Burden of disease during quiescent periods in patients with pemphigus

Autoimmune bullous diseases in pregnancy: an overview of pathogenesis, clinical presentations, diagnostics and available therapies

Autoimmune bullous diseases (AIBDs) are rare organ-specific diseases characterized by the appearance of blisters and erosions on the skin and mucous membranes. These dermatoses are marked by the development of autoantibodies targeting the autoantigens located in intercellular junctions, i.e., between keratinocytes or in the basement membrane area. Therefore, the fundamental division of AIBDs into the pemphigus and pemphigoid groups exists. Although AIBDs are uncommon in the general population, their overall incidence is somewhat higher in women of all ages, for which a pregnant women can be likely affected too. While the pemphigoid gestationis is exclusive bullous dermatosis of pregnancy, the other AIBDs can also start or worsen during this period. The appearance of AIBDs in childbearing women is a particularly sensitive situation requiring exceptional clinicians' caution due to the possibility of pregnancy complications with adverse effects and risks to the mother and the child. Also, there are numerous management difficulties in the period of pregnancy and lactation related to the drugs' choice and safety. This paper aimed to outline the pathophysiologic mechanisms, clinical manifestations, diagnostic approach and therapy of the most commonly recognized AIBDs in pregnancy.

The multifactorial complexities of autoimmune development in Pemphigus vulgaris: Critical evaluation of the role of environmental and lifestyle "exposome" factors

Pemphigus vulgaris (PV) is a potentially life-threatening blistering disorder characterized by autoantibodies directed against cell-cell adhesion molecules that serves as an excellent model to study human autoimmune development. Numerous studies have identified specific Human Leukocyte Antigen (HLA) genes, in particular DRB1*0402 and DQB1*0503, that confer disease risk. Although HLA is required, it is not sufficient for the initiation of disease. As with all autoimmune diseases, the etio-pathogenesis of PV is complex, meaning it is multifactorial. Susceptibility is polygenic, and the search for non-HLA disease-linked genes continues. Moreover, twin studies across autoimmune conditions indicate that non-genetic environmental and lifestyle factors, which can be collectively grouped under the term "exposome", are also major contributors to disease development. The literature presents evidence for the potential role of multiple triggers such as medications, infections, stress, diet, immunizations, and sleep to influence the etiology, pathophysiology, and prognosis of PV. However, a clear understanding of the degree to which specific factors impact PV is lacking. In this investigation, we comprehensively review the environmental elements listed above and consider the strength of evidence for these factors. The overall goals of this work are to provide greater insights into the factors that influence disease susceptibility, disease development and disease course and ultimately help to better guide clinicians and inform patients in the management of PV.

Burden of pemphigus vulgaris with a particular focus on women: A review

Pemphigus vulgaris is a chronic autoimmune mucocutaneous blistering disorder. Apart from the disease itself, other aspects of patients' life, including psychological, social, and financial, can be affected. Women are particularly more disposed to the impact of the disease due to their physiological characteristics, the specific periods of pregnancy and lactation as well as their social and familial role. In this review, we summarized the burden of pemphigus vulgaris on various aspects of women's lives. It is essential to understand these problems and provide appropriate support for patients with such a burdensome disease.

Psychological morbidity in pemphigus patients in clinical remission and its relation with clinico-demographic parameters

BACKGROUND AND OBJECTIVES

Significant psychological morbidity exists in patients with active pemphigus. Pemphigus being a chronic disease, psychological morbidity may exist in pemphigus patients in remission as well. The objectives of the study were to assess the psychological morbidity in pemphigus patients in clinical remission and to correlate it with clinico-demographic parameters.

PATIENTS AND METHODS

Pemphigus patients in clinical remission were consecutively included and were asked to respond to the Hindi/English version of Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7) and panic disorder module of PHQ.

