British Association of Dermatologists’ guidelines for the management of pemphigus vulgaris 2017

Unbiased screening identifies regulators of cell-cell adhesion and treatment options in pemphigus

Cell-cell junctions, and specifically desmosomes, are crucial for robust intercellular adhesion. Desmosomal function is compromised in the autoimmune blistering skin disease pemphigus vulgaris. We combine whole-genome knockout screening and a promotor screen of the desmosomal gene desmoglein 3 in human keratinocytes to identify novel regulators of intercellular adhesion. Kruppel-like-factor 5 (KLF5) directly binds to the desmoglein 3 regulatory region and promotes adhesion. Reduced levels of KLF5 in patient tissue indicate a role in pemphigus vulgaris. Autoantibody fractions from patients impair intercellular adhesion and reduce KLF5 levels in in vitro and in vivo disease models. These effects were dependent on increased activity of histone deacetylase 3, leading to transcriptional repression of KLF5. Inhibiting histone deacetylase 3 increases KLF5 levels and protects against the deleterious effects of autoantibodies in murine and human pemphigus vulgaris models. Together, KLF5 and histone deacetylase 3 are regulators of desmoglein 3 gene expression and intercellular adhesion and represent potential therapeutic targets in pemphigus vulgaris.

Pemphigus and Pregnancy

Pemphigus in pregnancy is a special clinical scenario that has potential consequences on both maternal and fetal outcomes. Being an autoimmune disease with Th2 preponderance, pemphigus is expected to flare in pregnancy, especially in the first two trimesters. Fetal outcomes like stillbirth and neonatal pemphigus have been reported, the latter being a consequence of a transient transplacental transfer of autoantibodies. Management needs to be individualized keeping the risk/benefit ratios of therapies in mind while optimizing maternal and fetal health. It is crucial to have appropriate counseling regarding conception for women with pemphigus in the child-bearing period because the probability of adverse materno-fetal outcomes is higher if the disease is severe.

Updates on the Management of Autoimmune Bullous Diseases

Background

Autoimmune bullous diseases are associated with high morbidity and mortality. Traditionally, systemic corticosteroids and conventional immunosuppressive agents have been the mainstay of treatment, but their broad immunosuppressive effects and long-term complications have prompted the exploration of newer more targeted therapies.

Materials and Methods

This review explores the evolving landscape of therapeutic options for immunobullous diseases, with a particular focus on pemphigus, bullous pemphigoid (BP), and mucous membrane pemphigoid, by searching PubMed, clinicaltrials.gov, and Cochrane databases for published literature from 2014 to 2023.

Results/Discussion

We discuss emerging treatments for pemphigus such as B cell modulatory drugs, anti-inflammatory drugs, those inhibiting autoantibody half-life or blister-inducing activity, and stem cell therapy, while offering insights into the level of evidence, potential benefits, and limitations of each approach. The role of biologics and novel therapies like rituximab, omalizumab, and dupilumab in reshaping the management of BP is also discussed.

Conclusion

The article highlights the need for further research, clinical trials, and comparative studies to determine the most effective and safest treatment options for patients with immunobullous diseases.

Pemphigus oral lesions area index (POLAI): A new scoring scale for assessing oral pemphigus vulgaris

OBJECTIVES

Current scales for Pemphigus vulgaris (PV) do not adequately represent the clinical variability of oral lesions. This study aimed to develop an independent scale, the Pemphigus Oral Lesions Area Index (POLAI), for assessment of oral PV exclusively, and compare POLAI, Pemphigus Disease Area Index (PDAI), Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) and Oral Disease Severity Score (ODSS) regarding inter- and intra-observer reliability and validity.

MATERIALS AND METHODS

Retrospective cohort included 209 sets of digital-photographs. Additional clinical cohort included 32 PV patients. All visits were assessed by four clinicians using the PDAI, ABSIS, ODSS and POLAI, and were rated by three specialists using the Physician's Global Assessment (PGA).

RESULTS

The intraclass correlation coefficient showed the inter-observer reliability with 0.89 and 0.86 for PDAI, 0.87 for ABSIS, 0.93 for ODSS, 0.96 for POLAI, and 0.97 and 0.96 for PGA. Intra-observer agreements showed excellent reliability for all 4 scores. Highest correlation was observed between PGA and POLAI (correlation coefficients were 0.96). The mean time taken to complete each scale was within 1.5 min.

CONCLUSION

POLAI is valid for the assessment of oral PV with superior inter- and intra-observer reliability to PDAI, ABSIS and ODSS, and is feasible in clinic.

A Case of an Autoimmune Blistering Disease: Pemphigus Vulgaris

Pemphigus vulgaris is a rare autoimmune disorder characterized by the formation of intraepithelial blisters that clinically appear as erosions and flaccid bullae on the skin and mucus membranes. Herein, we report a case of pemphigus vulgaris in an elderly male. He was initially misdiagnosed by his primary care provider and given topical lidocaine and acetaminophen with hydrocodone, without improvement in symptoms. This delay in treatment caused a worsening of his condition. The patient presented to our dermatology office two months after his primary care visit and reported worsening blisters and pain. Clinically he presented with flaccid bullae, crusted erosions, and erythematous plaques on the chest, back, abdomen, arms, and legs, and a tender oral ulcer. Two punch biopsies were obtained and sent for direct immunofluorescence and routine histology. The biopsy results confirmed the diagnosis of pemphigus vulgaris. Our patient achieved clearance after four weeks of oral prednisone and maintained clearance after a slow prednisone taper and the addition of mycophenolate mofetil 1g twice daily. We aim to bring awareness of the clinical presentation and treatment regimen of pemphigus vulgaris to prevent misdiagnosis and delayed care.

Autoimmune blistering diseases treated with glucocorticoids: An international study of steroid-induced myopathy

BACKGROUND

Patients with autoimmune blistering diseases (AIBDs) are often exposed to chronic glucocorticoid (GC) treatment with many side effects. Glucocorticoid-induced myopathy (GIM) is a well-established side effect, which particularly affects the proximal muscles. The Glucocorticoid Toxicity Index (GTI) is a validated global assessment tool which quantifies GC toxicity over time.

OBJECTIVES

This study marks the first study which analyses GIM in patients with AIBDs. The objectives of this study were to utilize the GTI to investigate the nature and prevalence of GIM in AIBD patients and explore potential risk factors.

METHODS

This international cohort study was conducted in blistering disease clinics across Australia, China, Greece, Iran, Japan, the Philippines, Turkey and the United States of America between February 2019 and July 2023. The GTI tool was completed by a medical practitioner at each patient visit. Data related to glucocorticoid toxicity were entered into the Steritas GTI 2.0 to generate an aggregate improvement and cumulative worsening score at each visit.

RESULTS

The study included 139 patients. There were 132 episodes of myopathy, and 47.5% of patients developed muscle weakness at some point during the study period. Cumulative GC dose correlated positively with myopathy risk, while average dose and treatment duration were not significant. Older age, male gender and obesity more than doubled the likelihood of developing GIM.

