features of neutrophilic urticarial dermatosis, as well as those of bullous SLE and finally a severe course of bacterial sepsis with Neisseria flavescens/macacae. CONCLUSIONS Here we show several unspecific but rather typical mucocutaneous symptoms in lupus patients that are indicative of SLE and thus may lead to an early diagnosis. Also, life-threatening bacterial sepsis may occur with microorganisms that are commonly considered "apathogenic", such as Neisseria flavescens/macacae, which exclusively affect immunosuppressed patients.
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Affiliation(s)
- T Stockinger
- Abteilung Dermatologie und Venerologie, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030, Wien, Österreich.
| | - L Richter
- Abteilung Dermatologie und Venerologie, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030, Wien, Österreich
| | - M Kanzler
- Abteilung Diabetologie, Endokrinologie und Nephrologie, Krankenanstalt Rudolfstiftung, Wien, Österreich
| | - M Melichart-Kotik
- Abteilung Diabetologie, Endokrinologie und Nephrologie, Krankenanstalt Rudolfstiftung, Wien, Österreich
| | - H Pas
- Abteilung Dermatologie, Zentrum für blasenbildende Erkrankungen, Universitätsklinik Groningen, Groningen, Niederlande
| | - K Derfler
- Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Allgemeines Krankenhaus Wien, Wien, Österreich
| | - E Schmidt
- Abteilung Dermatologie, Klinik für Dermatologie, Allergologie und Venerologie, Universität zu Lübeck, Lübeck, Deutschland
| | - K Rappersberger
- Abteilung Dermatologie und Venerologie, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030, Wien, Österreich
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Abstract
Rituximab, a monoclonal antibody targeting the B cell marker CD20, was initially approved in 1997 by the United States Food and Drug Administration (FDA) for the treatment of non-Hodgkin lymphoma. Since that time, rituximab has been FDA-approved for rheumatoid arthritis and vasculitides, such as granulomatosis with polyangiitis and microscopic polyangiitis. Additionally, rituximab has been used off-label in the treatment of numerous other autoimmune diseases, with notable success in pemphigus, an autoantibody-mediated skin blistering disease. The efficacy of rituximab therapy in pemphigus has spurred interest in its potential to treat other autoantibody-mediated diseases. This review summarizes the efficacy of rituximab in pemphigus and examines its off-label use in other select autoantibody-mediated diseases.
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Affiliation(s)
- Nina A Ran
- Department of Dermatology, University of Pennsylvania, 1009 Biomedical Research Building, 421 Curie Boulevard, PA, USA
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, 1009 Biomedical Research Building, 421 Curie Boulevard, PA, USA
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19
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Hashimoto T, Tsuruta D, Koga H, Fukuda S, Ohyama B, Komai A, Karashima T, Ohata C, Teye K, Ishii N. Summary of results of serological tests and diagnoses for 4774 cases of various autoimmune bullous diseases consulted to Kurume University. Br J Dermatol 2016; 175:953-965. [DOI: 10.1111/bjd.14692] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2016] [Indexed: 12/12/2022]
Affiliation(s)
- T. Hashimoto
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Fukuoka 830-0011 Japan
| | - D. Tsuruta
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Fukuoka 830-0011 Japan
| | - H. Koga
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Fukuoka 830-0011 Japan
| | - S. Fukuda
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Fukuoka 830-0011 Japan
| | - B. Ohyama
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Fukuoka 830-0011 Japan
| | - A. Komai
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Fukuoka 830-0011 Japan
| | - T. Karashima
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Fukuoka 830-0011 Japan
| | - C. Ohata
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Fukuoka 830-0011 Japan
| | - K. Teye
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Fukuoka 830-0011 Japan
| | - N. Ishii
- Department of Dermatology; Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology; Kurume Fukuoka 830-0011 Japan
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20
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Vorobyev A, Ludwig RJ, Schmidt E. Clinical features and diagnosis of epidermolysis bullosa acquisita. Expert Rev Clin Immunol 2016; 13:157-169. [PMID: 27580464 DOI: 10.1080/1744666x.2016.1221343] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Epidermolysis bullosa acquisita (EBA) is a rare autoimmune blistering disease of skin and mucous membranes. EBA is caused by autoantibodies against type VII collagen, which is a major component of anchoring fibrils, attaching epidermis to dermis. Binding of autoantibodies to type VII collagen leads to skin fragility and, finally, blister formation. The clinical picture of EBA is polymorphic, with several distinct phenotypes being described. Despite recent progress in understanding the pathophysiology of EBA, its diagnosis is still challenging. Areas covered: This review provides an update on the clinical manifestations and diagnostic methods of EBA. We searched PubMed using the terms 'epidermolysis bullosa acquisita' covering articles in English between 1 January 2005 and 31 May 2016. Relevant older publications were retrieved form cited literature. Expert commentary: While the clinical picture is highly variable, diagnosis relies on direct immunofluorescence (IF) microscopy of a perilesional skin biopsy. Linear deposits of IgG, IgA and/or C3 along the dermal-epidermal junction with an u-serrated pattern are diagnostic for EBA alike the detection of serum autoantibodies against type VII collagen. Several test systems for the serological diagnosis of EBA have recently become widely available. In some patients, sophisticated diagnostic approaches only available in specialized centers are required.
