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Sriram S, Hasan S, Mansoori S, Saeed S, Banerjee A, Ramalingam K. Juvenile pemphigus vulgaris: Literature review and a rare case report. Clin Case Rep 2024; 12:e8954. [PMID: 38756617 PMCID: PMC11096281 DOI: 10.1002/ccr3.8954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024] Open
Abstract
Pemphigus vulgaris (PV) is a chronic autoimmune blistering disorder characterized by the loss of intraepithelial adhesion affecting the skin and mucous membranes, predominantly affects females in their fifth and sixth decades of life. Due to its rare occurrence in children and adolescents, there is often a delay in diagnosis and treatment in this age group. PV should always be considered in the differential diagnosis of oral ulcerative and vesiculobullous lesions in both children and adolescents.
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Affiliation(s)
| | - Shamimul Hasan
- Department of Oral Medicine and RadiologyFaculty of Dentistry, Jamia Millia IslamiaNew DelhiIndia
| | - Shahnaz Mansoori
- Department of Oral Medicine and RadiologyFaculty of Dentistry, Jamia Millia IslamiaNew DelhiIndia
| | - Shazina Saeed
- Amity Institute of Public Health & Hospital AdministrationAmity UniversityNoidaUttar PradeshIndia
| | - Abhishek Banerjee
- Oral and Maxillofacial PathologyAwadh Dental College and HospitalJamshedpurJharkhandIndia
| | - Karthikeyan Ramalingam
- Department of Oral Pathology and Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical SciencesSaveetha UniversityChennaiIndia
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Santiago-Vázquez M, González-Molina VJ, Rodriguez-Ramos FM, Colón-Fontanez F, Carrasquillo OY. Successful Treatment of Recalcitrant Pediatric Pemphigus Vulgaris With Rituximab. Clin Pediatr (Phila) 2023; 62:541-547. [PMID: 36447375 PMCID: PMC10676037 DOI: 10.1177/00099228221140801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
| | | | | | | | - Osward Y. Carrasquillo
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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3
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Patel MH, Brumfiel CM, Bohrer N, Marsch AF. Efficacy of rituximab in pediatric pemphigus: A literature review. JAAD Int 2021; 6:6-10. [PMID: 34825231 PMCID: PMC8605268 DOI: 10.1016/j.jdin.2021.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Meera H Patel
- Creighton University School of Medicine Phoenix Regional Campus, Phoenix, Arizona
| | - Caitlin M Brumfiel
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Nicholas Bohrer
- Department of Dermatology, University of California, San Diego, California
| | - Amanda F Marsch
- Department of Dermatology, University of California, San Diego, California
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4
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Zamanian RT, Badesch D, Chung L, Domsic RT, Medsger T, Pinckney A, Keyes-Elstein L, D'Aveta C, Spychala M, White RJ, Hassoun PM, Torres F, Sweatt AJ, Molitor JA, Khanna D, Maecker H, Welch B, Goldmuntz E, Nicolls MR. Safety and Efficacy of B-Cell Depletion with Rituximab for the Treatment of Systemic Sclerosis-associated Pulmonary Arterial Hypertension: A Multicenter, Double-Blind, Randomized, Placebo-controlled Trial. Am J Respir Crit Care Med 2021; 204:209-221. [PMID: 33651671 PMCID: PMC8650794 DOI: 10.1164/rccm.202009-3481oc] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Rationale: Systemic sclerosis (SSc)-pulmonary arterial hypertension (PAH) is one of the most prevalent and deadly forms of PAH. B cells may contribute to SSc pathogenesis. Objectives: We investigated the safety and efficacy of B-cell depletion for SSc-PAH. Methods: In an NIH-sponsored, multicenter, double-blinded, randomized, placebo-controlled, proof-of-concept trial, 57 patients with SSc-PAH on stable-dose standard medical therapy received two infusions of 1,000 mg rituximab or placebo administered 2 weeks apart. The primary outcome measure was the change in 6-minute-walk distance (6MWD) at 24 weeks. Secondary endpoints included safety and invasive hemodynamics. We applied a machine learning approach to predict drug responsiveness. Measurements and Main Results: We randomized 57 subjects from 2010 to 2018. In the primary analysis, using data through Week 24, the adjusted mean change in 6MWD at 24 weeks favored the treatment arm but did not reach statistical significance (23.6 ± 11.1 m vs. 0.5 ± 9.7 m; P = 0.12). Although a negative study, when data through Week 48 were also considered, the estimated change in 6MWD at Week 24 was 25.5 ± 8.8 m for rituximab and 0.4 ± 7.4 m for placebo (P = 0.03). Rituximab treatment appeared to be safe and well tolerated. Low levels of RF (rheumatoid factor), IL-12, and IL-17 were sensitive and specific as favorable predictors of a rituximab response as measured by an improved 6MWD (receiver operating characteristic area under the curve, 0.88-0.95). Conclusions: B-cell depletion therapy is a potentially effective and safe adjuvant treatment for SSc-PAH. Future studies in these patients can confirm whether the identified biomarkers predict rituximab responsiveness. Clinical trial registered with www.clinicaltrails.gov (NCT01086540).