CONCLUSIONS

GIM is a common side effect experienced by AIBD patients on GC treatment. Muscle weakness is less likely to occur if cumulative GC dose is less than 0.75 mg/kg/day. Studies of exercise programs to mitigate myopathy and newer alternative treatments to reduce cumulative GC dose should be considered.

Epidemiology of malignant tumors in patients with pemphigus: an analysis of trends from 1955 to 2021

BACKGROUND

The incidence of malignant tumors has increased in patients with non-paraneoplastic pemphigus, although there has been no systematic analysis of global epidemiology.

OBJECTIVE

To explore the epidemiology of various types of non-paraneoplastic pemphigus associated with malignant tumors.

METHODS

Five databases from establishment through October 20, 2023, were searched. STATA SE 17 was used for the data analysis. Subgroup, meta-regression, and sensitivity analyses were used to evaluate the heterogeneity of pooled studies.

RESULTS

A total of 6679 participants were included in our meta-analysis from 16 studies. The aggregated prevalence of tumors in patients diagnosed with pemphigus was 8%. The prevalence was 7% in patients with pemphigus vulgaris, 10% in those with pemphigus foliaceus, and 12% in individuals diagnosed with other types of pemphigus. The prevalence was 8% in Asia, 11% in Europe, and 8% in North America. From a country-specific perspective, patients with pemphigus from Israel, Greece, and Germany exhibited a higher prevalence of tumors at 11%. Furthermore, when categorized by the duration of the study period, the highest prevalence was observed in studies spanning 10 to 20 years, at 11%.

CONCLUSION

These findings demonstrate the incidence and prevalence of malignant tumors in patients with non-paraneoplastic pemphigus, which may achieve early detection and intervention, and then reduce mortality rates.

Diagnosis and Management of Bullous Disease

Bullous diseases are a group of dermatoses primarily characterized by the presence of vesicles (0.1-0.9 cm) or bullae (>1 cm). There are various categories of bullous disease: allergic, autoimmune, infectious, mechanical, and metabolic. These diseases affect individuals in all decades of life, but older adults, age 65 and older, are particularly susceptible to bullous diseases of all etiologies. The incidence of these disorders is expected to increase given the advancing age of the general population. In this comprehensive review, we will outline the common bullous diseases affecting older individuals and provide an approach to evaluation and management.

Dapsone-Induced Methemoglobinemia Presenting Concomitantly With COVID-19 Pneumonia and Pulmonary Embolism: A Case Report

Acquired methemoglobinemia is a treatable condition that is often clinically subtle and can be missed on routine clinical assessment. We present a 73-year-old male who was evaluated in the emergency department with worsening respiratory symptoms requiring oxygen. He tested COVID-19 positive and had new pulmonary emboli evident on his CT chest. The patient was on dapsone therapy as a treatment for bullous pemphigoid. The discrepancy between his oxygen levels on the pulse oximeter and blood gas was noted and was treated with 3% methylene blue for dapsone-induced methemoglobinemia. The patient received treatment for COVID-19 pneumonia and pulmonary emboli. Our case demonstrates that dapsone-induced methemoglobinemia can present concomitantly with other more common causes of acute hypoxic respiratory failure. It is noteworthy for physicians to maintain a high index of suspicion for oxygen level discrepancy in hypoxic patients and consider the possibility of acquired methemoglobinemia. Hence, earlier detection and treatment of the etiology of tissue hypoxia.

The complicated use of dupilumab in the treatment of atypical generalized pemphigus Erythematous: A report of two cases

Pemphigus is a rare autoimmune disease and has the potential to be fatal without treatment. Pemphigus erythematosus (PE) is a benign type of pemphigus foliaceus. Glucocorticoids and immunosuppressive agents are primary therapeutic modalities in pemphigus erythematosus, which may lead to considerable side effects. There is a growing need for new pemphigus therapies with fewer adverse effects. Dupilumab is a humanized monoclonal IgG4 antibody that inhibits the signaling of interleukin-4 (IL-4) and interleukin-13 (IL-13) and has been applied for atopic dermatitis and asthma. Recently, dupilumab was thought to be beneficial in aggressive refractory pemphigus vulgaris. We report two cases: a 39-year-old male and a 59-year-old woman diagnosed with PE with atypical clinical features. With dupilumab, patients' skin lesions significantly improved, and suitable maintenance glucocorticosteroid doses were reached. In conclusion, we reported the short-term effectiveness and safety of dupilumab in two cases of atypical generalized PE. As an adjunct, such a biologic agent is expected to be efficacious in pemphigus erythematosus.

Erythema multiforme-like lip presentation in pemphigus vulgaris patients: a multicenter case series

Pemphigus vulgaris (PV) is a chronic autoimmune mucocutaneous blistering disease. Autoantibodies are directed against desmogleins, leading to the formation of intraepithelial bullae. PV, as with other autoimmune mucocutaneous disorders of the oral cavity, presents diagnostic and therapeutic challenges. Approximately 50-70% of cases present first with oral lesions. The lesions commonly start as vesicles or bullae that rapidly rupture, leading to erosions and ulcerations. The palatal, gingival, buccal, and labial mucosa are the most commonly affected sites. Oral PV can mimic several other diseases that cause mucosal erosions and/or ulcerations, including erythema multiforme (EM). EM is an acute, immune-mediated, self-limited hypersensitivity condition primarily associated with herpes simplex infection. Oral lesions can be variable, but a very characteristic presentation with labial hemorrhagic erosions, ulcerations and crusting is commonly seen. In this case series, we present six cases of PV: one male patient and five female patients whose ages ranged from 34 to 65 years old. All patients presented with hemorrhage and crusting of the lips in addition to multiple intraoral erosions and ulcerations. Three patients presented with oral and skin lesions. All patients underwent biopsies, and a diagnosis of PV was confirmed. All patients were treated with steroids (topical and systemic) and variable steroid-sparing agents. This case series emphasizes that oral PV may be misdiagnosed as EM in a subgroup of patients who present with persistent lip hemorrhage and crusting. Therefore, a comprehensive history, clinical examination and incisional biopsies should be considered in such patients.

Combination therapy for management of pemphigus patients with unexpected therapeutic response to rituximab: A report of five cases

Key Clinical Message

The immunosuppressant agents should be considered earlier in the course of treatment with rituximab, possibly after the unfavorable response at first cycle of treatment, especially in male patients and those with high BMI.

