Development of pemphigus herpetiformis in a patient with psoriasis receiving UV-light treatment

Rituximab-induced psoriasis in a patient with pemphigus vulgaris: A case report and literature review

Key Clinical Message

Rituximab which is established as a main treatment for pemphigus vulgaris can be a potential causative factor for development of psoriasis in some patients. It is preferred to avoid using rituximab in patients who had a history of psoriasis. Acquainting medical doctors about rituximab-related cutaneous complications will help them in detection and management.

Abstract

Rituximab is a human/murine monoclonal antibody targeting the CD20 antigen on B-lymphocytes surface. Although it is used as promising treatment for pemphigus, nowadays it is also a new therapy for other autoimmune diseases including systemic lupus erythematosus and rheumatoid arthritis, and others like non-Hodgkin's lymphoma. Although there is increasing evidence regarding the safety and effectiveness of rituximab in these diseases, many cutaneous adverse effects have been reported. Here, we describe a 48-years-old patient affected with pemphigus vulgaris who developed psoriatic lesions on her on scalp, trunk, and extremities, 4 months after the second course of rituximab.

Pemphigus: trigger and predisposing factors

Pemphigus is a life-threatening autoimmune blistering disease affecting skin and mucous membranes. Despite its etiopathogenesis remains largely unknown, several trigger and predisposing factors have been reported. Pemphigus is caused by autoantibodies that target desmoglein 1 and desmoglein 3, impacting desmosome function. However, circulating autoantibodies are often the consequence of a precipitating factor that occurs in predisposed individuals. This review aims to describe and discuss almost all trigger and predisposing factors reported as possible or probable cause of the disease. Among the reported trigger factors that may induce or exacerbate pemphigus, we have found of particular interest: drug intake (especially thiol- and phenol-containing compounds), vaccines, infections, as well as some reports about pregnancy, radiations, emotional stress, pesticides and physical trauma. Moreover, we discuss the possible role of food intake in pemphigus onset and particular attention is given to dietary factors containing thiol, phenol and tannin compounds. A trigger factor is "the straw that breaks the camel's back," and often acts together with predisposing factors. Here we discuss how pemphigus onset may be influenced by genetic susceptibility and comorbidities like thyroid diseases, malignancies and other autoimmune disorders. To identify other hitherto unknown trigger and predisposing factors, well designed prospective studies are needed. In this context, future research should explore their connection with the aim to advance our understanding of pemphigus pathogenesis.

A case of herpetiform pemphigus mimicking bullous pemphigoid after using secukinumab and successfully treated with sulfasalazine

Interleukin 17A (IL-17A) inhibitors, such as secukinumab, have been widely used as the mainstream treatment for chronic plaque psoriasis; however, cutaneous adverse events have been reported. Here, we report a 43-year-old Chinese man who developed herpetiform pemphigus (HP) during secukinumab treatment for his psoriasis. He presented with (1) clinical features of HP, which resembled bullous pemphigoid; histopathological features of intraepidermal blisters, eosinophilic/neutrophilic spongiosis, and liquefactive degeneration of the basal cell layer; (3) positive anti-desmoglein 1 antibody by enzyme-linked immunosorbent assay and cell surface IgG reactivity within the epidermis by indirect immunofluorescence assay; and (4) a satisfactory response to salicylazosulfapyridine (sulfasalazine). To the best of our knowledge, this is the first report of the development of HP after the use of secukinumab for psoriasis.

A Review of Acquired Autoimmune Blistering Diseases in Inherited Epidermolysis Bullosa: Implications for the Future of Gene Therapy

Gene therapy serves as a promising therapy in the pipeline for treatment of epidermolysis bullosa (EB). However, with great promise, the risk of autoimmunity must be considered. While EB is a group of inherited blistering disorders caused by mutations in various skin proteins, autoimmune blistering diseases (AIBD) have a similar clinical phenotype and are caused by autoantibodies targeting skin antigens. Often, AIBD and EB have the same protein targeted through antibody or mutation, respectively. Moreover, EB patients are also reported to carry anti-skin antibodies of questionable pathogenicity. It has been speculated that activation of autoimmunity is both a consequence and cause of further skin deterioration in EB due to a state of chronic inflammation. Herein, we review the factors that facilitate the initiation of autoimmune and inflammatory responses to help understand the pathogenesis and therapeutic implications of the overlap between EB and AIBD. These may also help explain whether corrections of highly immunogenic portions of protein through gene therapy confers a greater risk towards developing AIBD.

