Bullous pemphigoid: what is the prognosis?

Bullous Pemphigoid Complicated by Sepsis

Patients with bullous pemphigoid face many challenges when managing their disorder, one of which is balancing medication with their ailments. Because the patient population with bullous pemphigoid are primarily elderly, the current first-line treatment of corticosteroids tends to increase their rates of morbidity and mortality. During the acute process of the disease, providers must also consider the increased chance of infections caused by the opening in the skin. These patient cases are often complicated further by secondary symptoms such as pruritis and pain. Here we present a case in which we provided care to a 38-year-old female with a history of bullous pemphigoid and multiple medical problems who presented to the emergency department with nausea, vomiting, fevers, abdominal pain, and blisters on her forearm. Due to concern for sepsis and her past failure of outpatient therapy, the patient was hospitalized and treated for her possible infection, bullous pemphigoid, nausea, and pain.

Strategies to Improve Outcomes of Bullous Pemphigoid: A Comprehensive Review of Clinical Presentations, Diagnosis, and Patients' Assessment

Bullous pemphigoid (BP) is the most frequent autoimmune bullous disease mainly affecting elderlies. Diagnosis usually results from clinical features, histological examination, and the quantification of circulating typical autoantibodies, due to its higher incidence in elderly patients, bullous pemphigoid treatment and management still represents a challenge due to the higher frequency of several comorbidities in this group of patients, which may also be linked to a reduced tolerance to BP treatments. Hence, an early diagnosis and a prompt correct treatment are mandatory to reach better clinical outcomes and improve as much as possible BP outcomes. Herein, we carried out a comprehensive literature review about the known clinical presentations, diagnosis, assessment and monitoring procedures used in daily clinical practice in patients with BP, to better define strategies to improve as much as possible BP clinical outcomes.

Bipolar Patients and Bullous Pemphigoid after Risperidone Long-Acting Injectable: A Case Report and a Review of the Literature

Neuropsychiatric disorders are found to be associated with bullous pemphigoid (BP), an autoimmune subepidermal blistering disease. Antipsychotics have emerged as possible inducing factors of BP. However, large sample studies concerning BP associated with antipsychotics, as well as with specific mental disorders, are still lacking. Our review retrieved a few clinical studies and case reports on the topic, producing controversial results. We report for the first time a bipolar patient case presenting BP following five-month therapy with risperidone long-acting injectable (LAI). We hypothesize that the dermatological event is associated with the medication administered. The issue emerged during psychiatric consultation and was confirmed by histological examination, direct and indirect immunofluorescence studies, plus positive plasma and cutaneous BP180 and BP230 IgG. Neurodegeneration or neuroinflammation might represent a primary process leading to a cross-reactive immune response between neural and cutaneous antigens and contributing to self-tolerance failure. Furthermore, the time sequence of the shared biological mechanisms leading to clinical manifestations of the neuropsychiatric disorder and BP remains undefined. BP comorbid with bipolar disorder might occasionally represent a serious health risk and affect patients' physical and psychosocial quality of life. Thus, clinicians treating psychiatric patients should consider BP as a possible adverse effect of psychotropic medications.

Incidence of bullous pemphigoid and mortality of patients with bullous pemphigoid in Olmsted County, Minnesota, 1960 through 2009

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune blistering disease that is associated with increased mortality.

OBJECTIVE

We sought to determine the incidence and mortality of patients with BP.

METHODS

A total of 87 residents of Olmsted County, Minnesota, were identified who had their first lifetime diagnosis of BP from January 1960 through December 2009. Incidence and mortality were compared with age- and sex-matched control patients from the same geographic area.

RESULTS

The adjusted incidence of BP was 2.4 per 100,000 person-years (95% confidence interval, 1.9-2.9). Incidence of BP increased significantly with age (P < .001) and over time (P = .034). Trend tests indicate increased diagnosis of localized disease (P = .006) may be a contributing factor. Survival observed in the incident BP cohort was significantly poorer than expected (P < .001). Survival was not different among patients with multisite versus localized disease (P = .90).

LIMITATIONS

Retrospective study design and study population from a small geographic area are limitations.