RESULTS

Of 107 patients recruited, 41 (38.3 %, 95 % CI: 29.1-48.2 %) patients were found to have either depression (33 [30.8 %, 95 % CI: 22.2-40.5 %]) or anxiety (38 [35.5 %, 95 % CI: 26.5-45.4 %] syndrome based on cut-offs of PHQ-9 score and GAD-7 score, respectively. Number of patients with mild, moderate and moderately severe/severe depression syndrome were 26 (24.3 %, 95 % CI: 17.2-33.2 %), 7 (6.5 %, 95 % CI: 0.3-12.9 %) and 0 respectively and patients with mild, moderate, severe anxiety syndrome were 29 (27.1 %, 95 % CI: 19.6-36.2 %), 9 (8.4 %, 95 % CI: 4.5-15.2 %) and 0 respectively. Patients with anxiety or depression syndrome had significantly higher clinical disease activity in the past, number of days spent in dermatology inpatient and significantly shorter clinical remission at the time of assessment as compared to those without these symptoms.

CONCLUSIONS

Significant burden of mild/moderate depression or anxiety syndrome associated with past severity of disease and shorter duration of clinical remission was found.

Comorbid mental health issues in patients with pemphigus vulgaris and pemphigus foliaceus

The term 'pemphigus' refers to chronic autoimmune skin disorders that cause blistering erosions on the skin and oral mucosa. The two major clinical forms are pemphigus vulgaris and pemphigus foliaceus. Although rare, they confer a stark symptomatic burden upon patients that significantly impacts daily life. Comorbid mental health issues are not routinely screened for in patients with pemphigus, and current UK guidance provides no formal provision for the identification and treatment of psychological issues. This review is the first of its kind, to our knowledge, to systematically examine the available evidence on mental health issues in pemphigus. Published work suggests that the incidence of anxiety and depression is much higher in patients with pemphigus compared with both the general population and with patients having other chronic skin disorders. Disease severity appears to be closely linked to mental health, with worsening of pemphigus associated with deteriorations in psychological wellbeing. Corticosteroids, which are associated with depression in chronic use, are the current first-line therapy for pemphigus and have been identified as a potential confounder and independent risk factor for mental health comorbidity in pemphigus. Current evidence is unclear whether a bidirectional relationship exists between mental health and pemphigus severity, and more thorough research is required to develop understanding of this issue. In conclusion, we have identified a high incidence of mental health comorbidity in pemphigus, and recommend routine screening of patients with pemphigus for mental health issues and signposting toward mental health services as an initial measure to address this.

De-escalation of anti-CD20 monoclonal antibody (Rituximab) protocols in Pemphigus Vulgaris - a systematic review

Introduction: This review assesses current evidence supporting dose de-escalated rituximab therapy in pemphigus vulgaris, compared to standard protocols. Primary outcome measures were remission and relapse rates. Adverse effects, cumulative steroid dosages, and serological markers of disease activity were also reported.Areas covered: A literature search was performed to look for reports describing the use of de-escalated rituximab therapy in pemphigus vulgaris. Results from heterogenous studies showed a large variation in remission and relapse rates. Complete remission rates from de-escalated treatment ranged from 41.7 to 100.0%, while rates in the control groups ranged from 60.0 to 90.9%. Relapse rates varied from 8.0 to 81.3% in the de-escalated group and from 0.0 to 72.4% in the control group. Of the 165 patients included in this report, only two major adverse effects were reported.Expert Opinion: Overall, dose de-escalated rituximab protocols reported to date appear effective and safe. However, it is unclear if treatment effect parallels that of standard regimens in regard to disease control in the long term. A lower limit of effective dosing for rituximab in pemphigus vulgaris has not yet been reached or defined. The role for and timing of repeated cycles of low-dose rituximab therapy require further exploration.

Epidemiology of Pemphigus

Pemphigus is an epidemiologically heterogeneous group of autoimmune bullous diseases comprising pemphigus vulgaris (PV), pemphigus foliaceus, paraneoplastic pemphigus, IgA pemphigus, and pemphigus herpetiformis. Recently, our knowledge about the frequency of pemphigus, which is highly variable between different populations, has considerably expanded, and the first non-HLA genes associated with PV have been identified. In addition, a variety of comorbidities, including other autoimmune diseases, hematological malignancies, and psoriasis, have been described in this variant. Here, initial data about the impact of COVID-19 on this fragile patient population are discussed and perspectives for future epidemiological studies are outlined.

