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Iwata H, Vorobyev A, Koga H, Recke A, Zillikens D, Prost-Squarcioni C, Ishii N, Hashimoto T, Ludwig RJ. Meta-analysis of the clinical and immunopathological characteristics and treatment outcomes in epidermolysis bullosa acquisita patients. Orphanet J Rare Dis 2018; 13:153. [PMID: 30180870 PMCID: PMC6122731 DOI: 10.1186/s13023-018-0896-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/22/2018] [Indexed: 12/31/2022] Open
Abstract
Background Epidermolysis bullosa acquisita (EBA) is an orphan autoimmune disease. Several clinical phenotypes have been described, but subepidermal blistering is characteristic of all variants. Limited data on clinical and immunopathological characteristics and treatment outcomes in EBA are available. To fill this gap, we collected this information from EBA cases, meeting current diagnostic criteria, published between 1971 and 2016. Results We identified 1159 EBA cases. This number must be, however, interpreted with caution, as it is not possible to check for multiple reporting. The analysis of all cases indicated that EBA affects all age groups (median: 50 years, range: 1 to 94 years) at an equal gender distribution. Non-mechanobullous (non-MB) forms of EBA were observed in 55% of patients, whereas the mechanobullous variant (MB-EBA) or a combination of both variants was described in 38 or 7% of patients, respectively. Type VII collagen (COL7)-specific autoantibodies were primarily of the IgG isotype, but anti-COL7 IgA, IgM and IgE were also documented. Comparison of the 2 clinical EBA types showed a higher frequency of IgA deposits in non-MB EBA as opposed to MB EBA. Mucous membrane involvement was observed in 23% of patients, and 4.4% of cases were associated with other chronic inflammatory diseases. Of note, IgA deposits were more frequently observed in cases with mucous membrane involvement. Our analysis indicated that EBA is difficult to treat and that the choice of treatment varies widely. Chi square was applied to identify medications associated with complete remission (CR). Considering all EBA cases, intravenous immunoglobulin (IVIG, p = 0.0047) and rituximab (p = 0.0114) were associated with CR. Subgroup analysis demonstrated that no treatment was associated with CR for non-MB EBA, while IVIG (p = 0.003) was associated with CR in MB EBA. Conclusions Within the limitations of the study, we here document the clinical and immunopathological characteristics and treatment outcomes in a large cohort of EBA patients. The observed associations of single drugs with treatment outcome may serve as a guide to develop clinical trials. Electronic supplementary material The online version of this article (10.1186/s13023-018-0896-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hiroaki Iwata
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany.,Present address: Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Artem Vorobyev
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Hiroshi Koga
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany.,Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Kurume, Fukuoka, Japan
| | - Andreas Recke
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Catherine Prost-Squarcioni
- Referral center for auto-immune bullous diseases, Department of Dermatology, APHP, Avicenne Hospital, Bobigny, France
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Kurume, Fukuoka, Japan
| | - Takashi Hashimoto
- Department of Dermatology, Faculty of Medicine, Osaka City University, Osaka, Japan
| | - Ralf J Ludwig
- Department of Dermatology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany. .,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.
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Prost-Squarcioni C, Caux F, Schmidt E, Jonkman MF, Vassileva S, Kim SC, Iranzo P, Daneshpazhooh M, Terra J, Bauer J, Fairley J, Hall R, Hertl M, Lehman JS, Marinovic B, Patsatsi A, Zillikens D, Werth V, Woodley DT, Murrell DF. International Bullous Diseases Group: consensus on diagnostic criteria for epidermolysis bullosa acquisita. Br J Dermatol 2018; 179:30-41. [PMID: 29165796 DOI: 10.1111/bjd.16138] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Epidermolysis bullosa acquisita (EBA) is a complex autoimmune bullous disease disease with variable clinical presentations and multiple possible diagnostic tests, making an international consensus on the diagnosis of EBA essential. OBJECTIVES To obtain an international consensus on the clinical and diagnostic criteria for EBA. METHODS The International Bullous Diseases Group (IBDG) met three times to discuss the clinical and diagnostic criteria for EBA. For the final voting exercise, 22 experts from 14 different countries voted on 50 different items. When > 30% disagreed with a proposal, a discussion was held and re-voting carried out. RESULTS In total, 48 of 50 proposals achieved consensus after discussion. This included nine diagnostic criteria, which are summarized in a flow chart. The IBDG was unable to determine one procedure that would be applicable worldwide. A limitation of the study is that differential diagnosis of bullous systemic lupus erythematosus has not been addressed. CONCLUSIONS This first international consensus conference established generally agreed-upon clinical and laboratory criteria defining the clinical classification of and diagnostic testing for EBA. Holding these voting exercises in person with the possibility of discussion prior to voting has advantages in reaching consensus over Delphi exercises with remote voting.