Skin Barrier and Autoimmunity-Mechanisms and Novel Therapeutic Approaches for Autoimmune Blistering Diseases of the Skin

One of the most important functions of the skin besides regulating internal body temperature includes formation of the barrier between the organism and the external environment, hence protecting against pathogen invasion, chemical and physical assaults and unregulated loss of water and solutes. Disruption of the protective barrier is observed clinically in blisters and erosions of the skin that form in autoimmune blistering diseases where the body produces autoantibodies against structural proteins of the epidermis or the epidermal-dermal junction. Although there is no cure for autoimmune skin blistering diseases, immune suppressive therapies currently available offer opportunities for disease management. In cases where no treatment is sought, these disorders can lead to life threatening complications and current research efforts have focused on developing therapies that target autoantibodies which contribute to disease symptoms. This review will outline the involvement of the skin barrier in main skin-specific autoimmune blistering diseases by describing the mechanisms underpinning skin autoimmunity and review current progress in development of novel therapeutic approaches targeting the underlying causes of autoimmune skin blistering diseases.

Pemphigus group: overview, epidemiology, mortality, and comorbidities

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

The coexistence of pemphigus and psoriasis: a systematic review and meta-analysis

There is little consensus regarding the association between pemphigus and psoriasis. The aim of the current study is to synthesize existing data on the prevalence of psoriasis in patients with pemphigus and on the association between the two conditions. We performed a systematic review and meta-analysis of observational studies in Medline, Embase, and Web of Science (1900-2018). Reference lists of included studies were also searched for eligible studies. Quality of evidence was assessed using Newcastle-Ottawa scale (NOS). A meta-analysis was performed using random-effects models to estimate pooled prevalence rates and odds ratios (ORs) with 95% confidence intervals (CI). Subgroup and sensitivity analyses were also conducted. Twelve eligible studies comprising 12,238 patients with pemphigus were included in the quantitative synthesis. The overall random-effects pooled prevalence of psoriasis among patients with pemphigus was 2.4% (95% CI, 1.0-4.4) across all studies. The overall pooled multivariate OR for psoriasis in patients with pemphigus was significantly increased and estimated at 3.5 (95% CI, 1.6-7.6). In conclusion, a significant association was found between pemphigus and psoriasis. Physicians managing patients with pemphigus may be aware of this comorbidity. Further studies are warranted to establish the precise mechanisms underlying this relationship.

Interaction of Psoriasis and Bullous Diseases

Patients with psoriasis are frequently complicated with autoimmune bullous diseases, especially, pemphigoid diseases. It has been known that one-third cases of anti-laminin gamma1 pemphigoid, formerly anti-p200 pemphigoid, are associated with psoriasis whereas bullous pemphigoid is the most frequently associated bullous disease in psoriasis cases regardless of the lack of detectable levels of the accompanying anti-laminin gamma1 autoantibodies. Despite several suggestions, however, the definitive reason of the striking association of psoriasis and these autoimmune bullous diseases remains elusive. In this review, we look over the epidemiological evidence of the association of psoriasis and autoimmune bullous diseases and the information of genetic susceptibilities of each disease, and discuss the possible mechanisms of their complication with reference to the recent understandings of each pathogenesis.

Association between climate, pollution and hospitalization for pemphigus in the USA

BACKGROUND

Little is known about the impact of ultraviolet exposure, climate factors and pollutants on pemphigus.

AIM

To determine whether these factors are associated with pemphigus exacerbation resulting in hospitalization.

METHODS

The analysis used data from the 2002-2012 National Inpatient Sample in the USA, including 68 476 920 children and adults, and measurements of relative humidity (%), ultraviolet (UV) index, outdoor air temperature and particulate matter of ≤ 2.5 or ≤ 10 μm (PM2.5 and PM10).