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Affiliation(s)
- Artem Vorobyev
- a Department of Dermatology , University of Lübeck , Lübeck , Germany.,b Lübeck Institute of Experimental Dermatology (LIED) , University of Lübeck , Lübeck , Germany
| | - Ralf J Ludwig
- a Department of Dermatology , University of Lübeck , Lübeck , Germany.,b Lübeck Institute of Experimental Dermatology (LIED) , University of Lübeck , Lübeck , Germany
| | - Enno Schmidt
- a Department of Dermatology , University of Lübeck , Lübeck , Germany.,b Lübeck Institute of Experimental Dermatology (LIED) , University of Lübeck , Lübeck , Germany
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Hashimoto T, Jin Z, Ishii N. Clinical and immunological studies for 105 Japanese seropositive patients of epidermolysis bullosa acquisita examined at Kurume University. Expert Rev Clin Immunol 2016; 12:895-902. [PMID: 27247994 DOI: 10.1080/1744666x.2016.1196136] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Using our serological diagnostic criteria, we selected 105 Japanese patients with epidermolysis bullosa acquisita (EBA), an autoimmune bullous disease (AIBD) reacting with type VII collagen, from our cohort of 5063 AIBD patients. METHODS We examined the patients clinically and immunologically. RESULTS We found diversity of clinical manifestations in both cutaneous and oral mucosal lesions and a high rate of inflammatory-type EBA patients in Japan. Common treatments were systemic steroids, followed by immunosuppressives, DDS, tetracycline/minocycline and colchicine. Immunological studies revealed that indirect immunofluorescence of 1M-NaCl-split skin, immunoblotting of dermal extract, and type VII collagen ELISA were sensitive methods, with possible multiplicity of circulating autoantibodies against other basement membrane autoantigens. CONCLUSION The present study analyzed the largest cohort of EBA patients, confirming the scarcity of EBA (only 105 of the 5063 AIBD patients), and showed that the three serological tests are useful for the diagnosis of EBA.
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Affiliation(s)
- Takashi Hashimoto
- a Department of Dermatology , Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology , Fukuoka , Japan
| | - Zhexiong Jin
- a Department of Dermatology , Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology , Fukuoka , Japan
| | - Norito Ishii
- a Department of Dermatology , Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology , Fukuoka , Japan
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22
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Goyal N, Rao R, Balachandran C, Pai S, Bhogal BS, Schmidt E, Zillikens D. Childhood Epidermolysis Bullosa Acquisita: Confirmation of Diagnosis by Skin Deficient in Type VII Collagen, Enzyme-linked Immunosorbent Assay, and Immunoblotting. Indian J Dermatol 2016; 61:329-32. [PMID: 27293257 PMCID: PMC4885189 DOI: 10.4103/0019-5154.182420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Epidermolysis bullosa acquisita (EBA) is an acquired subepidermal bullous disorder characterized by autoantibodies against Type VII collagen. It usually affects adults; childhood EBA is rare. We describe a 10-year-old girl presenting with recurrent tense blisters predominantly on legs, dorsa of hands and feet accompanied by oral erosions since the age of 5 years. Direct immunofluorescence (IF) microscopy showed linear deposition of IgG and C3 along the basement membrane zone (BMZ); indirect IF microscopy on salt-split skin revealed staining of IgG to the dermal side of the split. The patient's serum did not show BMZ staining in recessive dystrophic epidermolysis bullosa skin deficient for Type VII collagen, thus confirming autoantibody reactivity against Type VII collagen. Circulating antibodies against the immunodominant noncollagenous 1 domain of Type VII collagen were detected by ELISA and immunoblotting studies. The patient was treated with oral corticosteroids and dapsone with good improvement.