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Affiliation(s)
- C Prost-Squarcioni
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, APHP, Avicenne Hospital, Bobigny, France.,Department of Histology, UFR Léonard de Vinci, University Paris 13, Bobigny, France.,Department of Pathology, APHP, Avicenne Hospital, Bobigny, France
| | - F Caux
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, APHP, Avicenne Hospital, Bobigny, France
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - M F Jonkman
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - S Vassileva
- Department of Dermatology, Medical University of Sofia, Sofia, Bulgaria
| | - S C Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - P Iranzo
- Department of Dermatology, Hospital Clinic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - M Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - J Terra
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - J Bauer
- Division of Molecular Dermatology, Department of Dermatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - J Fairley
- Department of Dermatology, University of Iowa and Department of Veterans Affairs Medical Center, Iowa City, IA, U.S.A
| | - R Hall
- Department of Dermatology, Duke Medical Center, Durham, NC, U.S.A
| | - M Hertl
- Department of Dermatology, University Hospital, Marburg, Germany
| | - J S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, MN, U.S.A
| | - B Marinovic
- Department of Dermatology and Venereology, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - A Patsatsi
- Second University Dermatology Department, Aristotle University School of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | | | - V Werth
- Department of Dermatology, University of Pennsylvania and Philadelphia Department of Veterans Affairs Medical Center, Philadelphia, PA, U.S.A
| | - D T Woodley
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, U.S.A
| | - D F Murrell
- Department of Dermatology at St George Hospital, University of New South Wales, Sydney, Australia
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Didona D, Di Zenzo G. Humoral Epitope Spreading in Autoimmune Bullous Diseases. Front Immunol 2018; 9:779. [PMID: 29719538 PMCID: PMC5913575 DOI: 10.3389/fimmu.2018.00779] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/28/2018] [Indexed: 12/15/2022] Open
Abstract
Autoimmune blistering diseases are characterized by autoantibodies against structural adhesion proteins of the skin and mucous membranes. Extensive characterization of their autoantibody targets has improved understanding of pathogenesis and laid the basis for the study of antigens/epitopes diversification, a process termed epitope spreading (ES). In this review, we have reported and discussed ES phenomena in autoimmune bullous diseases and underlined their functional role in disease pathogenesis. A functional ES has been proposed: (1) in bullous pemphigoid patients and correlates with the initial phase of the disease, (2) in pemphigus vulgaris patients with mucosal involvement during the clinical transition to a mucocutaneous form, (3) in endemic pemphigus foliaceus, underlining its role in disease pathogenesis, and (4) in numerous cases of disease transition associated with an intermolecular diversification of immune response. All these findings could give useful information to better understand autoimmune disease pathogenesis and to design antigen/epitope specific therapeutic approaches.
