Targeting interleukin 4 receptor α: A new approach to the treatment of cutaneous autoimmune bullous diseases?

Case report: Bullous pemphigoid combined with Sjögren's syndrome complicated by central nervous system infection

Background

Bullous pemphigoid (BP) is the most common autoimmune blistering skin disease in humans, characterized by tense blisters, erosions, urticarial lesions, and itching on normal or erythematous skin. Many autoimmune diseases are considered comorbidities of BP, but clinical case reports of BP complicated by Sjögren's syndrome are very scarce. Furthermore, cases of central nervous system infection secondary to both autoimmune diseases are even rarer.

Case presentation

We report a 74-year-old woman diagnosed with bullous pemphigoid, who showed relief of active lesions after treatment with methylprednisolone and dupilumab injections. However, she was admitted for pulmonary infection during which she was diagnosed with Sjögren's syndrome (SS). Subsequently, the patient developed altered consciousness, indicating a central nervous system infection. Adjustment of steroid dosage and aggressive antimicrobial therapy led to alleviation of symptoms.

Conclusion

The coexistence of autoimmune subepidermal blistering diseases and SS is rare. The role of SS in the pathogenesis of skin lesions is unclear, and the relationship between these blistering diseases and SS remains elusive. Further research is needed to determine whether there are common pathological mechanisms between the two conditions.

Successful Treatment of Mucous Membrane Pemphigoid with Dupilumab: A Case Report

Abstract is missing (Short communication)

Study Design of a Phase 2/3 Randomized Controlled Trial of Dupilumab in Adults with Bullous Pemphigoid: LIBERTY-BP ADEPT

BACKGROUND

Bullous pemphigoid (BP) is a rare, autoimmune, blistering skin disease associated with high disease burden, profoundly decreased quality of life and increased morbidity. Emerging evidence supports an important role for type 2 inflammation in disease pathogenesis. Current management relies on topical and/or systemic corticosteroids, non-selective immunosuppressants and antibiotics with anti-inflammatory properties, which are all limited by side effects and toxicities. Therefore, targeted, efficacious and safe therapies are needed. Dupilumab blocks the shared receptor component for interleukin (IL)-4 and IL-13, key and central drivers of type 2 inflammation. Several reports of patients successfully treated with dupilumab have been published; however, dupilumab has not been formally assessed in a double-blind, placebo-controlled trial.

OBJECTIVES

We report the design of LIBERTY-BP ADEPT, a multicenter, randomized, double-blind, placebo-controlled clinical trial to evaluate the efficacy and safety of dupilumab in adults with BP.

METHODS

LIBERTY-BP ADEPT comprises a 35-day screening, 52-week treatment and 12-week follow-up period. Approximately 98 adults aged 18-90 years with moderate-to-severe BP are being enrolled at 51 sites on 4 continents and randomized 1:1 to subcutaneous dupilumab or placebo every 2 weeks. All participants will receive concomitant oral corticosteroids (OCS).

PLANNED OUTCOMES

The primary endpoint is the proportion of patients achieving complete remission off steroid therapy at week 36. Key secondary endpoints include total cumulative OCS dose to week 36, percent change and proportion of patients with ≥ 4-point reduction in the weekly average of daily Peak Pruritus Numerical Rating Scale from baseline to week 36 and percent change in Bullous Pemphigoid Area Index score from baseline to week 36.

CONCLUSION

The trial results will provide evidence on whether the efficacy and safety of dupilumab support its use as a potential novel treatment approach for BP and will provide new insights into the role of type 2 inflammation in BP pathogenesis.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04206553.

What is novel in the clinical management of pemphigus vulgaris?

INTRODUCTION

Pemphigus, an uncommon autoimmune blistering disorder affecting the skin and mucous membranes, currently with mortality primarily attributed to adverse reactions resulting from treatment protocols. Additionally, the existing treatments exhibit a notable recurrence rate. The high incidence of relapse and the considerable adverse effects associated with treatment underscore the imperative to explore safer and more effective therapeutic approaches. Numerous potential therapeutic targets have demonstrated promising outcomes in trials or preliminary research stages. These encompass anti-CD-20 agents, anti-CD-25 agents, TNF-α inhibition, FAS Ligand Inhibition, FcRn inhibition, BAFF inhibition, Bruton's tyrosine kinase (BTK) inhibition, CAAR T Cells, JAK inhibition, mTOR inhibition, abatacept, IL-4 inhibition, IL-17 inhibition, IL-6 inhibition, polyclonal Regulatory T Cells, and autologous hematopoietic stem cell transplantation.