RESULTS

Higher rates of admission primarily for pemphigus occurred during the summer and autumn months (June-November), with the highest admission rates in July and October (both 19.7 per million). There was significant statewide variation of the prevalence of hospitalization for pemphigus, with apparent hotspots located in the southwest and northeast states. Hospitalization for a primary diagnosis of pemphigus vs. other diagnosis was associated with significantly lower humidity [mean (95% confidence interval): 64.8% (63.2-66.4%) vs. 66.4% (65.6-67.3%); analysis of variance, P < 0.01) and higher temperature [58.7 (57.1-60.2) vs. 56.3 (55.8-56.7)°F, P = 0.001], UV index [6.0 (5.7-6.2) vs. 5.7 (5.6-5.7), P = 0.02], PM2.5 [12.9 (12.0-13.7) vs. 11.8 (11.5-12.0) mg/m³ , P < 0.001] and PM10 [26.2 (24.5-27.9) vs. 23.1 (22.6-23.6) mg/m³ , P < 0.001]. All associations remained significant in multilevel regression models that controlled for age, sex and race/ethnicity, except for ultraviolet index, which was associated with pemphigus hospitalization only for Hispanic patients [odds ratio (95% CI) for quartile 4: 2.07 (1.02-4.21)].

CONCLUSION

Increasing temperature, UV exposure and small particle air pollution are associated with increased hospitalization for pemphigus. Patients with pemphigus may benefit from avoidance of these potential environmental triggers.

An Erythrodermic Variant of Pemphigus Foliaceus with Puzzling Histologic and Immunopathologic Features

Background:

Pemphigus foliaceus is an autoimmune blistering disorder that affects the skin owing to autoantibodies against desmoglein 1.

Methods:

We employed clinical, histologic, immunopathologic, and serum laboratory studies to investigate a case of an erythrodermic variant of pemphigus foliaceus in an elderly man following treatment with bisoprolol-hydrochlorothiazide.

Results:

Early histopathology revealed psoriasiform dermatitis, but later biopsies showed subcorneal and granular layer separation with neutrophilic infiltrate. Direct immunofluorescence showed intercellular deposits of immunoglobulin G throughout the epidermis, granular staining of C3 along the basement membrane zone, and fibrin and C3 deposition around the blood vessels. Indirect immunofluorescence on monkey esophagus showed a titer of greater than 1:1,280. Indirect immunofluorescence on rat bladder, antinuclear antibody, lupus panel, and kidney function panel were all negative.

Conclusion:

There are no reports in the literature of pemphigus foliaceus being induced by bisoprolol, but reports exist of propanolol resulting in drug-induced pemphigus foliaceus.

Non-classical forms of pemphigus: pemphigus herpetiformis, IgA pemphigus, paraneoplastic pemphigus and IgG/IgA pemphigus

The pemphigus group comprises the autoimmune intraepidermal blistering diseases classically divided into two major types: pemphigus vulgaris and pemphigus foliaceous. Pemphigus herpetiformis, IgA pemphigus, paraneoplastic pemphigus and IgG/IgA pemphigus are rarer forms that present some clinical, histological and immunopathological characteristics that are different from the classical types. These are reviewed in this article. Future research may help definitively to locate the position of these forms in the pemphigus group, especially with regard to pemphigus herpetiformis and the IgG/ IgA pemphigus.

The desmosomal protein desmoglein 1 aids recovery of epidermal differentiation after acute UV light exposure

Epidermal structure is damaged by exposure to UV light, but the molecular mechanisms governing structural repair are largely unknown. UVB (290-320 nm wavelengths) exposure before induction of differentiation reduced expression of differentiation-associated proteins, including desmoglein 1 (Dsg1), desmocollin 1 (Dsc1), and keratins 1 and 10 (K1/K10), in a dose-dependent manner in normal human epidermal keratinocytes (NHEKs). The UVB-induced reduction in both Dsg1 transcript and protein was associated with reduced binding of the p63 transcription factor to previously unreported enhancer regulatory regions of the Dsg1 gene. As Dsg1 promotes epidermal differentiation in addition to participating in cell-cell adhesion, the role of Dsg1 in aiding differentiation after UVB damage was tested. Compared with controls, depleting Dsg1 via short hairpin RNA resulted in further reduction of Dsc1 and K1/K10 expression in monolayer NHEK cultures and in abnormal epidermal architecture in organotypic skin models recovering from UVB exposure. Ectopic expression of Dsg1 in keratinocyte monolayers rescued the UVB-induced differentiation defect. Treatment of UVB-exposed monolayer or organotypic cultures with trichostatin A, a histone deacetylase inhibitor, partially restored differentiation marker expression, suggesting a potential therapeutic strategy for reversing UV-induced impairment of epidermal differentiation after acute sun exposure.