Abstract

Rituximab (RTX) has recently been proposed as an alternative first-line therapy for pemphigus patients. However, there are some rare reports of worsening of pemphigus following RTX therapy in the literature. This study aimed to evaluate the efficacy and safety of using a combination treatment of mycophenolate mofetil or dapsone and methotrexate in case of nonresponse, exacerbation or development of allergic reactions following rituximab therapy in pemphigus patients. In this case series, archive files of pemphigus patient in a tertiary care hospital from 2016 to 2021 who were treated with rituximab were reviewed and those with failure in treatment process including nonresponsiveness, exacerbation or development of allergic reactions to rituximab were identified and assessed. The study includes five patients out of 1245 RTX-treated patients, who did not respond to RTX (one patient) or experienced an exacerbation of disease (two patients) or development of allergic reactions (two patients). Male patients with high BMI (BMI > 25) whose response to rituximab was not good at first cycle and happened to receive rituximab later in the course of disease, had highest number of relapses and benefited the most from this combination immunosuppressive treatment as an alternative for repeating rituximab cycles. The lower risk of relapse and a better chance of remission might indicate the efficacy of adjuvant immunosuppressant therapy in patients with no-response, exacerbation, or allergic reaction to rituximab. These therapeutic effects were better observed in patients who received lower doses of rituximab which could suggest that the immunosuppressant agents should be considered earlier in the course of the disease, possibly after the first failed trial of rituximab therapy.

Outcome of COVID-19 in patients with autoimmune bullous diseases

Background Data on outcomes of Coronavirus disease 2019 (COVID-19) infection in autoimmune bullous diseases (AIBDs) patients is scarce. Materials and methods This single-centre survey-based-observational study included patients registered in the AIBD clinic of the Postgraduate Institute of Medical Education and Research, Chandigarh, India. All registered patients were contacted over telephone between June and October 2021. A survey was conducted after obtaining informed consent. Results Among 1389 registered patients, 409 completed the survey. Two hundred and twenty-two (55.3%) patients were females and 187 (45.7%) were males. The mean age was 48.52 ± 14.98 years. Active disease was reported by 34% patients. The frequency of COVID-19 infection in responders was 12.2% (50/409), with a case-fatality ratio of 18% (9/50). Rituximab infusion after the onset of pandemic significantly increased the risk of COVID-19 infection. Active AIBD and concomitant comorbidities were significantly associated with COVID-19 related death. Limitation Relative risk of COVID-19 infection and complications among AIBD patients could not be estimated due to lack of control group. The incidence of COVID-19 in AIBD could not be determined due to lack of denominator (source population) data. Other limitations include telephonic nature of the survey and lack of COVID-19 strain identification. Conclusion Use of rituximab is associated with higher probability of COVID-19 infection, while advanced age, active disease and presence of comorbidities may increase the risk of COVID-19 mortality in AIBD patients.

The top 10 research priorities for the treatment of bullous pemphigoid, mucous membrane pemphigoid and pemphigus vulgaris in the UK: results of a James Lind Alliance Priority Setting Partnership

To identify priorities for future research into the treatment of bullous pemphigoid, mucous membrane pemphigoid and pemphigus vulgaris, we conducted a Priority Setting Partnership (PSP) using James Lind Alliance methodology. The top 10 priorities identified in this PSP represent the key questions that patients, carers and healthcare professionals have about the treatment of these diseases and which future research will hopefully address.

Taiwanese dermatological association (TDA) consensus for the management of pemphigus

Pemphigus is an uncommon but life-threatening autoimmune blistering disease characterized by the presence of antibodies against desmogleins. Without effective treatment, pemphigus can result in significant morbidity and mortality. Existing consensus statements on pemphigus management from international medical groups provide varying guidelines, especially on treatment. Thus, on January 4, 2020, a panel of seven dermatology experts from the Taiwanese Dermatological Association (TDA) and one rheumatology expert convened to develop a consensus for the management of pemphigus. These experts with extensive experience in pemphigus management were recommended by their respective teaching hospitals and primary care clinics in Taiwan and by the TDA. The meeting reviewed the available consensus statements from international dermatology groups, including the European Dermatology Forum (EDF), the European Academy of Dermatology and Venereology (EADV), and the International Bullous Diseases Consensus Group. Using these guidelines as a basis for discussion and consensus formulation, these experts formulated their consensus statement that provides practical, concise but comprehensive recommendations as to the diagnosis, treatment, and monitoring of pemphigus patients in Taiwan. This consensus serves as a clinical reference for physicians for the management of pemphigus in Taiwan or wherever it may be applicable.

Novel pain management therapies for patients with pemphigus

Pemphigus is a class of rare autoimmune diseases that causes incredibly painful blistering of the skin and significantly impacts patients' day-to-day lives and well-being. Many strides have been made in treating pemphigus; however, no comprehensive literature exists on how to treat the pain that accompanies the disease. It is important to remember that treating pemphigus involves a two-fold treatment plan assessing both the underlying autoimmune disease and the pain involved with the lesions. This literature review explores novel therapies that have been shown to be effective in treating pain in pemphigus.

CARs: a new approach for the treatment of autoimmune diseases

The development of chimeric antigen receptor (CAR)-based therapeutic interventions represented a breakthrough in cancer treatment. Following the success of the CAR-T-cell strategy, this novel therapeutic approach has been applied to other diseases, including autoimmune diseases. Using CAR-T cells to deplete pathological immune cells (i.e., B cells, autoreactive B or T cells, and accessory antigen-presenting cells (APCs)) has resulted in favorable outcomes in diseases characterized by excessive autoantibody levels or hyperactive lymphocyte cell numbers. The importance of immunosuppressive regulatory T cells (Tregs) in restoring immune tolerance has been well established, and CAR-Tregs have shown promising therapeutic potential in treating autoimmune diseases. Moreover, prior experience from the cancer field has provided sufficient paradigms for understanding how to optimize the structure and function of CARs to improve their function, persistence, stability and safety. In this review, we describe the potential application of CAR-T cells and CAR-Tregs in the treatment of autoimmune diseases, and we summarize the currently available strategies of gene editing and synthetic biological tools that have improved the practical application of CAR-based therapies.

Post-Pemphigus Acanthomata Presenting as an Isolated, Hyperkeratotic Plaque

Post-pemphigus acanthomas have been rarely discussed in the literature. A prior case series identified 47 cases of pemphigus vulgaris and 5 cases of pemphigus foliaceus, out of which 13 developed acanthomata as a part of the healing process. Additionally, a case report by Ohashi et al. reported similar recalcitrant lesions on the trunk of a patient with pemphigus foliaceus being treated with prednisolone, IVIG, plasma exchange, and cyclosporine. Some view post-pemphigus acanthomas as variants of hypertrophic pemphigus vulgaris, being difficult to diagnose when they present as only single lesions, with a clinical differential of an inflamed seborrheic keratosis or squamous cell carcinoma. Here, we present a case of a 52-year-old female with a history of pemphigus vulgaris and four months of only topical therapy (fluocinonide 0.05%) who presented with a painful, hyperkeratotic plaque on the right mid-back that was found to be a post-pemphigus acanthoma.