The health-related quality of life and psychological profile in patients with oropharyngeal Pemphigus Vulgaris in complete clinical remission: A case-control study

BACKGROUND

Pemphigus Vulgaris (PV) is a severe autoimmune blistering disease which may affect the patient's health-related quality of life (HR-QoL) and mood even during quiescent disease activity. We sought to evaluate HR-QoL, quality of sleep (QoS), anxiety and depression in oropharyngeal PV patients (OPV) in complete clinical remission on or off therapy (CCR-on, CCR-off).

METHODS

Thirty OPV patients and 30 healthy controls were enrolled. The Short Form 36 Health Survey Questionnaire (SF-36), Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Hamilton Rating Scale for Depression (HAM-D) and Hamilton Rating Scale for Anxiety (HAM-A) were administered. Descriptive statistics, including the Mann-Whitney U test and hierarchical multiple linear regression analysis, were used.

RESULTS

The OPV patients had statistically lower scores in the majority of items of the SF-36 and higher scores in the PSQI, HAM-A and HAM-D than the healthy controls (P < .004; P < .001; and P < .001 respectively). Nine (30%) of the OPV patients were poor sleepers (PSQI > 5) with higher scores in the SF-36, HAM-A and HAM-D compared with the good sleepers (PSQI < 5). No statistically significant difference was detected in the OPV group when comparing patients in CCR-on and CCR-off, or in consideration of the cumulative time of the disease duration.

CONCLUSIONS

HR-QoL of OPV patients can be impaired even over periods of relatively well-being, therefore, clinicians should monitor periodically their HR-QoL, QoS and psychological profile in order to guide treatments also toward improving their HR-QoL.

Association between schizophrenia and an autoimmune bullous skin disease-pemphigus: a population-based large-scale study

AIMS

Immunological hypotheses have become increasingly prominent suggesting that autoimmunity may be involved in the pathogenesis of schizophrenia. Schizophrenia was found to be associated with a wide range of autoimmune diseases. However, the association between pemphigus and schizophrenia has not been established yet. We aimed to estimate the association between pemphigus and schizophrenia using a large-scale real-life computerised database.

METHODS

This study was conducted as a cross-sectional study utilising the database of Clalit Health Services. The proportion of schizophrenia was compared between patients diagnosed with pemphigus and age-, gender- and ethnicity-matched control subjects. Univariate analysis was performed using χ2 and Student's t-test and a multivariate analysis was performed using a logistic regression model.

RESULTS

A total of 1985 pemphigus patients and 9874 controls were included in the study. The prevalence of schizophrenia was greater in patients with pemphigus as compared to the control group (2.0% v. 1.3%, respectively; p = 0.019). In a multivariate analysis, pemphigus was significantly associated with schizophrenia (OR, 1.5; 95% CI, 1.1-2.2). The association was more prominent among females, patients older than 60 years, and Jews.

CONCLUSIONS

Pemphigus is significantly associated with schizophrenia. Physicians treating patients with pemphigus should be aware of this possible association. Patients with pemphigus should be carefully assessed for comorbid schizophrenia and be treated appropriately.

Pemphigus group: overview, epidemiology, mortality, and comorbidities

Pemphigus forms a group of rare autoimmune bullous diseases that affect the skin and mucous membranes. This group has a chronic course leading to high morbidity and mortality. It is characterized by the production of pathogenic autoantibodies directed against different proteins of the desmosome, leading histologically to intraepidermal cleavage, and clinically to vesicles and erosions on the epithelium of the mucous membranes and/or the skin. The diagnosis of the subtype of pemphigus is based on clinical features, the level of histologic cleavage, and the identification of the antigens recognized by circulating autoantibodies by immunoserological analyses. The epidemiological features of pemphigus vary considerably in different regions of the world. Observational studies examining comorbidities and associations among patients with pemphigus are scarce and sometimes inconclusive. The prognosis, mortality, and clinical outcomes in pemphigus have undergone dramatic change throughout the years. This review provides a brief overview about the different subtypes of pemphigus: pemphigus vulgaris, pemphigus foliaceus, paraneoplastic pemphigus, pemphigus herpetiformis, and IgA pemphigus. In addition, it summarizes the most recent understanding of the epidemiology, mortality data, and comorbidities of this group of organ-specific autoimmune diseases.

