Treatment of benign familial pemphigus (Hailey-Hailey) by skin grafting

Hailey-Hailey disease: clinical, diagnostic and therapeutic update

Hailey-Hailey disease is a rare genodermatosis described in 1939, with an autosomal dominant inheritance pattern, characterized by compromised adhesion between epidermal keratinocytes. It has an estimated prevalence of 1/50,000, with no gender or race predilection. It results from a heterozygous mutation in the ATP2C1 gene, which encodes the transmembrane protein hSPA1C, present in all tissues, with preferential expression in keratinocytes. Mutations in the ATP2C1 gene cause changes in the synthesis of junctional proteins, leading to acantholysis. It usually begins in adulthood, with isolated cases at the extremes of life. It manifests as vesico-bullous lesions mainly in the flexural areas, which develop into erosions and crusts. Chronic lesions may form vegetative or verrucous plaques. Pruritus, a burning feeling and pain are common. It evolves with periods of remission and exacerbation, generally triggered by humidity, friction, heat, trauma and secondary infections. The diagnosis is based on clinical and histopathological criteria: marked suprabasal acantholysis, loosely joined keratinocytes, giving the appearance of a "dilapidated brick wall", with a few dyskeratotic cells. The acantholysis affects the epidermis and spares the adnexal epithelia, which helps in the differential diagnosis with pemphigus vulgaris. Direct immunofluorescence is negative. The main differential diagnoses are Darier disease, pemphigus vegetans, intertrigo, contact dermatitis, and inverse psoriasis. There is no cure and the treatment is challenging, including measures to control heat, sweat and friction, topical medications (corticosteroids, calcineurin inhibitors, antibiotics), systemic medications (antibiotics, corticosteroids, immunosuppressants, retinoids and immunobiologicals) and procedures such as botulinum toxin, laser and surgery. There is a lack of controlled clinical trials to support the choice of the best treatment.

A Narrative Review on the Usage of Surgical Skin Grafting, Acitretin, and Tacrolimus in the Treatment of Hailey-Hailey Disease

Hailey-Hailey disease is a rare genetic disease that causes irregular blistering. The irregular blistering is also usually accompanied by skin lesions in the affected skin area. The symptoms and signs of Hailey-Hailey disease differ from one case to another. There is no one standard treatment method for Hailey-Hailey disease. However, there are certain treatment methods that do show some promise. This review will analyze the use and fruitfulness of surgical skin grafting, tacrolimus, and acitretin in multiple settings to treat Hailey-Hailey disease. Surgical skin grafting is done by removing the epidermis and a portion of the dermis, if not all of the dermis, healthy skin from a different part of the body, and transplanting it to the damaged area of the body. Acitretin is a retinoid that is a derivative of vitamin A that reduces abnormal differentiation of keratinocytes and inflammation which prove useful for helping skin diseases. Tacrolimus is an immunosuppressive drug that works by limiting the activity of the immune system to prevent it from producing substances that contribute to the redness and dryness of the skin, making it a candidate to be used for Hailey-Hailey disease treatment. The understood results of tacrolimus, acitretin, and surgical skin grafting on Hailey-Hailey disease are very limited and should be given more attention by healthcare leaders to the potential outcomes of these treatments on patients who have Hailey-Hailey disease.

Two Novel Variants and One Previously Reported Variant in the ATP2C1 Gene in Chinese Hailey-Hailey Disease Patients

Hailey-Hailey disease (HHD) is a rare autosomal dominant genodermatosis. It is characterized clinically by recurrent erosions, blisters and erythematous plaques at the sites of friction and intertriginous areas. The pathogenic gene of HHD was reported to be the ATPase calcium-transporting type 2C member 1 gene (ATP2C1). In this study, genomic DNA polymerase chain reaction (PCR) and direct sequencing of ATP2C1 were performed from 3 Chinese pedigrees and 4 sporadic cases of HHD. We detected 3 heterozygous mutations, including 2 novel mutations (c.1673_1674insGTTG and c.2225A>G) and 1 recurrent nonsense mutation (c.1402C>T; NM_014382.4). The ATP2C1 gene was also screened in the asymptomatic members of pedigrees. Our results would further expand the mutation spectrum of the ATP2C1 gene and be helpful in the genetic counseling of patients with HHD.

Management of familial benign chronic pemphigus

Benign familial chronic pemphigus or Hailey-Hailey disease is caused by an autosomal dominant mutation in the ATP2C1 gene leading to suprabasilar acantholysis. The disease most commonly affects intertriginous areas symmetrically. The chronic nature of the disease and multiple recurrences make the disease bothersome for patients and a treatment challenge for physicians. Treatments include topical and/or systemic agents and surgery including laser. This review summarizes the available treatment options.

Two patients with Hailey-Hailey disease, multiple primary melanomas, and other cancers

BACKGROUND

Hailey-Hailey Disease (HHD) is an autosomal dominant skin disorder that is characterized by erythematous and sometimes vesicular, weeping plaques of intertriginous regions. Squamous cell carcinoma and basal cell carcinoma arising in lesions of HHD have been described in the literature. To our knowledge, there are no reports of melanoma or noncutaneous malignant neoplasms associated with HHD.