AREAS COVERED

The most significant studies regarding the impact and efficacy of the mentioned treatments on pemphigus were meticulously curated through a comprehensive search conducted on the PubMed database. Moreover, the investigations of interest cited in these studies were also integrated.

EXPERT OPINION

The efficacy and safety profiles of the other treatments under discussion do not exhibit the same level of robustness as anti-CD20 therapy, which is anticipated to endure as a critical element in pemphigus treatment well into the foreseeable future.

Potential Indications of Dupilumab in Th-2 Inflammatory Disease

Dupilumab is a fully humanized IgG4 monoclonal antibody, inhibiting IL-4 and IL-13 signaling, which are the main cytokines involved in type 2 inflammatory diseases. Its introduction was a breakthrough in the treatment of moderate-to-severe atopic dermatitis, but it is also used in other inflammatory diseases, including asthma, eosinophilic esophagitis and chronic rhinosinusitis with nasal polyposis. Recent advances in the understanding of inflammatory pathways have revealed that Th2-type inflammation is involved in a wider range of diseases than previously thought. The aim of our review is to examine off-label therapeutic indications of dupilumab, including bullous dermatoses (pemphigus, bullous pemphigoid) and alopecia areata, and to investigate its potential applications in cancer patients on anti-PD1 therapy.

Study of cytokine-induced immunity in bullous pemphigoid: recent developments

Bullous pemphigoid (BP) is an organ-specific disease. Its pathogenesis has not been clearly studied yet; However, studies in recent years have shown that its pathogenesis is related to T helper cells. The pathogenesis of BP is mainly related to Th2 and Th17-related cytokines. IL-4, IL-5 and IL-13 cause eosinophil recruitment, promote antibody production, trigger pruritus and promote blister formation and other symptoms. IL-17 and IL-23 promote the production of matrix metalloproteinase-9 (MMP-9) by related cells, which causes dermo-epidermal junction (DEJ) separation to form bullae and blisters, and can persist in BP inflammation. The serum concentrations of IL-17 and IL-23 are related to the prognosis of BP. In this paper, we focus on the role of related cytokines in the pathogenesis of bullous pemphigoid and the relationship between the related cytokine populations secreted by three major T helper cells-helper T lymphocytes 1 (Th1), Th2, and Th17. A better understanding of the biological and immunological functions of cytokines associated with BP patients will provide opportunities for therapeutic targets in BP.

Concomitant use of dupilumab with glucocorticoid in bullous pemphigoid reduces disease severity: A preliminary study

OBJECTIVE

To retrospectively analyze the efficacy and safety of dupilumab in the treatment of bullous pemphigoid.

METHODS

From October 2020 to October 2022, the medical records of patients with bullous pemphigoid who were treated with dupilumab in our department were collected retrospectively to analyze the therapeutic effect and changes in laboratory indexes.

RESULTS

The records of a total of 11 patients with bullous pemphigoid who were treated with dupilumab was reviewed. Within 2 weeks of the treatment, 10 (90.9%) of the 11 patients had complete or substantial control of the disease. The BPDAI scores of the patients decreased from baseline 113 (62, 181) to 37 (6, 130) at 2 weeks (p = .001) and 4 (0, 37) at 12 weeks after treatment (p < .001). In the 11 patients treated with dupilumab, the relief time of pruritus was 0-3 days (0.5, 7) days, and the pruritus was significantly alleviated after 2 weeks (t = 15.925, p < .001). The DLQI score decreased from (25.5 ± 2.5) before treatment, to (11.8 ± 4.4) at 2 weeks (t = 10.764, p < .001) and (2.1 ± 1.9) at 12 weeks (t = 30.038, p < .001). The patients had high eosinophil counts, high serum IgE levels, low serum total protein levels, and abnormal blood coagulation function. The aforementioned indicators gradually returned to normal after treatment. No adverse reactions occurred during the treatment.

CONCLUSION

Dupilumab can effectively control the condition of bullous pemphigoid, efficiently relieve pruritus symptoms, and is relatively safe.