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Affiliation(s)
- Nupur Goyal
- Department of Dermatology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Raghavendra Rao
- Department of Dermatology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - C Balachandran
- Department of Dermatology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Sathish Pai
- Department of Dermatology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Balbir S Bhogal
- Department of Immunodermatology, St. John's Institute of Dermatology, St. Thomas Hospital, London
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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23
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Seta V, Aucouturier F, Bonnefoy J, Le Roux-Villet C, Pendaries V, Alexandre M, Grootenboer-Mignot S, Heller M, Lièvre N, Laroche L, Caux F, Titeux M, Hovnanian A, Prost-Squarcioni C. Comparison of 3 type VII collagen (C7) assays for serologic diagnosis of epidermolysis bullosa acquisita (EBA). J Am Acad Dermatol 2016; 74:1166-72. [DOI: 10.1016/j.jaad.2016.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 12/26/2015] [Accepted: 01/01/2016] [Indexed: 10/22/2022]
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Marzano AV, Cozzani E, Biasin M, Russo I, Alaibac M. The use of Biochip immunofluorescence microscopy for the serological diagnosis of epidermolysis bullosa acquisita. Arch Dermatol Res 2016; 308:273-6. [PMID: 26895535 DOI: 10.1007/s00403-016-1632-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 01/21/2016] [Accepted: 02/09/2016] [Indexed: 11/26/2022]
Abstract
Epidermolysis bullosa acquisita is a rare autoimmune bullous disease characterized by the presence of circulating antibodies directed against the collagen type VII. Diagnosis is generally based on clinical history, clinical features, histology, direct and indirect immunofluorescence, immunoblotting and ELISA. Our study aims to determine the validity of the Biochip immunofluorescence microscopy for the serological diagnosis of epidermolysis bullosa acquisita. Six patients with epidermolysis bullosa acquisita and presence of antibodies against type VII collagen confirmed by ELISA were included in the study. Subsequently, all sera of patients were analyzed using Biochip. Antibodies anti-collagen type VII were detected in all sera by means of the Biochip technology. Thus, Biochip shows a good correlation with ELISA and seems to be an appropriate method for the diagnosis of epidermolysis bullosa acquisita. It is an easy, fast and standardized method which could facilitate the diagnosis of this autoimmune bullous disease. We suggest that it could be used as an initial screening test to identify patients with epidermolysis bullosa acquisita.
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Affiliation(s)
- Angelo Valerio Marzano
- Unit of Dermatology, Fondazione IRCCS Ca' Granda -Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Pace 9, 20122, Milan, Italy
| | - Emanuele Cozzani
- Unit of Dermatology, University of Genoa, IRCCS A.O.U. San Martino-IST, Genoa, Italy
| | - Matteo Biasin
- Unit of Dermatology, Department of Medicine, University of Padua, Via C. Battisti 206, 35121, Padua, Italy
| | - Irene Russo
- Unit of Dermatology, Department of Medicine, University of Padua, Via C. Battisti 206, 35121, Padua, Italy
| | - Mauro Alaibac
- Unit of Dermatology, Department of Medicine, University of Padua, Via C. Battisti 206, 35121, Padua, Italy.
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25
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Turcan I, Jonkman MF. Blistering disease: insight from the hemidesmosome and other components of the dermal-epidermal junction. Cell Tissue Res 2014; 360:545-69. [PMID: 25502077 DOI: 10.1007/s00441-014-2021-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 09/25/2014] [Indexed: 02/07/2023]
Abstract
The hemidesmosome is a specialized transmembrane complex that mediates the binding of epithelial cells to the underlying basement membrane. In the skin, this multiprotein structure can be regarded as the chief adhesion unit at the site of the dermal-epidermal junction. Focal adhesions are additional specialized attachment structures located between hemidesmosomes. The integrity of the skin relies on well-assembled and functional hemidesmosomes and focal adhesions (also known as integrin adhesomes). However, if these adhesion structures are impaired, e.g., as a result of circulating autoantibodies or inherited genetic mutations, the mechanical strength of the skin is compromised, leading to blistering and/or tissue inflammation. A particular clinical presentation emerges subject to the molecule that is targeted. None of these junctional complexes are simply compounds of adhesion molecules; they also play a significant role in signalling pathways involved in the differentiation and migration of epithelial cells such as during wound healing and in tumour invasion. We summarize current knowledge about hereditary and acquired blistering diseases emerging from pathologies of the hemidesmosome and its neighbouring proteins as components of the dermal-epidermal junction.
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Affiliation(s)
- Iana Turcan
- Centre for Blistering Diseases, Department of Dermatology, University Medical Centre Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands,
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26
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Iranzo P. Comments on "Bullous pemphigoid associated with chronic renal allograft rejection". J Am Acad Dermatol 2014; 71:194-5. [PMID: 24947691 DOI: 10.1016/j.jaad.2013.11.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 11/10/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Pilar Iranzo
- Dermatology Department, Hospital Clínic, Barcelona, Spain.
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27
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Ingen-Housz-Oro S, Grootenboer-Mignot S, Ortonne N, Nahon S, Horvath J, Bernardeschi C, Laffitte E, André C, Chollet-Martin S, Wolkenstein P, Chosidow O. Epidermolysis bullosa acquisita-like eruption with anticollagen VII autoantibodies induced by D-penicillamine in Wilson disease. Br J Dermatol 2014; 171:1574-6. [PMID: 24888462 DOI: 10.1111/bjd.13153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- S Ingen-Housz-Oro
- Department of Dermatology, AP-HP, Henri Mondor Hospital, 51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France
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