CONCLUSION

Incidence of BP in the United States is comparable with that found in Europe and Asia. The mortality of BP is lower in the United States than Europe, but higher than previous estimates.

The use of i.v. IG therapy in dermatology

The intravenous administration of exogenous pooled human immunoglobulin (i.v. IG) was originally licensed as antibody replacement therapy in patients with primary immunodeficiencies and there are currently six FDA-approved uses for this agent. Despite a current lack of FDA approval, off-label treatment of a multitude of dermatologic disorders with i.v. IG has shown exciting potential for this unique treatment modality. The diseases successfully treated with i.v. IG include autoimmune bullous diseases, connective tissue diseases, vasculitides, toxic epidermal necrolysis, and infectious disorders (such as streptococcal toxic shock syndrome). Currently the biggest drawback in the consideration of i.v. IG therapy in dermatologic disorders is the lack of randomized controlled trials. Nevertheless, there is a significant body of evidence demonstrating the efficacy of i.v. IG in patients with dermatologic disorders that are resistant to treatment with standard agents. In summary, i.v. IG constitutes a valuable and potentially life-saving agent in managing patients with a variety of dermatologic disorders under the appropriate circumstances.

[Replacing systemic with topical corticotherapy in patients with generalized bullous pemphigoid and serious steroid-induced iatrogenesis]

We describe four patients with generalized bullous pemphigoid, who received treatment with oral prednisone and suffered serious corticosteroid-induced iatrogenesis. In all cases, we decided to quickly withdraw the systemic corticosteroid treatment and begin treatment with 0.05 % clobetasol propionate (20 g/day). New outbreaks of pemphigoid or significant side effects were not seen after this change in medication. The topical treatment went on for five to twelve months, and the patients were followed up for extended periods after treatment ended, with no recurrences being observed. Systemic corticosteroid treatment may be replaced by topical treatment without complications, and this may be especially indicated in patients with serious corticosteroid-induced iatrogenesis.

Comparison of cost of immune globulin intravenous therapy to conventional immunosuppressive therapy in treating patients with autoimmune mucocutaneous blistering diseases

Autoimmune mucocutaneous blistering diseases (AMBD) are a group of potentially fatal diseases that affect the skin and mucous membranes. AMBD have different target antigens as well as variable clinical presentation, course, and prognosis. The mainstay of conventional immunosuppressive therapy (CIST) for AMBD is long-term high-dose systemic corticosteroids and immunosuppressive agents. Such therapy has proven effective in many patients; however, in some patients, the disease continues to progress with significant sequelae such as blindness, loss of voice, anal, and vaginal stenosis which causes poor quality of life. Furthermore, the CIST may have some serious side effects including opportunistic infections which may cause death. Immune globulin intravenous (IGIV) therapy has been reportedly used in the management of patients with AMBD refractory to CIST. IGIV has shown to be more clinically beneficial than CIST by bringing about long-term clinical remission and less recurrence. The high cost of the IGIV is of concern to patients, physicians, and insurance companies. In this report, we compare the cost of IGIV to that of CIST in treating a cohort of 15 mucous membrane pemphigoid (MMP), 10 ocular cicatricial pemphigoid (OCP), 15 bullous pemphigoid (BP), and 32 pemphigus vulgaris (PV) patients. In each cohort of patients, CIST had significant side effects, many of which were hazardous and required prolonged and frequent hospitalizations. Some of these side effects were severe enough to require discontinuation of the treatment. We consider the total cost of CIST to be the actual cost of the drug, plus the cost of management of the side effects produced by CIST. In the same patient cohort, no significant side effects to IGIV were observed. None of the IGIV treated patients required physician visits, laboratory tests, or hospitalizations specifically related to IGIV therapy. Hence, the total cost of the IGIV therapy is the actual cost of the IGIV only. The mean total cost of treatment of IGIV therapy is statistically significantly less than that of CIST during the entire course of the disease and on an annual basis. In conclusion, IGIV therapy is a safe, clinically beneficial, and a cost effective alternative treatment in patients with AMBD, non-responsive to CIST.