Ocular cicatricial pemphigoid associated with practolol therapy

Position Paper: Oral Features of Mucocutaneous Disorders

Part of periodontology involves the diagnosis and treatment of a variety of non-plaque-related diseases of the periodontium. The International Workshop for a Classification of Periodontal Diseases and Conditions noted that the periodontist may be called upon to manage non-plaque-related mucocutaneous disorders either alone, or as part of a treatment team consisting of physicians, dentists or other allied health care professionals. This informational paper will review the etiology, clinical manifestations, diagnosis, and treatment of the most common chronic mucocutaneous diseases, including those that may present as desquamative gingivitis or intraoral vesiculobullous lesions. This paper is intended for the use of periodontists and other members of the dental profession.

Cicatricial pemphigoid

Cicatricial pemphigoid (CP) is a heterogeneous group of rare, chronic, subepithelial blistering disorders of the mucous membranes and, occasionally, the skin, which can have serious and rarely fatal consequences. The most common clinical features are desquamative gingivitis, oral erosions, and conjunctival fibrosis. Skin lesions occur less frequently and may present as widespread vesicles and bullae, as in bullous pemphigoid (BP). In some patients, the scarring can be a source of significant morbidity because it can result in odynophagia, strictures of the upper aerodigestive tract, or corneal opacities leading to eventual blindness. This article is a comprehensive review and discusses clinical, pathologic, and pathophysiologic aspects of this group of disorders collectively known as CP. (J Am Acad Dermatol 2000;43:571-91.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the clinical spectrum of CP, the histopathologic and immunopathologic characteristics, the differential diagnosis, the treatment, and the natural history of the disease. Furthermore, this learning activity should facilitate early diagnosis of CP and should promote the idea that the involvement of other specialists, including ophthalmologists, otolaryngologists, gastroenterologists, and oral medicine specialists, as appropriate, will aid in providing these patients with the highest quality of care.

Drug-induced ocular cicatricial pemphigoid: a series of clinico-pathological reports

Ocular cicatricial pemphigoid is a slowly progressive disease of mucous membranes and skin of unknown but presumed autoimmune aetiology. We describe eight cases of presumed drug-induced cicatrising conjunctival changes simulating ocular cicatricial pemphigoid, following the chronic use of topical glaucoma medication. In three of four patients who underwent conjunctival biopsy of the inferior fornix, this revealed histopathological changes similar to ocular cicatricial pemphigoid.

Pemphigoid in children

Pemphigoid is an autoimmune blistering disease that is rare in childhood. A review of the English, German, and French literature published prior to 1989 revealed 31 cases of juvenile bullous pemphigoid and 12 of other forms (10 cases of juvenile cicatricial and 2 of juvenile localized bullous pemphigoid). Childhood pemphigoid, although less frequent, seems no different than its adult counterpart. While oral lesions are more common in the juvenile bullous form, there is no association with malignancy, which is a controversial and presumably incorrectly assumed association in the adult disease. The prognosis for children is good in most cases, and the disease is self-limiting. The mainstay of therapy has been oral corticosteroids, but dapsone also often produces a good response. A relatively new approach is to give a combination of erythromycin and niacinamide with dapsone for a steroid-sparing effect. In some patients the response to erythromycin plus niacinamide alone has been satisfactory; however, controlled therapeutic trials are lacking. It has been stated that high doses of steroids and immunosuppressive drugs are indicated for the cicatricial, as opposed to juvenile, bullous pemphigoid. From this review of the few cases of childhood cicatricial disease, it seems that the therapeutic approach might be the same for both forms.

Cicatricial pemphigoid in a 6-year-old child: report of a case and review of the literature

Cicatricial pemphigoid has been documented previously in only four patients under the age of 20 years. We report a 6-year-old male who had erosions of the oral and genital mucosa, conjunctivitis, hoarseness, dysphagia, recurrent vomiting, and weight loss. Upper airway obstruction due to a chronically inflamed and scarred epiglottis necessitated tracheostomy. Biopsy of tissue from a solitary cutaneous lesion demonstrated a subepidermal bulla. Direct and indirect immunofluorescence confirmed a diagnosis of cicatricial pemphigoid. Therapy was begun consisting of prednisone, 2 mg per kg per day, in combination with dapsone, 2 mg per kg per day. He did not improve until the prednisone dosage was increased to 4 mg per kg per day.

Drug-induced anogenital cicatricial pemphigoid

A case of cicatricial pemphigoid (CP) with a rare primary localization on the mucosal surfaces of the anus and the vulva and on perianal skin, associated with long-term therapy with clonidine, is described. Direct immunofluorescence investigation of lesional skin suggests possible complement mediated tissue injury in between basement membrane and epidermal basal cells. The possibility is discussed that drug induced metabolic disturbance (cyclic AMP-system) at a local level at the site of the basal cells might lead to the formation of immunogens and be one of the initiating factors in subepidermal bullous immune dermatoses. It is concluded that in cases of cicatricial pemphigoid the use of drugs must be considered as one of the aetiological possibilities.

Dermatitis as a side-effect of long-term topical treatment with certain beta-blocking agents

Three groups of glaucoma patients, treated topically with various beta-blocking agents, were studied for mucocutaneous side-effects of long-term therapy. In five of eleven patients with ocular and/or periocular dermatitis as an adverse reaction to long-term treatment with metoprolol eye drops a dermatitis, reproducible by patch tests with pure metoprolol 3%, was demonstrable. Histopathological examination of positive patch tests examined in three cases showed a picture compatible with a delayed type of hypersensitivity. Four atenolol treated patients showed adverse reactions, but negative patch tests to atenolol were found. In addition new data are reported in favour of cross-reactivity between certain beta-blocking agents.