SARA suppresses myofibroblast precursor transdifferentiation in fibrogenesis in a mouse model of scleroderma

We previously reported that Smad anchor for receptor activation (SARA) plays a critical role in maintaining epithelial cell phenotype. Here, we show that SARA suppressed myofibroblast precursor transdifferentiation in a mouse model of scleroderma. Mice overexpressing SARA specifically in PDGFR-β+ pericytes and pan-leukocytes (SARATg) developed significantly less skin fibrosis in response to bleomycin injection compared with wild-type littermates (SARAWT). Single-cell RNA-Seq analysis of skin PDGFR-β+ cells implicated pericyte subsets assuming myofibroblast characteristics under fibrotic stimuli, and SARA overexpression blocked the transition. In addition, a cluster that expresses molecules associated with Th2 cells and macrophage activation was enriched in SARAWT mice, but not in SARATg mice, after bleomycin treatment. Th2-specific Il-31 expression was increased in skin of the bleomycin-treated SARAWT mice and patients with scleroderma (or systemic sclerosis, SSc). Receptor-ligand analyses indicated that lymphocytes mediated pericyte transdifferentiation in SARAWT mice, while with SARA overexpression the myofibroblast activity of pericytes was suppressed. Together, these data suggest a potentially novel crosstalk between myofibroblast precursors and immune cells in the pathogenesis of SSc, in which SARA plays a critical role.

Concurrent bullous pemphigoid and plaque psoriasis successfully treated with Janus kinase inhibitor Baricitinib

We report a case of aggressive bullous pemphigoid (BP) concurrent with plaque psoriasis successfully treated with Janus kinase inhibitor Baricitinib. The 83-year-old Chinese man suffered ten years of psoriasis and developed bullous pemphigoid with typical intense blisters and significantly elevated serum anti-BP180 autoantibodies. Due to concerns on his poor health conditions including stage III hypertension and potential serious side effects of standard treatment with systematic steroid, he was given Baricitinib orally 4mg/day. Significant improvement in skin lesions and pruritus was noted following treatment for 12falseweeks, from which the dose of Baricitinib was halved and continued for an additional 12falseweeks. He showed a complete remission of both bullous and psoriatic lesions without any adverse effects at the 24-week follow-up visit. Our observation suggests a potential of Baricitinib as a new alternative therapeutic option for concurrent plaque psoriasis and bullous pemphigoid or either of them. This article is protected by copyright. All rights reserved.

Dupilumab combined with low-dose systemic steroid therapy improves efficacy and safety for bullous pemphigoid

BACKGROUND

Routine systemic therapy for bullous pemphigoid (BP) has been challenged due to the inevitably adverse effects. According to the successful applications of dupilumab in BP cases reported, therefore, we investigate the real-life efficacy and safety of dupilumab combined with low-dose oral steroid for BP.

RESEARCH DESIGN AND METHODS

A cohort of BP patients who received either dupilumab plus low-dose methylprednisolone (dupilumab group) or merely methylprednisolone (control group) was retrospectively reviewed. The time to disease control was investigated. Additionally, the control dose and cumulative dosage of steroids, Bullous Pemphigoid Disease Area Index(BPDAI) scores, pruritus scores, and adverse events were assessed.

RESULTS

A total of 40 patients, with 20 in each group, were retrospectively studied. The time to disease control was shorter in the dupilumab group than the control group (14 days vs. 19 days, p=0.043). When the disease was controlled, the control dose and cumulative dosage of methylprednisolone in the dupilumab group were substantially lower than those of the control (24.6mg vs. 48.8mg, 376.8mg vs. 985.6mg, both p<0.01). Compared with the control, the percentage change from baseline in BPDAI scores and pruritus scores were both significantly reduced, and the adverse events were also less frequent in the dupilumab group.

CONCLUSIONS

The combination therapy of dupilumab plus low-dose methylprednisolone exhibits superior efficacy and safety in comparison with the current first-line systemic therapy for BP. This article is protected by copyright. All rights reserved.

Use of Dupilumab in Bullous Pemphigoid: Where Are We Now?

Bullous pemphigoid (BP) is the most frequent autoimmune subepidermal bullous disease. At present, the main treatment options are represented by corticosteroids and immunosuppressant drugs. Steroids often need to be administered in high doses, with subsequent adverse events and safety issues, as BP mainly affects elderly people. As dupilumab, a recombinant fully human IgG4 monoclonal antibody with binding specificity to human interleukin-4 receptor IL-4Rα has become paramount in the treatment of atopic dermatitis, its use in autoimmune bullous diseases has been theorized and it has been used to treat patients with BP. Dupilumab seems to be an effective and safe option to treat recalcitrant BP. Here, we report the results of a literature review on the use of dupilumab in BP, including a total of 30 treated patients in 9 papers.