B-cell targeted therapy of pemphigus

Pemphigus is an autoimmune disease that causes blistering and erosion of the skin and mucous membranes because of autoantibodies against desmoglein, which plays an important role in adhesion between epidermal keratinocytes. Treatment of pemphigus has long been centered on corticosteroids, and the guidelines for management of pemphigus have recommended high-dose systemic corticosteroids as the first-line treatment. While guideline-based treatment has been shown to be beneficial in patients with pemphigus, it has also become clear that this treatment is accompanied by significant burden and risk. The challenge for future pemphigus treatment is to maximize efficacy while minimizing risk during the course of the disease. In this regard, treatment targeting B cells is expected to become increasingly important as autoreactive B cells in pemphigus patients are thought to play a major role in the production of autoantibodies, which form the basis of the pathogenesis. The recent expansion of insurance coverage to rituximab, a monoclonal antibody against CD20, for refractory pemphigus in the USA, Europe, and Japan has opened up a new era of pemphigus treatment by enabling treatment strategies with drugs targeting B cells in patients. Here, we discuss the current status and future prospects of pemphigus treatment, focusing on rituximab and Bruton's tyrosine kinase inhibitors, which are expected to become essential drugs for pemphigus treatment in the future.

Rituximab therapy for intractable pemphigus: A multicenter, open-label, single-arm, prospective study of 20 Japanese patients

This was a multicenter clinical trial of rituximab, a chimeric monoclonal IgG antibody directed against CD20, for the treatment of refractory pemphigus vulgaris and pemphigus foliaceus. In total, 20 patients were treated with two doses of rituximab (1000 mg; 2 weeks apart) on days 0 and 14. The primary end point was the proportion of patients who achieved complete or partial remission on day 168 following the first rituximab dose. Of the 20 enrolled patients, 11 (55%) and four (20%) achieved complete and partial remission, respectively; therefore, remission was achieved in a total of 15 patients (75.0% [95% confidence interval, 50.9%-91.3%]). It was demonstrated that the remission rate was greater than the prespecified threshold (5%). In addition, a significant improvement in clinical score (Pemphigus Disease Area Index) and decrease in serum anti-desmoglein antibody level were observed over time. Four serious adverse events (heart failure, pneumonia, radial fracture, and osteonecrosis) were recorded in two patients, of which only pneumonia was considered causally related with rituximab. The level of peripheral blood CD19-positive B lymphocytes was decreased on day 28 after rituximab treatment and remained low throughout the study period until day 168. Our results confirm the efficacy and safety of rituximab therapy for refractory pemphigus in Japanese patients.

Clinical severity scores as a guide for prediction of initial treatment responses in pemphigus and pemphigoid patients

Pemphigus and pemphigoid are autoimmune blistering diseases that affect mucosa and skin. Several clinical scoring systems, including the pemphigus disease area index (PDAI) and the bullous pemphigoid disease area index (BPDAI), have been validated for managing disease activity and severity. Current guidelines recommend that treatment response be evaluated with clinical scores and that additional second-line therapies be considered if initial treatment is insufficient for disease control. However, there have been few studies analyzing correlations between PDAI/BPDAI transitions and initial treatment effects. To investigate whether PDAI/BPDAI transitions during the treatment initiation phase correlate with initial treatment responses and whether such information can be used as a guide for necessary additional treatment, we retrospectively analyzed 67 pemphigus patients and 47 pemphigoid patients who received initial treatment at Keio University between 2012 and 2018. The clinical symptoms were evaluated weekly with PDAI/BPDAI. The patients were divided into two groups: in group A, disease was controlled only with oral corticosteroids and immunosuppressants (initial treatment), whereas in group B additional therapies were required due to insufficient responses. In pemphigus, the PDAI ratio of day 7/day 0 was significantly reduced in group A compared to group B (0.548 vs 0.761, P < 0.01) after initial treatment had started. In pemphigoid, the ratios of day 7/day 0 of BPDAI (erosion/blister) and BPDAI (urticaria/erythema) significantly decreased in group A compared to group B (0.565 vs 0.901 and 0.350 vs 0.760, respectively, P < 0.05). Receiver operating characteristic analyses on PDAI, BPDAI (erosion/blister) and BPDAI (urticaria/erythema) revealed that the cut-off values in the ratios of day 7/day 0 were 0.762, 0.675, and 0.568, respectively. Our results suggest that PDAI/BPDAI transitions during the initial phase of the treatments may be useful to predict the outcome of the treatment provided and the necessity of additional therapies to achieve disease control.

Association of gut microbiome and metabolites with onset and treatment response of patients with pemphigus vulgaris

Background

Gut dysbiosis and gut microbiome-derived metabolites have been implicated in both disease onset and treatment response, but this has been rarely demonstrated in pemphigus vulgaris (PV). Here, we aim to systematically characterize the gut microbiome to assess the specific microbial species and metabolites associated with PV.

Methods

We enrolled 60 PV patients and 19 matched healthy family members, and collected 100 fecal samples (60 treatment-naïve, 21 matched post-treatment, and 19 controls). Metagenomic shotgun sequencing and subsequent quality control/alignment/annotation were performed to assess the composition and microbial species, in order to establish the association between gut microbiome with PV onset and treatment response. In addition, we evaluated short-chain fatty acids (SCFAs) in PV patients through targeted metabolomics analysis.

Results

The diversity of the gut microbiome in PV patients deviates from the healthy family members but not between responder and non-responder, or before and after glucocorticoid treatment. However, the relative abundance of several microbial species, including the pathogenic bacteria (e.g., Escherichia coli) and some SCFA-producing probiotics (e.g., Eubacterium ventriosum), consistently differed between the two groups in each comparison. Escherichia coli was enriched in PV patients and significantly decreased after treatment in responders. In contrast, Eubacterium ventriosum was enriched in healthy family members and significantly increased particularly in responders after treatment. Consistently, several gut microbiome-derived SCFAs were enriched in healthy family members and significantly increased after treatment (e.g., butyric acid and valeric acid).

Conclusions

This study supports the association between the gut microbiome and PV onset, possibly through disrupting the balance of gut pathogenic bacteria and probiotics and influencing the level of gut microbiome-derived SCFAs. Furthermore, we revealed the potential relationship between specific microbial species and glucocorticoid treatment.

Identification of Six microRNAs as Potential Biomarkers for Pemphigus Vulgaris: From Diagnosis to Pathogenesis

BACKGROUND

Pemphigus vulgaris (PV) is a potentially fatal autoimmune bullous disease. The role of microRNA (miRNA, miR) in the diagnosis and pathogenesis of PV remains unknown. This study aims to provide potential miRNA biomarkers for PV diagnosis and therapy options.

METHODS

Serum samples were obtained from 22 PV patients, 15 mucous membrane pemphigoid (MMP) patients, and 10 normal controls (NC). Total RNA was extracted from the serum samples, and 12 selected miRNAs were detected by quantitative real-time polymerase chain reaction (qRT-PCR). Bioinformatic analyses including target gene prediction and enrichment analysis were performed.