OBSERVATIONS

We discuss the mechanisms of oncogenicity, including genetic, environmental, and iatrogenic factors, in 2 patients with HHD, multiple primary melanomas, and other cancers. Patient 1 had a mucoepidermoid carcinoma of the parotid gland. Patient 2 had a history of acute monoblastic leukemia and malignant peripheral nerve sheath tumor as well as radiologic evidence of an acoustic neurilemmoma.

CONCLUSIONS

The cause of the cancers in these 2 patients is likely multifactorial. We describe the patients to draw attention to the possible association between HHD and cancer. Additional research should be performed to determine whether patients with HHD have an increased incidence of cancer.

Squamous cell carcinoma arising in Hailey-Hailey disease

Hailey-Hailey disease is a recurrent, autosomal dominant vesiculobullous dermatotis with a predilection for intertrigenous areas. We report what we believe to be the first case of squamous cell carcinoma arising de novo in a skin lesion of Hailey-Hailey disease. The occurrence of malignant neoplasms arising in the skin lesions of Hailey-Hailey disease and other acantholytic dermatoses is reviewed.

Botulinum toxin type A for the treatment of axillary Hailey-Hailey disease

BACKGROUND

Hailey-Hailey disease is an inherited acantholytic disorder affecting the intertriginous areas of the body which is exacerbated by sweat, moisture, and friction. The disease is frequently resistant to conventional nonsurgical treatment.

OBJECTIVE

To evaluate whether chemodenervation of sweat glands would improve the course of the disease in a patient with Hailey-Hailey.

METHODS

We used low-dose treatment of the left axilla with botulinum toxin type A, the right axilla being used as a control, followed by treatment of both axillae with the optimal dose routinely used for the treatment of axillary hyperhidrosis.

RESULTS

After one treatment with a low dose of botulinum toxin type A, we observed partial improvement of the treated axilla. With subsequent treatment of both axillae with the recommended dose for axillary hyperhidrosis, we observed a sustained complete remission of the disease in the treated axillae.

CONCLUSION

Botulinum toxin type A may be an effective and safe nonsurgical alternative for the treatment of benign familial pemphigus in intertriginous areas such as the axillae.

Human papillomavirus types 16 and 39 in a vulval carcinoma occurring in a woman with Hailey-Hailey disease

A woman with Hailey-Hailey disease, suffering from carcinoma of the vulva, was examined by histology and for the presence of human papillomavirus (HPV) DNA by polymerase chain reaction (PCR) and in situ hybridization. Our diagnosis by histological examination revealed the vulval carcinoma to be a squamous cell carcinoma (SCC), adjacent to lesions of Hailey-Hailey disease and severe dysplasia/carcinoma in situ [vulval intraepithelial neoplasia (VIN) III]. The PCR with consensus primers for the L1 region (L1-PCR) successfully amplified HPV DNA using total DNA extracted from formalin-fixed and paraffin-embedded tissue specimens. Restriction fragment length polymorphism analysis and sequencing of L1-PCR products revealed HPV types 16 and 39. HPV 16-specific primers for the E6 region identified HPV 16 DNA. In situ hybridization analysis with biotinylated HPV 16 and 39 DNA probes revealed the presence of the HPV 39 genome in the nuclei of the tumour cells in the SCC. These results indicate that HPV 16 and 39 are associated with lesions in vulval carcinoma. Regarding the patient's susceptibility to infection in the case of Hailey-Hailey disease, there is a possibility that HPV was inoculated into the lesions of Hailey-Hailey disease and induced those of VIN III and SCC.

Squamous cell carcinoma arising in Hailey-Hailey disease

A case of squamous cell carcinoma (SCC) arising in a lesion of Hailey-Hailey disease at the penoscrotal junction is reported. The patient was treated with arsphenamine (Salvarsan 606) early in the disease. It is possible that this carcinogen, as well as friction and the local irritation of long-standing Hailey-Hailey skin lesions, may be the predisposing factors for the development of SCC in this case.

Surgical control of Hailey-Hailey disease

Hailey-Hailey disease is a benign, chronic genodermatosis manifested by recurrent lesions with a predilection for the intertriginous areas. The malodorous, weeping sores are a source of great discomfort to the patient. Medical therapy controls most lesions adequately; however, some are refractory. Experience with excision of skin involved with Hailey-Hailey disease is reported. The best results were obtained in those patients whose wounds were resurfaced with split skin grafts. Primary suture was associated with recurrent disease and residual morbidity. The findings of other isolated reports in the literature are also summarised. The results show that surgical control of Hailey-Hailey disease is indicated in recalcitrant cases.

Surgical management of Hailey-Hailey disease: report of a case

An intractable and disabling case of Hailey-Hailey disease largely in the groins is reported. Conservative treatment was ineffective, but surgical excision and grafting had good results.

Generalized Hailey-Hailey disease

A woman of 60 developed a generalized erythroderma. The case history revealed classical symptoms of Hailey-Hailey disease for 17 years. Light- and electron microscopic investigations confirmed the diagnosis of generalized Hailey-Hailey disease--an extremely rare condition. Two additional cases with widespread clinical manifestations are presented. These observations underline the fact that the whole epidermis is genetically disturbed and may react to various insults with suprabasal acantholysis.