A Review of the Immunologic Pathways Involved in Bullous Pemphigoid and Novel Therapeutic Targets

Bullous pemphigoid (BP) is a rare, chronic antibody-mediated autoimmune blistering disease primarily affecting the elderly, with an age of onset over 60. Current treatment options are limited and involve the use of corticosteroids and immunosuppressants, but their long-term use is associated with significant morbidity and mortality. In Japan, human intravenous immunoglobin is approved for the treatment of corticosteroid-refractory BP. However, no treatment option is approved by the Food and Drug Administration for the management of BP. Therefore, developing effective therapies free of debilitating side effects is imperative. In this review, we summarize the main immunologic pathways involved in the pathogenesis of BP, with an emphasis on the role of eosinophils, immunoglobulins, cytokines such as the interleukin (IL)-4 and IL-5, and complements. We further discuss the latest advances with novel therapeutic targets tested for the management of BP. Ongoing efforts are needed to run well-designed controlled trials and test the efficacy and safety of investigational drugs while providing much-needed access to these medications for refractory patients who will not otherwise be able to afford them as off-label prescriptions.

A Novel Combined Use of Dupilumab for Treatment of Aggressive Refractory Pemphigus Vulgaris Complicated With Pulmonary Tuberculosis: A Case Report and the RNA-seq Analysis

Background

Pemphigus vulgaris (PV) is a kind of IgG-mediated autoimmune blistering disease (AIBD) that is characterized by loss of keratinocyte adhesion in the epithelium of mucous membranes or skin. Recently, pemphigus vulgaris was thought to be associated with classical T helper 2 (T_H2)-type cytokines such as interleukin-4 (IL-4) and interleukin-17 (IL-17) signaling pathway. A humanized monoclonal IgG4 antibody called dupilumab binds to the alpha subunit of the interleukin-4 receptor (IL-4Rα) and inhibits the signaling of IL-4 and interleukin-13 (IL-13), which has been successfully applied for atopic dermatitis and asthma. Currently, the clinical trial evaluating dupilumab in bullous pemphigoid is ongoing.

Objective

To determine whether dupilumab may be of benefit in the aggressive refractory pemphigus vulgaris.

Methods

We report a 35-year old male with refractory pemphigus vulgaris and pulmonary tuberculosis who received treatment with dupilumab for 10 weeks. The mRNA expression of peripheral blood mononuclear cells (PBMCs) was analyzed by RNA sequencing (RNA-seq) which showed the gene expression changes after treatment.

Results

The skin lesions of the patient improved in response to the combined use of dupilumab, moderate dose of glucocorticosteroids, and intravenous immune globulin (IVIG). Downregulations of inflammatory response-related genes and IL-17 signaling pathway-related genes were observed in PBMCs.

Conclusion

We describe a patient with refractory pemphigus vulgaris and pulmonary tuberculosis who had the disease under control with combined use of dupilumab as an add-on treatment. Dupilumab may provide a beneficial effect in aggressive refractory pemphigus vulgaris.

A blistering new era for bullous pemphigoid: A scoping review of current therapies, ongoing clinical trials, and future directions

Bullous pemphigoid (BP) is a severe autoimmune blistering skin disorder that primarily causes disease in the older population and is the most prevalent subepidermal variant of the pemphigoid diseases. It manifests as exquisitely pruritic vesiculobullous eruptions and is associated with significant morbidity and mortality. Studies are reporting an increase in prevalence, and, among the elderly, BP is no longer considered to be as rare as previously thought. The pathogenesis involves autoantibodies directed against proteinaceous components of hemidesmosomes, with consequent autoimmune destruction of the dermal-epidermal junction. In recent times, more complex elements of the underlying inflammatory orchestra have been elucidated and are being used to develop targeted immunotherapies. The primary treatment modalities of BP include the use of topical and systemic corticosteroids, certain non-immunosuppressive agents (tetracyclines, nicotinamide, and sulfone), and immunosuppressants (methotrexate, azathioprine, cyclophosphamide, and Mycophenolate). However, in the long term, most of these agents are associated with substantial toxicities while recurrence rates remain high. Such egregious prospects led to significant efforts being directed towards developing newer targeted therapies which work by attenuating specific newly discovered pillars of the inflammatory pathway, and these efforts have garnered hope in providing safer alternatives. Our review focuses on presenting the various therapeutic options that are currently in trial since December 2019, as well as on summarizing presently established treatment guidelines to provide readers with the latest exciting updates.

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Bullous pemphigoid (BP) is a severe autoimmune blistering skin disorder that primarily causes disease in the older population and is the most prevalent subepidermal variant of the pemphigoid diseases.

•

In recent times, more complex elements of the underlying inflammatory orchestra have been elucidated and are being used to develop targeted immunotherapies.