RESULTS

Twelve miRNAs were increased in the serum of the PV group compared with the NC group, in which six miRNAs had good efficacy to diagnose PV from MMP with the area under the receiver operator characteristic curves of 0.970 to 0.988. A series test for the combination of miR-584-5p and miR-155-5p reached the sensitivity and specificity of 95.5% and 100%. Bioinformatic analysis revealed target gene enrichment in the cell adhesion pathways, immune-relating pathways, and P38 mitogen-activated protein kinases signaling pathway.

CONCLUSION

The study provides new insights and targets of miRNAs for the precise diagnosis and the exploration of pathogenesis for PV, which may serve as a reference for further research into autoimmune bullous diseases.

Oral Pemphigus Vulgaris Treatment with Corticosteroids and Azathioprine: A Long-Term Study in Shiraz, Iran

Background

Treating oral mucosal lesions of Pemphigus Vulgaris (PV) disease is usually challenging for clinicians. We studied the treatment outcomes of the oral PV patients referred to the Oral Medicine Department of Shiraz University of Medical Sciences from 2004 to 2018.

Methods

The medical records of 54 oral PV patients with histopathological confirmation who were treated by a single protocol were studied. The protocol consisted of initial treatment with 1 mg/kg/day of oral prednisolone for all patients. After 4-6 weeks, all patients were prescribed 40 mg of prednisolone. If lesion recovery was not observed or new lesions had developed, adjuvant therapy (maximum dose of 200 mg per day of Azathioprine (AZA)) was initiated anytime during the treatment. The oral prednisolone dosage was gradually tapered to 5 mg/alternate day in 9 months.

Results

47 patients were included in the study. 34.04% were male and 65.96% were female with a mean age of 41.83 ± 12.520. The mean follow-up period was 50.806 ± 44.417 months (over 4 years). The severity of oral involvement was mild in 21.27%, moderate in 36.17%, and severe in 42.6%. During treatment, all patients except one experienced complete remission. The mean time to achieve complete remission was 150.39 ± 224.075 days. Most of the patients experienced relapse due to self-discontinuation of treatment. 55% had complete remission and 43% were in partial remission at the last follow-up session. In 65.96% of patients, treatment-associated side effects were observed. The patients treated with prednisolone alone had significantly more side effects than those using AZA as an adjuvant (80% vs 50%, respectively; P=0.030). The mean duration of follow-ups was longer for patients with side effects (P < 0.01). Topical corticosteroids were used for all patients sometime during the treatment. No deaths were recorded.

Conclusion

Prescribing low-dose prednisolone and adding AZA in nonresponding cases has good clinical outcomes for the treatment of oral lesions of PV. Adjuvant therapy can avoid the increase in corticosteroid dosage and side effects. The treatment method described in this study can be a helpful guide for clinicians, especially when other immunosuppressive drugs are not available.

Refractory pemphigus vulgaris and high-intensity extracorporeal photopheresis: A case report

A 41-year-old man with oral pemphigus vulgaris (PV) presented to our clinic with a history of no response to numerous immunosuppressant agents and was referred for extracorporeal photopheresis (ECP) therapy. Although the patient underwent a high-intensity ECP regimen for five months, which included two different photopheresis systems, his oral dysesthesia continued to interfere with oral intake, leading to continued weight loss and other adverse events. The intervention was associated with changes in several immune cell subpopulations without modifying the anti-epidermal antibody titers, aligned with his poor clinical outcome. To the best of the authors' knowledge, this is the first report to examine immunophenotyping of a PV patient who was refractory to previous immunosuppression and recalcitrant to high-intensity ECP therapy.

Pemphigus during the COVID-19 Epidemic: Infection Risk, Vaccine Responses and Management Strategies

Pemphigus is a rare autoimmune blistering disease, involving potentially life-threatening conditions often requiring immunosuppression. Currently, the COVID-19 pandemic caused by severe acute respiratory disease coronavirus 2 (SARS-CoV-2) infection has become a global public emergency. Vaccines are the most effective defense against COVID-19 infection. However, in clinic, there are cases of new onset or flare of pemphigus following COVID-19 vaccination, where vaccines have manifested significantly desirable risk-benefit profiles for patients. Although Rituximab, as first-line therapy, may impair humoral immunity, pemphigus may not predispose to develop COVID-19 infection compared to a healthy population. Conversely, delay or interruption of immunosuppressants probably results in unfavorable clinical outcomes for disease progression. Overall, clinicians should encourage their patients to undergo the vaccination after a comprehensive assessment. The definite association between COVID-19 vaccination and pemphigus remains to be further elucidated. Herein, we provide an overview of the published studies to date on COVID-19 and pemphigus as well as the exploration of their complicated interplay. In addition, we discuss the management strategies for pemphigus patients in this special period, in an effort to more effectively establish a standard treatment paradigm for this particular patient group.

The Nitrogen Mustards

The nitrogen mustards are powerful cytotoxic and lymphoablative agents and have been used for more than 60 years. They are employed in the treatment of cancers, sarcomas, and hematologic malignancies. Cyclophosphamide, the most versatile of the nitrogen mustards, also has a place in stem cell transplantation and the therapy of autoimmune diseases. Adverse effects caused by the nitrogen mustards on the central nervous system, kidney, heart, bladder, and gonads remain important issues. Advances in analytical techniques have facilitated the investigation of the pharmacokinetics of the nitrogen mustards, especially the oxazaphosphorines, which are prodrugs requiring metabolic activation. Enzymes involved in the metabolism of cyclophosphamide and ifosfamide are very polymorphic, but a greater understanding of the pharmacogenomic influences on their activity has not yet translated into a personalized medicine approach. In addition to damaging DNA, the nitrogen mustards can act through other mechanisms, such as antiangiogenesis and immunomodulation. The immunomodulatory properties of cyclophosphamide are an area of current exploration. In particular, cyclophosphamide decreases the number and activity of regulatory T cells, and the interaction between cyclophosphamide and the intestinal microbiome is now recognized as an important factor. New derivatives of the nitrogen mustards continue to be assessed. Oxazaphosphorine analogs have been synthesized in attempts to both improve efficacy and reduce toxicity, with varying degrees of success. Combinations of the nitrogen mustards with monoclonal antibodies and small-molecule targeted agents are being evaluated. SIGNIFICANCE STATEMENT: The nitrogen mustards are important, well-established therapeutic agents that are used to treat a variety of diseases. Their role is continuing to evolve.

Pediatric Autoimmune Bullous Disease: A Literature Review and Update on Management

Pediatric autoimmune bullous disease is a rare group of blistering skin disorders in children that result from autoimmunity against intercellular and basement membrane antigens in the skin and mucous membranes. Most pediatric cases are treated with oral corticosteroids or longer-term immunosuppressants such as azathioprine or mycophenolate mofetil. Immunomodulating drugs such as rituximab are increasingly being considered as options for refractory disease.