Illness perception of patients with pemphigus vulgaris

Objective

Little is known about illness perception in patients with pemphigus vulgaris (PV). We designed a cross-sectional study to clarify the beliefs about PV.

Methods

A total of 100 patients with PV (45 men, 55 women) completed the Illness Perception Questionnaire-Revised to assess beliefs about seven aspects of illness perception, including chronicity, recurrence, consequences, self and medicine role in controlling illness, coherence, and emotional representation. The relationship between illness perception and clinical and demographic variables was evaluated.

Results

Patients viewed PV as a chronic and cyclical disease with important impression on their life and emotions. Patients had a good understanding of the disease and supposed an acceptable role for themselves and medical treatment. Interestingly, the clinical subtype and severity of the disease did not influence any aspect of illness perception, but some differences on the basis of demographic data were demonstrated.

Conclusion

Our patients had a relatively good understanding of their illness and a correct perception about chronicity and the cyclical identity of illness. The patients believed that their life and emotions had been strongly influenced by the disease but were hopeful for a cure. Because correction of misconceptions about a disease may improve treatment outcomes, an assessment of patients' illness perception may be useful to try and modify perception.

Validity of the EQ-5D in patients with pemphigus vulgaris and pemphigus foliaceus

BACKGROUND

No studies to date have employed the EuroQoL EQ-5D questionnaire to assess health-related quality of life (HRQoL) in patients with pemphigus.

OBJECTIVES

To evaluate the HRQoL of patients with pemphigus by the EQ-5D and to analyse the convergent and known-groups validity of the EQ-5D in this patient population.

METHODS

Between 2014 and 2017, a multicentre cross-sectional study was carried out. Outcome measures included the five-level EQ-5D (EQ-5D-5L), Dermatology Life Quality Index (DLQI), Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) and an average pain intensity visual analogue scale (VAS) for the past 3 months.

RESULTS

In total, 109 consecutive patients with pemphigus participated in the study (mean age 57 years; 64% women). Among the EQ-5D dimensions, the most problems were reported regarding pain/discomfort (50%), mobility (43%) and anxiety/depression (43%). No significant difference was found in mean EQ-5D index scores between patients with pemphigus vulgaris and those with pemphigus foliaceus (0·81 vs. 0·86, P = 0·14). The mean EQ-5D index scores of patients with limited, moderate, significant and extreme pemphigus were 0·88, 0·82, 0·72 and 0·67, respectively (P = 0·001). The number of comorbidities was associated with greater impairment in EQ-5D index scores (P < 0·001). DLQI (r_s = -0·62, P < 0·001) and the average pain intensity VAS (r_s = -0·59, P < 0·001) more strongly correlated with the EQ-5D index scores than did ABSIS (r_s = -0·40, P < 0·001).

CONCLUSIONS

This is the first study employing the EQ-5D questionnaire in pemphigus. The EQ-5D is a valid measure of HRQoL in patients with pemphigus that can be useful both in clinical practice and in economic evaluations to assess the health gains associated with new effective treatments.

The effects of autoimmune blistering diseases on work productivity: A review

This review examines the work productivity in patients with autoimmune blistering diseases (AIBDs). Work productivity and employment are important aspects of a patient's life, which can be affected by diseases. The Work Productivity and Activity Impairment Questionnaire (WPAIQ) is a validated instrument that can measure work productivity and assess the impact of disease on patients' work lives. There is currently a paucity of research that investigates the reason why AIBDs cause such a large impact on work productivity and whether AIBDs affect employment status. Using quality of life (QoL) instruments in conjunction with the creation of an adapted WPAIQ to examine the reasons behind work impairment may further characterize these effects and unveil a deeper understanding of stigmatization in the workplace as a factor of loss of work productivity.

Bipolar Disorder Associated with Another Autoimmune Disease-Pemphigus: A Population-based Study

OBJECTIVES

Recent evidence suggests a notable role for inflammation and immune dysregulation in the neuroprogression of bipolar disorders (BD). Several autoimmune comorbidities have been reported in association with BD. However, the epidemiological relationship between pemphigus and BD has not yet been elucidated. We aimed to estimate the association between pemphigus and BD using a large-scale, real-life computerized database.