•

The present review focuses on presenting the various therapeutic options that are currently in trial since December 2019, as well as on summarizing presently established treatment guidelines to provide readers with the latest exciting updates.

Recent developments in the pathogenesis of pruritus in bullous pemphigoid

Bullous pemphigoid (BP) is a common autoimmune bullous disease which mainly affects the elderly. The incidence of BP is gradually increasing and associated with high mortality. This disease is clinically characterized by intensely pruritic and widespread bullous lesions. Alternative therapy options for pruritus in patients with BP are limited primarily because pathophysiological mechanisms of itching in BP are still unclear. This review aims to explain crucial concepts of the pathogenesis of pruritus in BP. Vital findings in recent years will be summarized, and cofactors of the pathogenesis of pruritus will be discussed in detail. We will summarize knowledge on pathogenic factors in the immunologic level conducing to skin pruritus in BP.

The emerging role of dupilumab in dermatological indications

INTRODUCTION

Dupilumab represents a breakthrough in the management of atopic dermatitis (AD), thanks to its powerful T-helper (Th)2-mediated immunity modulating activity. It can reduce the atopic skin molecular signature and induce a significant decrease in the clinical signs and symptoms of AD patients.

AREAS COVERED

Th2 activation has been confirmed or suspected in skin diseases other than AD, and several reports about the treatment with dupilumab in these conditions have been published. In order to review the new indications of dupilumab in dermatology, we performed a search on PubMed, Embase, Cochrane Skin databases, and clinicaltrials.gov.

EXPERT OPINION

The analysis of available literature suggests that dupilumab may have a large application in dermatology, besides AD. Clinical trials are underway on some widespread disease (i.e. chronic urticaria, bullous pemphigoid, alopecia areata, or allergic contact dermatitis). The data are still partial, but they seem to indicate that dupilumab is efficacious and safe. On the other hand, the dupilumab use in some rare skin diseases remains only hypothetical or linked to few case reports. Dupilumab could have a prominent position in the therapeutic algorithm of chronic skin diseases that significantly affect the quality of life of patients, require long-term treatment, or lacking effective therapies.

Case Report: Combination of Omalizumab and Dupilumab for Recalcitrant Bullous Pemphigoid

Bullous pemphigoid (BP) is a blistering autoimmune skin disease. Omalizumab, a monoclonal antibody directed to IgE, showed a beneficial effect in treatment of recalcitrant BP in case series. More recently, dupilumab, an interleukin (IL)-4-receptor alpha antagonist, also showed promising preliminary results. We describe a patient with refractory BP who showed a complete response to a combination therapy with omalizumab and dupilumab.

Eosinophils in Bullous Pemphigoid

Bullous pemphigoid (BP) is an autoimmune blistering disorder with substantial morbidity and mortality. BP is regarded as a disorder driven by IgG due to BP180 and BP230 IgG autoantibodies, yet, new advances highlight the function of eosinophils and IgE autoantibodies in BP. Evidence supports that eosinophils are involved in BP pathogenesis, notably, these include the presence of IL-5, eotaxin, and eosinophil-colony stimulating factor in blister fluid, peripheral blood eosinophilia is present in nearly 50% of affected patients, eosinophils are found against the dermo-epidermal junction (DEJ) when BP serum is present, metalloprotease-9 is secreted by eosinophils at blister sites, blister fluid of BP patients contains eosinophil granule proteins which are located along the lamina lucida of the BMZ in patients with BP and correspond with disease clinically, eosinophil extracellular traps (EET) have been linked to DEJ splitting, IL-5 activated eosinophils cause DEJ separation when BP serum is present, and eosinophils are requisite to drive anti-BP180 IgE mediated blistering of the skin. Yet, the mechanism whereby eosinophils contribute to the pathogenesis of BP remains to be explored. In this review, we examine the role of eosinophils in BP while offering a basis to explain the pathomechanisms of eosinophils in BP.

Targeting interleukin 4 receptor α: A new approach to the treatment of cutaneous autoimmune bullous diseases?

Bullous pemphigoid, mucous membrane pemphigoid, and pemphigus vulgaris are different cutaneous autoimmune blistering diseases, with complex pathogenic mechanisms. In all of them, a type-2 response is thought to have a central role. Interleukin 4 and Interleukin 13 are crucial cytokines in type-2 response. Treatment of these conditions is often challenging. Dupilumab, a recombinant fully human IgG4 monoclonal antibody with binding specificity to human interleukin-4 receptor IL-4Rα, has the potential to inhibit both IL-4 and IL-13. We propose IL-4Rα as a theoretical drug target for cutaneous autoimmune bullous diseases.