Molecular diagnosis in autoimmune skin blistering conditions

Blister formation in skin and mucous membranes results from a loss of cell-cell or cell-matrix adhesion and is a common outcome of pathological events in a variety of conditions, including autoimmune and genetic diseases, viral and bacterial infections, or injury by physical and chemical factors. Autoantibodies against structural components maintaining cell-cell and cell-matrix adhesion induce tissue damage in autoimmune blistering diseases. Detection of these autoantibodies either tissue-bound or circulating in serum is essential to diagnose the autoimmune nature of disease. Various immunofluorescence methods as well as molecular immunoassays, including enzyme-linked immunosorbent assay and immunoblotting, belong to the modern diagnostic algorithms for these disorders. There is still a considerable need to increase awareness of the rare autoimmune blistering diseases, which often show a severe, chronic-relapsing course, among physicians and the public. This review article describes the immunopathological features of autoimmune bullous diseases and the molecular immunoassays currently available for their diagnosis and monitoring.

Autoimmune bullous diseases associations

The presence of one autoimmune disorder helps lead to the discovery of other autoimmune conditions. It is thought that diseases in which autoimmunity is a feature tend to be associated together more often than one can ascribe to chance. A variety of diseases have been implicated in the onset of intraepidermal and subepidermal autoimmune diseases. The presence of one autoimmune disease should alert the physician to watch for a second immunologic disorder. A list of autoimmune bullous diseases associations includes autoimmune bullous diseases, pemphigus, pemphigoid, epidermolysis bullosa acquisita, dermatitis herpetiformis (Duhring), linear immunoglobulin A disease, and multiple autoimmune syndrome.

Pemphigus Foliaceus Associated with Psoriasis during the Course of Narrow-Band UVB Therapy: A Simple Coincidence?

Although psoriasis and bullous diseases are considered to be completely different disease entities, the literature has reported a few cases of psoriasis associated with bullous diseases, most of which are bullous pemphigoid. In limited cases, pemphigus foliaceus has also been reported in association with psoriasis. In most of them, pemphigus lesions usually developed on an untreated patient with a chronic history of psoriasis. Herein, we report a case of 53-year-old male with a chronic history of psoriasis who first developed generalized erosive lesions after 26 cycles of narrow-band ultraviolet B (NBUVB) therapy. A diagnosis of pemphigus foliaceus was made based on skin biopsy and direct immunofluorescence assay. Pemphigus lesions were well controlled with combination therapy of oral steroid and azathioprine. This is the first case where pemphigus foliaceus co-occurred with psoriasis during NBUVB therapy.

Pénfigo

Pemphigus is an infrequent, organ-specific, autoimmune bullous disease, which affects the skin, mucous membranes and appendages. Histopathologically, it is characterized by acantholysis. Pemphigus has classically been divided into two major groups, pemphigus vulgaris and pemphigus foliaceus, with their respective clinical variants pemphigus vegetans and pemphigus erythematosus. In recent years, new variants of pemphigus have been described: paraneoplastic pemphigus, IgA pemphigus and pemphigus herpetiformis. This article reviews the epidemiology, etiopathogenesis, clinical symptoms, diagnosis, treatment and prognosis of pemphigus. Advances in molecular biology techniques have made it possible to more precisely identify the different antigens against which antibodies are directed, and to fine-tune ELISA diagnostic techniques. Treating pemphigus vulgaris and foliaceus with general steroids has modified their prognosis; it is estimated that mortality in recent decades is less than 10 %. Managing the clinical complications that appear during the evolution of the pemphigus has contributed to reducing morbidity and mortality.