METHODS

Data for this study were retrieved from the database of the Clalit Health Services, the largest, state-mandated, health service organization in Israel. This study was designed as a cross-sectional study. The proportion of patients with BD was compared between patients diagnosed with pemphigus and age-, sex-, and ethnicity-matched control subjects. A logistic regression model was performed to estimate how pemphigus and other covariates contributed as risk factors for BD.

RESULTS

A total of 1,985 pemphigus cases and 9,874 controls were included in the study. The prevalence of BD was greater in cases with pemphigus than in controls (1.0% v. 0.5%, respectively; P = 0.023). This coexistence was more prominent among patients of Jewish ethnicity. After controlling for confounders, such as age, sex, ethnicity, socioeconomic status, drug abuse, alcohol abuse, smoking, healthcare utilization, and comorbidities, pemphigus demonstrated a substantial independent association with BD (OR, 1.7; 95% CI, 1.0 to 2.9).

CONCLUSIONS

Pemphigus is significantly associated with BD. Patients with pemphigus should be assessed for comorbid BD. Experimental research is needed to better recognize the biological mechanisms underlying this observation.

The effect of autoimmune blistering diseases on work productivity

BACKGROUND

Autoimmune blistering diseases (AIBD) are known to negatively impact upon quality of life (QoL); however, there is a paucity of research on the effect of AIBD on work productivity. AIBD can be quite disfiguring in terms of a patient's appearance due to their blistering nature.

OBJECTIVE

To determine the impact of AIBD on work productivity and to determine whether patients are stigmatized at work due to their appearance.

METHODS

Sixty-one patients with AIBD completed the Work Productivity and Activity Impairment Questionnaire-Specific Health Problem (WPAIQ-SHP), the Dermatology Life Quality Index (DLQI), the Autoimmune Bullous Disease Quality of Life (ABQOL) and the Treatment of Autoimmune Bullous Disease Quality of Life questionnaires (TABQOL).

RESULTS

Non-responders to treatment had more work and activity impairment compared to responders. Worse WPAIQ-SHP scores were correlated with higher ABQOL, TABQOL and DLQI scores. Approximately 14.8% of subjects experienced stigmatization at work due to their appearance. The most common body areas stigmatized were easily visible sites, particularly the hands, arms and feet, with the majority of occurrences related to co-workers; for some patients, this stigmatization occurred on a daily basis. Loss of productivity at work was statistically much higher in those with higher disease severity, ABQOL & TABQOL scores and in non-responders to treatment.

CONCLUSION

Autoimmune blistering diseases negatively impacts upon work productivity and activity. Stigmatization was common in the workplace which leads to increased stress, itself a stimulator of pemphigus.

Psychosocial impact of inherited and autoimmune blistering diseases

Inherited and autoimmune blistering diseases are rare, chronic, and often severe disorders that have the potential to significantly affect patients' quality of life. The effective management of these conditions requires consideration of the physical, emotional, and social aspects of the disease. Self-esteem is integral to patients' ability to cope with their illness, participate in treatment, and function in society. This article discusses quality-of-life studies of patients with blistering diseases with a particular focus on self-esteem issues that patients may face.

Pemphigus

Pemphigus is a group of IgG-mediated autoimmune diseases of stratified squamous epithelia, such as the skin and oral mucosa, in which acantholysis (the loss of cell adhesion) causes blisters and erosions. Pemphigus has three major subtypes: pemphigus vulgaris, pemphigus foliaceus and paraneoplastic pemphigus. IgG autoantibodies are characteristically raised against desmoglein 1 and desmoglein 3, which are cell-cell adhesion molecules found in desmosomes. The sites of blister formation can be physiologically explained by the anti-desmoglein autoantibody profile and tissue-specific expression pattern of desmoglein isoforms. The pathophysiological roles of T cells and B cells have been characterized in mouse models of pemphigus and patients, revealing insights into the mechanisms of autoimmunity. Diagnosis is based on clinical manifestations and confirmed with histological and immunochemical testing. The current first-line treatment is systemic corticosteroids and adjuvant therapies, including immunosuppressive agents, intravenous immunoglobulin and plasmapheresis. Rituximab, a monoclonal antibody against CD20⁺ B cells, is a promising therapeutic option that may soon become first-line therapy. Pemphigus is one of the best-characterized human autoimmune diseases and provides an ideal paradigm for both basic and clinical research, especially towards the development of antigen-specific immune suppression treatments for autoimmune diseases.