A randomised clinical trial to assess the adjuvant potential of methotrexate to corticosteroids in mucosal or limited mucocutaneous pemphigus vulgaris

Glucocorticoids are the mainstay of treatment for pemphigus vulgaris (PV). However, the requirement of high doses for long durations often leads to serious adverse events. Methotrexate as an adjuvant has shown potential in retrospective studies but randomized trials are lacking. The objective of the study was to assess the adjuvant potential of methotrexate in mucosal/limited mucocutaneous PV. In this randomised prospective study, 44 patients with mucosal/limited mucocutaneous PV were randomised (1:1) to receive either prednisolone 1 mg/kg/day (later fixed at a maximum dose of 60 mg/day) alone or with methotrexate 0.3 mg/kg/week for 9-months study period. Prednisolone dose was tapered once there was an 80% reduction in Pemphigus Disease Activity Index. Outcome measures were total cumulative dose of prednisolone, the proportion of patients achieving disease control, time taken for disease control and remission on minimal treatment, and adverse effects. No significant difference in the total cumulative dose of prednisolone among the groups was observed (p = 0.68). Disease control was achieved in 95.5% and 86.4% of patients in the prednisolone alone group, and prednisolone and methotrexate group respectively (p = 0.61). No statistically significant difference was observed among the groups with respect to the proportion of patients achieving remission, time taken for disease control and remission, and the number of adverse events. Our study showed no additional benefit of methotrexate to prednisolone in the treatment of mucosal/limited mucocutaneous PV.

Trial registration: CTRI/2018/07/015002; Registered on 23/07/2018]; Trial Registered Retrospectively. http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=24964&EncHid=&modid=&compid=%27,%2724964det%27.

Assessment of anti-desmoglein antibodies levels and other laboratory indexes as objective comprehensive indicators of patients with pemphigus vulgaris of different severity: a single-center retrospective study

The aim of this study is to assess the utility of anti-desmoglein (Dsg) antibodies levels, hematological biomarkers levels, the albumin to globulin (A/G) ratio, blood lipids levels, and lymphocyte subpopulation percentages as objective laboratory indicators of disease severity of pemphigus vulgaris (PV). A retrospective study of 187 PV patients with 256 medical records between January 2013 and December 2020. PV patients were divided into three groups by disease severity according to the pemphigus disease area index (PDAI) score: mild (0-8), moderate (9-24), and severe (≥ 25). The levels of anti-Dsg antibodies, hematological biomarkers, A/G ratio, blood lipids, and the percentage of lymphocyte subpopulations were measured. We assessed the correlations of quantitative variables by Pearson correlation (r). Multivariable linear regression was used to identify the variables associated with the disease severity of PV (PDAI score). The results show that the levels of Dsg1 (r = 0.294, P < 0.001) and Dsg3 (r = 0.206, P = 0.011), monocyte count (r = 0.210, P = 0.001), neutrophil-to-lymphocyte ratio (NLR) (r = 0.123, P = 0.049), and platelet-to-lymphocyte ratio (PLR) (r = 0.170, P = 0.006) were positively correlated with the PDAI score. However, the A/G ratio (r = - 0.399, P < 0.001), and the levels of total serum cholesterol (r = - 0.140, P = 0.026) and HDL (r = - 0.143, P = 0.023) were negatively correlated with the PDAI score. Multiple linear regression showed that the factors associated with the PDAI score were higher level of anti-Dsg1 antibody (P = 0.001), a higher NLR (P = 0.005), and a lower A/G ratio (P < 0.001). The linear regression equation was Y_(PDAI) = 32.798 + 0.058X_(Dsg1) + 0.846 X_(NLR)-16.472 X_(A/G) (R² = 0.586). Therefore, high levels of anti-Dsg1 antibody and NLR combined with a low A/G ratio could explain the PDAI score. These findings might provide a more comprehensive and objective evaluation system for reflecting the disease severity of PV based on laboratory indicators.

A Retrospective Evaluation of the Steroid-Sparing Effect of Oral Modified Ciclosporin for Treatment of Canine Pemphigus Foliaceus

The efficacy of ciclosporin as an adjuvant immunosuppressant administered with glucocorticoids (GCs) for induction of canine PF remission is unknown. This study is a retrospective review of medical records from 2015 to 2020 to evaluate the therapeutic outcomes of 11 PF dogs treated with oral modified ciclosporin and GCs. Concurrent GCs were given with ciclosporin to all PF dogs. Nine dogs (9/11) achieved complete remission (CR); five dogs received ciclosporin at a mean dose of 6.2 mg/kg/day; and four dogs received a combination of ciclosporin and ketoconazole at a mean dose of 3 mg/kg/day, respectively. Two dogs (2/11) showed only 25% or poor response, with the development of new PF lesions during treatment. The mean duration of ciclosporin therapy for nine dogs to achieve CR was 65 days (median 57 days, range 24–119 days). Slow tapering of oral GCs while continuing ciclosporin at the same dose and frequency in nine dogs with CR led to recurrence of PF lesions in four dogs, whereas, in five dogs, oral glucocorticoids were discontinued without a PF flare. Oral modified ciclosporin combined with GCs achieved CR in 9 out of 11 PF dogs during the induction phase in this study.

Autoimmune Pemphigus: Latest Advances and Emerging Therapies

Pemphigus represents a group of rare and severe autoimmune intra-epidermal blistering diseases affecting the skin and mucous membranes. These painful and debilitating diseases are driven by the production of autoantibodies that are mainly directed against the desmosomal adhesion proteins, desmoglein 3 (Dsg3) and desmoglein 1 (Dsg1). The search to define underlying triggers for anti-Dsg-antibody production has revealed genetic, environmental, and possible vaccine-driven factors, but our knowledge of the processes underlying disease initiation and pathology remains incomplete. Recent studies point to an important role of T cells in supporting auto-antibody production; yet the involvement of the myeloid compartment remains unexplored. Clinical management of pemphigus is beginning to move away from broad-spectrum immunosuppression and towards B-cell-targeted therapies, which reduce many patients’ symptoms but can have significant side effects. Here, we review the latest developments in our understanding of the predisposing factors/conditions of pemphigus, the underlying pathogenic mechanisms, and new and emerging therapies to treat these devastating diseases.

Pemphigus Vulgaris Relapse During the Coronavirus Disease Pandemic

Pemphigus vulgaris (PV) is the most common type of pemphigus group of autoimmune skin diseases. The treatment of PV relapse is challenging especially during the coronavirus disease (COVID-19) pandemic. In this prospective study, we aimed to evaluate the treatment of patients with relapsing PV during the pandemic. Twelve patients with PV who experienced relapse from March 2020 to January 2022 were included. The patients were asked whether they experienced COVID-19 symptoms and the pemphigus disease area index (PDAI) was measured. PCR for COVID-19, chest computed tomography, routine investigations, and electrocardiography were performed for the admitted patients. The mean PDAI of the patients during relapse was 23.6 ± 14.8 (range, 5-60). Seven patients received azathioprine; one patient received mycophenolate mofetil; and six patients received 1000 mg of rituximab (RTX) twice at an interval of 14 days. None of the 12 patients had COVID-19-suggestive symptoms. Only 1 patient relapsed after receiving the COVID-19 vaccine. The six admitted patients who received RTX were negative for COVID-19 based on the PCR testing results. Out of the 12 patients, eight achieved complete remission, while four achieved partial remission. No major adverse effects were observed. In conclusion, the treatments with systemic steroids, immunosuppressive drugs, and rituximab were well tolerated by the patients with relapsing PV, provided that there was no contact with individuals with COVID-19. These treatments can then be provided to patients with PV during the pandemic with careful follow-up.