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Affiliation(s)
- Dario Didona
- Clinic for Dermatology and Allergology, University Hospital Marburg, University of Marburg, Marburg, Germany
| | - Giovanni Di Zenzo
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
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Yamase A, Kono T, Ishii N, Hashimoto T, Saeki H. An autoimmune bullous dermatosis with clinical, histopathological and immunological features of bullous pemphigoid and epidermolysis bullosa acquisita in an adult. Br J Dermatol 2016; 175:790-3. [PMID: 26989994 DOI: 10.1111/bjd.14553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A Yamase
- Department of Dermatology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - T Kono
- Department of Dermatology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - N Ishii
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Fukuoka, Japan
| | - T Hashimoto
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Fukuoka, Japan
| | - H Saeki
- Department of Dermatology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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Tan TS, Ng YZ, Badowski C, Dang T, Common JEA, Lacina L, Szeverényi I, Lane EB. Assays to Study Consequences of Cytoplasmic Intermediate Filament Mutations: The Case of Epidermal Keratins. Methods Enzymol 2016; 568:219-53. [PMID: 26795473 DOI: 10.1016/bs.mie.2015.09.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2022]
Abstract
The discovery of the causative link between keratin mutations and a growing number of human diseases opened the way for a better understanding of the function of the whole intermediate filament families of cytoskeleton proteins. This chapter describes analytical approaches to identification and interpretation of the consequences of keratin mutations, from the clinical and diagnostic level to cells in tissue culture. Intermediate filament pathologies can be accurately diagnosed from skin biopsies and DNA samples. The Human Intermediate Filament Database collates reported mutations in intermediate filament genes and their diseases, and can help clinicians to establish accurate diagnoses, leading to disease stratification for genetic counseling, optimal care delivery, and future mutation-aligned new therapies. Looking at the best-studied keratinopathy, epidermolysis bullosa simplex, the generation of cell lines mimicking keratinopathies is described, in which tagged mutant keratins facilitate live-cell imaging to make use of today's powerful enhanced light microscopy modalities. Cell stress assays such as cell spreading and cell migration in scratch wound assays can interrogate the consequences of the compromised cytoskeletal network. Application of extrinsic stresses, such as heat, osmotic, or mechanical stress, can enhance the differentiation of mutant keratin cells from wild-type cells. To bring the experiments to the next level, 3D organotypic human cultures can be generated, and even grafted onto the backs of immunodeficient mice for greater in vivo relevance. While development of these assays has focused on mutant K5/K14 cells, the approaches are often applicable to mutations in other intermediate filaments, reinforcing fundamental commonalities in spite of diverse clinical pathologies.
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Affiliation(s)
| | | | | | - Tram Dang
- Institute of Medical Biology, Singapore
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Motegi SI, Abe M, Tamura A, Ishii N, Hashimoto T, Ishikawa O. Childhood Bullous Pemphigoid Successfully Treated with Diaminodiphenyl Sulfone. J Dermatol 2014; 32:809-12. [PMID: 16361732 DOI: 10.1111/j.1346-8138.2005.tb00849.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2005] [Accepted: 05/02/2005] [Indexed: 11/29/2022]
Abstract
Bullous pemphigoid (BP) is an acquired autoimmune blistering disease which predominantly affects the elderly. It is rare in children and infants. We reported a 14-year-old girl presenting with a month history of relapsing tense bullae on the face and extremities. Histopathological examination of the lesional skin revealed a subepidermal bulla with infiltration of eosinophils, neutrophils, and lymphocytes. Direct immunofluorescence showed linear deposits of IgM and C3 at the basement membrane zone. Indirect immunofluorescence using normal human skin sections as a substrate detected IgG anti-basement membrane zone antibodies in the patient's serum and that using 1M NaCl split skin sections showed that the patient's antibodies bound to the epidermal side of the split skin. Immunoblot analysis using normal human epidermal extracts demonstrated the presence of autoantibodies against the 230-kDa BP antigen. Furthermore, the patient's serum reacted with the recombinant protein of the NC16a domain of the 180-kDa BP antigen by immunoblot analysis and enzyme-linked immunosorbent assay. Our patient showed significant improvement of the skin lesions with systemic administration of diaminodiphenyl sulfone.
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Affiliation(s)
- Sei-Ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Gunma, Japan
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Yang B, Wang C, Wu M, Du D, Yan X, Zhou G, Zhang F. A case of pemphigoid gestationis with concurrent IgG antibodies to BP180, BP230 and type VII collagen. Australas J Dermatol 2014; 55:e15-8. [PMID: 23082779 DOI: 10.1111/j.1440-0960.2012.00960.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Accepted: 08/25/2012] [Indexed: 12/23/2022]
Abstract
A 22-year-old primigravida had a pruritic, erythematous, bullous eruption on the skin during the 26th week of gestation. After delivery the eruption flared up. The diagnosis of pemphigoid gestationis was confirmed based on histopathological and immunofluorescence findings. The result of immunoblotting showed IgG autoantibodies which reacted against BP230 in epidermal extracts and 290 kDa type VII collagen in dermal extracts. The BP180 antibodies were also detected by an enzyme-linked immunosorbent assay BP180NC16a diagnosis kit. Pulsed corticosteroid and cyclophosphamide resulted in a favourable response at the acute stage. The patient was cured in 2 years. The analysis of the patient's autoantibodies provides strong evidence for the involvement of epitope spreading in her autoimmune disease.