Outcome measures for autoimmune blistering diseases

Outcome measures are crucial in assessing an autoimmune blistering disease's (AIBD) severity as well as its impact on the patient's quality of life (QOL). The standardization of AIBD outcome measures is pivotal to accurately monitor the patient and to pool results from randomized controlled trials for meta-analysis, and thereby provide knowledge of the optimal AIBD therapies. In the past decade, several AIBD severity outcome measures have been developed and validated. For pemphigus severity, the Pemphigus Disease Area Index (PDAI) developed by the International Pemphigus Definitions Group was shown to be the most superior, followed by the Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) by the German group. For bullous pemphigoid severity, the Bullous Pemphigoid Disease Area Index (BPDAI) was shown to be an accurate and valid measure. To quantify the burden of AIBD and its treatments on QOL, the Autoimmune Bullous Disease Quality of Life (ABQOL) and the Treatment of Autoimmune Bullous Disease Quality of Life (TABQOL) were also developed, validated, and are now being validated in multiple languages and cultures.

Valuation of pemphigus vulgaris and pemphigus foliaceus health states: a convenience sample experiment

BACKGROUND

Health-related quality of life (HRQoL) in pemphigus has been widely investigated; nevertheless, utility values for economic evaluations are still lacking.

OBJECTIVES

To estimate health utilities for hypothetical pemphigus vulgaris (PV) and pemphigus foliaceus (PF) health states in a general population sample.

METHODS

Three health states (uncontrolled PV, uncontrolled PF and controlled pemphigus) were developed based on a systematic literature review of HRQoL studies in pemphigus. Utilities were obtained from a convenience sample of 108 adults using a visual analogue scale (VAS) and 10-year time trade-off (TTO). Lead-time TTO was applied for health states regarded as worse than dead with a lead time to disease time ratio of 1 : 1.

RESULTS

The mean VAS utility scores for PV, PF and controlled pemphigus were 0·25 ± 0·15, 0·37 ± 0·17 and 0·63 ± 0·16, respectively. Corresponding TTO utilities were as follows: 0·34 ± 0·38, 0·51 ± 0·32 and 0·75 ± 0·31. Overall, 14% and 6% judged PV and PF as being worse than dead. For both VAS and TTO values, significant differences were observed between all health states (P < 0·001). VAS utilities were rated significantly lower compared with TTO in each health state (P < 0·001).

CONCLUSIONS

This is the first study that reports health utility values for PV and PF. Successful treatment of pemphigus might result in significant utility gain (0·24-0·41). These empirical findings with respect to three health states in pemphigus may serve as anchor points for further utility studies and cost-effectiveness analyses.

Quality of Life Assessment in Korean Patients with Pemphigus

Background

Measuring the quality of life (QOL) is important in the evaluation of nonclinical aspects of diseases, for the discovery of functional and psychological limitations, and in choosing treatment in the initial phase of the disease. Pemphigus is a potentially fatal autoimmune bullous disease caused by autoantibodies against desmogleins (cadherin family proteins in desmosomes). Thus far, there has been no published study on QOL in Korean patients with pemphigus.

Objective

To study the impact of pemphigus on the QOL in a large number of Korean patients.

Methods

Sixty-six patients enrolled at the Gangnam Severance Hospital from March 2012 to March 2013 were assessed for QOL by using the Dermatology Life Quality Index (DLQI), and for anxiety and depression by using the General Health Questionnaire (GHQ). Spearman's rank-order correlation, t-test, and ANOVA were used to identify the relations between the DLQI score and other clinical variables.