Gefitinib induced Pemphigus Vulgaris with PRIDE complex

Introduction: Pemphigus Vulgaris is a rare, noncommunicable, non-hereditary fatal autoimmune dermatological manifestation in which a painful blister initiates from the oral cavity. PRIDE complex stands for Papulopustules or paronychia, regulatory abnormality of hair and nails, itching, and dryness due to inhibition of EGFR. Both of these mucocutaneous manifestations are rare and are often caused by drugs. Case report: Our case reports 53-year-old patient presented with multiple crusted plaques, multiple hyperpigmented macules to patches, Solitary fluid-filled lesions on several parts of the body, and numerous erosions positive over buccal mucosa on initial follow up which was diagnosed as Pemphigus Vulgaris with PRIDE complex induced by Gefitinib. Management and outcome: The patient was treated with almost all possible treatment options, i.e., both steroids plus adjuvant therapy for pemphigus and antihistaminic, antibiotics, moisturizer, and lotions for PRIDE complex. The patient was initially admitted for infusion of the first dose of rituximab and later for management of flare-up condition and infusion of the second dose of rituximab infusion. Discussion: The complexity of the management of Pemphigus Vulgaris and PRIDE complex demands adequate monitoring of the patient's anti-cancerous therapy by clinical pharmacists, which can impact the clinical outcomes by providing pharmaceutical care and minimize the economic burden.

CAR Treg: A new approach in the treatment of autoimmune diseases

Regulatory T cells (Tregs) have the role of regulating self-tolerance, and suppressing immune responses. Defects in Treg function and number can lead to in loss of tolerance or autoimmune disease. To treat or control autoimmune diseases, one of the options is to develop immune tolerance for Tregs cell therapy, which includes promotion and activation. Recently, cell-based treatment as a promising approach to increase cells function and number has been developed. Cell therapy by chimeric T antigen receptor (CAR-T) cells has shown significant efficacy in the treatment of leukemia, which has led researchers to use CAR-T cells in other diseases like autoimmune diseases. Here, we describe the existing treatments for autoimmune diseases and the available treatments based on Treg, their benefits and restrictions for implementation in clinical trials. We also discussed potential solutions to overcome these limitations. It seems novel designs of CARs to be new hope for autoimmune diseases and expected to be a potential cure option in a wide array of disease in the future. Therefore, it is very important to address this issue and increase information about it.

Effect of NUDT15 polymorphisms on early hematological safety of low-dose azathioprine in Chinese patients with pemphigus vulgaris: A prospective cohort study

Azathioprine (AZA) is the preferred immunosuppressant for treating pemphigus vulgaris (PV), with discontinuation mainly attributed to hematological adverse events (AE). Reportedly, nucleoside diphosphate‐linked moiety X‐type motif 15 (NUDT15) polymorphisms have been strongly associated with thiopurine‐induced leukopenia. To investigate hematological AE of low‐dose AZA based on NUDT15 genotypes among patients with PV, a prospective cohort study was conducted in patients with PV, followed‐up for the first 8 weeks after AZA administration. All patients were divided into wild homozygous and heterozygous NUDT15 groups. Both groups initiated AZA at low dose (50 mg/day) and continued with different dose‐escalating approaches. Bone marrow suppression was considered the principal outcome. Overall, 62 patients with PV were enrolled (48 in the wild homozygous NUDT15 group vs. 14 in the heterozygous NUDT15 group). Except for median maintenance doses of AZA, no statistically significant differences were observed between the two groups in terms of age, sex, white blood cells, neutrophil count, platelet count, hemoglobin level, median final doses of corticosteroids (mg prednisone equivalent), pemphigus disease area index, and anti‐desmoglein 1/3 autoantibodies. In both groups, patients presented similar hematological AE and treatment responses after administration of different low‐dose AZA treatment strategies. Low‐dose AZA based on NUDT15 genotypes can reduce the risk of early hematological AE among patients with PV.

Intravenous Ig Regulates Anti-Desmoglein 3 IgG Production in B220- Antibody-Producing Cells in Mice with Pemphigus Vulgaris

Intravenous Ig (IVIG) is a treatment option for intractable cases of pemphigus vulgaris (PV), an autoimmune blistering disease caused by autoantibodies against desmoglein 3 (DSG3). To investigate the efficacy of IVIG on autoantibody secretion, we produced PV model mice by adoptive transfer of immunized Dsg3^-/- splenocytes to Rag2^-/- mice. We found that circulating anti-DSG3 IgG ELISA titer decreased in PV model mice after 5 days of treatment with IVIG compared with PBS-treated mice, whereas the F(ab')₂ fragment did not suppress the anti-DSG3 IgG titer. enzyme-linked immunospot assay revealed that IVIG treatment reduced the frequency of anti-DSG3 antibody-secreting cells in the spleen but not in lymph nodes and bone marrow. Moreover, this reduction was observed only in the splenic B220^- fraction but not in the B220⁺ fraction. Furthermore, IVIG decreased the serum levels of anti-DSG3 IgG, even after a significant reduction of its titer, owing to antibody-mediated CD20⁺ B cell depletion. In addition, IVIG suppressed anti-DSG3 IgG production in B220^-CD138⁺ plasma cells derived from PV model mice ex vivo. These results indicate that IVIG reduced autoantibody production in B220^- cells containing plasma cells in PV model mice, and this function may indicate one of the mechanisms of action of IVIG on PV.

Pemphigus-The Crux of Clinics, Research, and Treatment during the COVID-19 Pandemic

Pemphigus is a rare autoimmune disease characterised by the production of pathogenic autoantibodies in response to different desmosome proteins. The pathophysiological process leads to the development of blisters and erosions on mucosal and/or skin surfaces. The classical clinical variants of pemphigus are pemphigus vulgaris and pemphigus foliaceus. A diagnostic delay is very common in pemphigus, especially among patients with mucosal involvement. However, in recent years we have witnessed considerably fewer patients with extensive mucocutaneous manifestations, since patients with oral lesions are referred to dermatologists to start the treatment much sooner than they had been previously. Among non-classical variants of pemphigus, unusual cases with discrepancies between autoantibody profiles and clinics challenge the "desmoglein compensation theory". The identification of several other autoantigens that perform a role in the pathogenesis of different variants of pemphigus will progress immunodermatology towards an approach that will determine personalized pemphigus subtypes for each patient. Comorbidities among patients are primarily associated with the prolonged use of corticosteroids and other immunosuppressive agents. The SARS-CoV-2 pandemic raised concerns regarding the immunosuppressive effects of treatment and the risk of a more complicated COVID-19 infection, as well as on the ability to develop an adequate vaccine response.