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Affiliation(s)
- Baoqi Yang
- Shandong Provincial Institute of Dermatology and Venereology, Shandong Provincial Academy of Medical Science; Shandong Provincial Key Lab for Dermatovenereology
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Le Roux-Villet C, Prost-Squarcioni C. L’épidermolyse bulleuse acquise : revue de la littérature. Ann Dermatol Venereol 2011; 138:228-46. [DOI: 10.1016/j.annder.2011.01.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 01/13/2011] [Indexed: 01/06/2023]
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9
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Bullous pemphigoid in infancy: Clinical and epidemiologic characteristics. J Am Acad Dermatol 2008; 58:41-8. [DOI: 10.1016/j.jaad.2007.08.010] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2007] [Revised: 07/24/2007] [Accepted: 08/01/2007] [Indexed: 11/24/2022]
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Osawa M, Demitsu T, Toda S, Yokokura H, Umemoto N, Yamada T, Yoneda K, Kakurai M, Yoshida M, Hashimoto T. A Case of Mixed Bullous Disease of Epidermolysis bullosa acquisita and Linear IgA Bullous Dermatosis. Dermatology 2005; 211:146-8. [PMID: 16088162 DOI: 10.1159/000086445] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2004] [Accepted: 11/05/2004] [Indexed: 11/19/2022] Open
Abstract
A 75-year-old Japanese male visited us with bullous eruptions on the extremities. Physical examination revealed large bullae on the hands, lower legs and feet. The oral mucosa was also involved. Histology disclosed subepidermal blister with inflammatory cell infiltrates in the dermis. Direct immunofluorescence showed deposits of IgG and IgA at the cutaneous basement membrane zone. Indirect immunofluorescence on 1 M NaCl-split human skin sections demonstrated that the patient's IgG antibodies reacted with the dermal side of the split, while IgA antibodies reacted with the epidermal side. Immunoblotting showed that the patient's serum reacted with the NC1 domain of type VII collagen (290-kDa epidermolysis bullosa acquisita antigen) as well as the 120-kDa linear IgA bullous dermatosis antigen, LAD-1. Systemic prednisolone resulted in a favorable response. From the clinicopathological findings, the present case is not consistent with either epidermolysis bullosa acquisita or IgA bullous dermatosis. Therefore, we regarded the case as mixed bullous disease of epidermolysis bullosa acquisita and linear IgA bullous dermatosis. Such a case has not been previously reported.
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Affiliation(s)
- Masumi Osawa
- Department of Dermatology, Jichi Medical School, Omiya Medical Center, Saitama, Japan
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Fairley JA, Woodley DT, Chen M, Giudice GJ, Lin MS. A patient with both bullous pemphigoid and epidermolysis bullosa acquisita: an example of intermolecular epitope spreading. J Am Acad Dermatol 2004; 51:118-22. [PMID: 15243536 DOI: 10.1016/j.jaad.2003.12.033] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Bullous pemphigoid (BP) and epidermolysis bullosa acquisita are distinct autoimmune blistering disorders. BP is characterized by autoantibodies directed against the NC16A domain of collagen XVII, whereas patients with epidermolysis bullosa acquisita have autoantibodies against the NC1 domain of type VII collagen. We followed up a patient with BP for 9 years. During that time his clinical disease took on several features suggestive of epidermolysis bullosa acquisita. The objective of this study was to determine if the patient's autoantibody profile reflected the change in his clinical picture. Enzyme-linked immunosorbent assay and immunoblotting for detection and subclass determination of autoantibodies to type XVII and type VII collagen were performed on banked patient sera from the 9-year period. The patient's initial autoantibodies were exclusively IgG1 directed against collagen XVII. During the course of his illness, the subclass specificity of the patient's type XVII collagen autoantibodies shifted to the IgG4 subclass and during the same time interval the patient developed IgG2 autoantibodies directed against type VII collagen. This patient with BP exhibited both subclass shifting and development of a second autoantibody system that correlated with a change in the clinical appearance of the disease. The analysis of the patient's autoantibodies provides strong evidence for the involvement of epitope spreading in the evolution of his autoimmune disease.
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Affiliation(s)
- Janet A Fairley
- Department of Dermatology, Medical College of Wisconsin, Milwaukee 53226, USA.
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Brenner S, Mashiah J. Autoimmune blistering diseases in children: signposts in the process of evaluation. Clin Dermatol 2000; 18:711-24. [PMID: 11173206 DOI: 10.1016/s0738-081x(00)00154-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- S Brenner
- Department of Dermatology, Tel Aviv Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Israel
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