Results

Pemphigus vulgaris and pemphigus foliaceus significantly reduced the QOL of patients. The average DLQI score for all patients was 10.18. The mean DLQI score was 13.45 in patients in the active state and 5.15 in the patients in the remission state. The DLQI score highly correlated with disease severity, titer of anti-desmoglein 1 in enzyme-linked immunosorbent assay, and the corticosteroid dose. However, the QOL was not affected by sex, age, subtype of pemphigus, duration of disease, or comorbidities. Forty-two percent of the patients showed a positive result in the GHQ, reflecting probable minor psychiatric nonpsychotic conditions, and the GHQ score positively correlated to the DLQI score.

Conclusion

Pemphigus significantly impairs the QOL of patients. The QOL of Korean pemphigus patients significantly correlates with clinical severity. Therefore, considerable attention should be paid to the patients' QOL and psychological states as well as clinical status.

A pilot comparison study of four clinician-rated atopic dermatitis severity scales

BACKGROUND

There are multiple severity outcome measures for atopic dermatitis (AD). There is a need to compare the reliability of these measures.

OBJECTIVES

To compare the inter-rater and intrarater reliability of the objective Scoring Atopic Dermatitis (oSCORAD), Eczema Area and Severity Index (EASI), Six Area, Six Sign Atopic Dermatitis (SASSAD) and Three Item Severity index (TIS); and to analyse the correlation between these outcome measures and the quality-of-life instruments Patient-Orientated Eczema Measurement, Dermatology Life Quality Index and Skindex-29.

METHODS

Twelve patients with AD attended a 1-day scoring exercise by five trained dermatology clinicians. Inter-rater and intrarater reliability were assessed using the intraclass correlation coefficient (ICC). Correlation between clinician-rated and patient-reported measures was analysed using Spearman's rho.

RESULTS

Regarding inter-rater reliability, EASI and SASSAD showed good reliabilities, with ICCs of 0·730 [95% confidence interval (CI) 0·500-0·900] and 0·680 (95% CI 0·440-0·880), respectively. However, the ICCs were poor for TIS and oSCORAD, with 0·497 (95% CI 0·233-0·785) and 0·498 (95% CI 0·234-0·785), respectively. Separate body surface area (BSA) component analyses showed that the oSCORAD BSA component contributed to its inter-rater variations. Regarding intrarater reliability, EASI and TIS showed excellent ICCs of 0·886 (95% CI 0·744-0·952) and 0·820 (0·614-0·923), respectively, while SASSAD showed a good reliability with an ICC of 0·720 (95% CI 0·424-0·878). However, the intrarater ICC was poor for oSCORAD, with 0·446 (95% CI 0·037-0·730). Regarding correlation with patient-reported measures, only SASSAD demonstrated moderate correlation with Skindex-29 (ρ = 0·611, P = 0·035).

CONCLUSIONS

EASI demonstrated the highest inter-rater and intrarater reliability, supporting it as the optimal AD severity outcome measure.

Autoimmune blistering diseases in females: a review

The autoimmune blistering diseases (AIBDs) are a group of heterogeneous skin diseases with autoantibodies directed against structural proteins in the skin. A new interest in the female bias towards autoimmune diseases in general has led to our attention to focus on how and why this female bias manifests in AIBD. The authors aim to review and explore the various aspects of AIBD affecting females more than males, including the higher prevalence, worse quality of life, and complex management issues such as pregnancy and lactation.

What is already known on this topic?

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Echoing autoimmune diseases in general, most autoimmune blistering diseases (AIBDs) have a female predominance, but the exact level of predominance is unknown.

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Pregnancy raises several complicated management issues for females with an AIBD.

What does this article add to our knowledge?

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Review of sex-specific epidemiology and etiology of each AIBD.

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Exploration and explanation of the key factors underlying the detrimental impacts of AIBD on women’s quality of life (QOL).

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Discussion of management issues in pregnancy and lactation for females with an AIBD.

How does this information impact clinical practice and/or change patient care?

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An awareness and understanding of the female predominance in AIBDs will ensure more appropriate diagnosis, evaluation, and future research.

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Emphasizing holistic care targeting the debilitating effects of AIBDs on women’s QOL.

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Informing the reader of optimal, yet safe interventions for pregnant women with an AIBD.