A retrospective evaluation of the steroid sparing effects of oral mycophenolate mofetil (MMF) as an adjunct immunosuppressant for the treatment of canine pemphigus foliaceus

BACKGROUND

Oral mycophenolate mofetil (MMF) is currently considered a low-risk steroid-sparing therapeutic option the management of canine pemphigus foliaceus (PF).

OBJECTIVES

This retrospective study evaluates the therapeutic outcomes of dogs with PF treated with the combination of oral MMF and GC. Clinical outcomes and side effects are reported.

ANIMALS

Eleven dogs diagnosed with PF.

METHODS AND MATERIALS

Retrospective review of medical records from dogs presented with PF to the dermatology service of a veterinary teaching hospital 2015-2020.

RESULTS

Eleven dogs were identified which had received concurrent GCs and MMF. The MMF dose range was 19.8-45 mg/kg/day. Only two dogs (2/11) treated with a mean MMF dosage of 39 mg/kg/day along with oral prednisone or dexamethasone achieved complete remission (CR). Partial remission (PR) was achieved in 4/11 dogs who received either prednisone, prednisolone or dexamethasone along with MMF (mean dosage 26 mg/kg/day). Four dogs (4/11) showed poor response to MMF given at 28.5 mg/kg/day along with prednisone or dexamethasone. In one dog (1/11) MMF was discontinued due to severe GI upset; transient vomiting and diarrhea was observed in 4/11 dogs. The median duration of MMF therapy in conjunction with GC for all groups was 70.5 days. Tapering of oral GCs while continuing MMF administration at the same dosage and frequency led to recurrence of lesions in all PF patients.

CONCLUSION

Oral MMF combined with GC achieved CR in 2 out of 11 PF dogs included in this study. Further research of MMF efficacy in PF may need to be performed.

An Updated Review of Pemphigus Diseases

Clinicians may encounter a variety of skin conditions that present with vesiculobullous lesions in their everyday practice. Pemphigus vulgaris, pemphigus foliaceus, IgA pemphigus, and paraneoplastic pemphigus represent the spectrum of autoimmune bullous dermatoses of the pemphigus family. The pemphigus family of diseases is characterized by significant morbidity and mortality. Considering the risks associated with a delayed diagnosis or misdiagnosis and the potential for overlap in clinical features and treatment, evaluation for suspected pemphigus disease often requires thorough clinical assessment and laboratory testing. Diagnosis is focused on individual biopsies for histopathology and direct immunofluorescence. Additional laboratory methods used for diagnosis include indirect immunofluorescence and enzyme-linked immunosorbent assay. Recent advancements, including anti-CD20 therapy, have improved the efficacy and reduced the morbidity of pemphigus treatment. This contribution presents updates on the pathophysiology, clinical features, diagnostic work-up, and medical management of pemphigus. Improved strategies for diagnosis and clinical assessment are reviewed, and newer treatment options are discussed.

Treatment of pemphigus vulgaris and foliaceus with efgartigimod, a neonatal Fc receptor inhibitor: a phase II multicentre, open-label feasibility trial

BACKGROUND

Pemphigus vulgaris and pemphigus foliaceus are potentially life-threatening autoimmune disorders triggered by IgG autoantibodies against mucosal and epidermal desmogleins. There is an unmet need for fast-acting drugs that enable patients to achieve early sustained remission with reduced corticosteroid reliance.

OBJECTIVES

To investigate efgartigimod, an engineered Fc fragment that inhibits the activity of the neonatal Fc receptor, thereby reducing serum IgG levels, for treating pemphigus.

METHODS

Thirty-four patients with mild-to-moderate pemphigus vulgaris or foliaceus were enrolled in an open-label phase II adaptive trial. In sequential cohorts, efgartigimod was dosed at 10 or 25 mg kg^-1 intravenously with various dosing frequencies, as monotherapy or as add-on therapy to low-dose oral prednisone. Safety endpoints comprised the primary outcome. The study is registered at ClinicalTrials.gov (identifier NCT03334058).

RESULTS

Adverse events were mostly mild and were reported by 16 of 19 (84%) patients receiving efgartigimod 10 mg kg^-1 and 13 of 15 (87%) patients receiving 25 mg kg^-1 , with similar adverse event profiles between dose groups. A major decrease in serum total IgG and anti-desmoglein autoantibodies was observed and correlated with improved Pemphigus Disease Area Index scores. Efgartigimod, as monotherapy or combined with prednisone, demonstrated early disease control in 28 of 31 (90%) patients after a median of 17 days. Optimized, prolonged treatment with efgartigimod in combination with a median dose of prednisone 0·26 mg kg^-1 per day (range 0·06-0·48) led to complete clinical remission in 14 of 22 (64%) patients within 2-41 weeks.

CONCLUSIONS

Efgartigimod was well tolerated and exhibited an early effect on disease activity and outcome parameters, providing support for further evaluation as a therapy for pemphigus.

Direct immunofluorescence analysis of oral Tzanck smears for pemphigus vulgaris: A diagnostic test

BACKGROUND

Pemphigus vulgaris (PV) is a rare and potentially fatal autoimmune blistering disease. Direct immunofluorescence (DIF) and histopathological analysis are crucial methods for PV diagnosis, but oral tissue biopsy is difficult to perform because of the fragile characteristics of the oral mucosa. However, no well-designed diagnostic studies addressing the validity of DIF analysis of oral Tzanck smears for the diagnosis of PV exist. We aimed to design a diagnostic test based on DIF analysis combined with oral Tzanck smears and evaluate its diagnostic accuracy for PV.

METHODS

We enrolled 81 patients with oral erosive lesions, of whom 41 patients had PV and 40 were non-PV controls. Oral Tzanck smears were obtained from oral mucosal lesions and observed under a fluorescence microscope after fixing and fluorescence staining. The diagnostic efficacy indexes including sensitivity, specificity, predictive value, Youden index, diagnostic odds ratio, and likelihood ratio were calculated.

RESULTS

Of the 41 PV patients, 36 showed DIF-positive findings for oral Tzanck smears, and all 36 DIF-positive PV patients showed IgG and/or C3 deposition, with seven also showing IgA and/or IgM positivity. None of the non-PV controls showed DIF positivity. The sensitivity and specificity of DIF analysis with oral Tzanck smears were 87.80% and 100%, respectively. The area under the receiver operator characteristic curve (ROC) was 0.939, with the test demonstrating significantly high diagnostic efficacy.

CONCLUSION

DIF analysis of oral Tzanck smears is a minimally invasive and easy-to-operate technique that can assist the rapid and accurate diagnosis of PV in dental clinic.