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Affiliation(s)
- Roham T Zamanian
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California
| | - David Badesch
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lorinda Chung
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Division of Rheumatology and Immunology, Stanford University, Stanford University School of Medicine, Stanford, California
| | - Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas Medsger
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Carla D'Aveta
- Rho Federal Systems Division, Durham, North Carolina
| | | | - R James White
- Division of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, New York
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, Texas
| | - Andrew J Sweatt
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California
| | - Jerry A Molitor
- Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, Minnesota
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
| | - Holden Maecker
- Division of Pulmonary, Allergy, and Critical Care Medicine and
| | - Beverly Welch
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland; and
| | - Ellen Goldmuntz
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland; and
| | - Mark R Nicolls
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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5
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Kianfar N, Dasdar S, Mahmoudi H, Tavakolpour S, Balighi K, Daneshpazhooh M. Rituximab in childhood and juvenile autoimmune bullous diseases as first-line and second-line treatment: a case series of 13 patients. J DERMATOL TREAT 2020; 33:869-874. [DOI: 10.1080/09546634.2020.1788702] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Nika Kianfar
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shayan Dasdar
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Mahmoudi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Soheil Tavakolpour
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Balighi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
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7
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Bilgic-Temel A, Özgen Z, Harman M, Kapıcıoğlu Y, Uzun S. Rituximab therapy in pediatric pemphigus patients: A retrospective analysis of five Turkish patients and review of the literature. Pediatr Dermatol 2019; 36:646-650. [PMID: 31355479 DOI: 10.1111/pde.13926] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND/OBJECTIVES There is inadequate knowledge regarding rituximab (RTX) administration in autoimmune bullous diseases (AIBDs), disease prevalence, clinical characteristics, and treatment outcomes within pediatric populations due to the rarity of AIBDs affecting the pediatric age group. The aim of this retrospective analysis was to evaluate the effectiveness, safety of RTX, and treatment outcomes in Turkish pediatric patients with pemphigus vulgaris (PV) and to review the literature. METHODS Five patients under 18 years of age and diagnosed with PV received RTX treatment and were identified in four dermatology departments of Turkey. RESULTS The mean age of the patients at the time of RTX therapy initiation was 15 years (range: 11-17 years), and the total duration of follow-up after RTX therapy was 42.6 months (range: 19-60 months). All patients showed a clinical response. At the last visit, complete remission off therapy was achieved in three patients. The remaining two patients achieved partial remission off therapy. No adverse events were observed. CONCLUSIONS This retrospective case series of five pediatric patients showed that RTX treatment can be effective and safe for the treatment of recalcitrant PV in pediatric patients. With increasing evidence, RTX is a good treatment choice in adults and pediatric patients with pemphigus.
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Affiliation(s)
- Aslı Bilgic-Temel
- Dermatology Clinic, Seydisehir State Hospital, Seydisehir, Konya, Turkey
| | - Züleyha Özgen
- Department of Dermatology and Venereology, Marmara University, Istanbul, Turkey
| | - Mehmet Harman
- Department of Dermatology and Venereology, Dicle University, Diyarbakır, Turkey
| | - Yelda Kapıcıoğlu
- Department of Dermatology and Venereology, Inönü University, Malatya, Turkey
| | - Soner Uzun
- Department of Dermatology and Venereology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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8
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Comparison between the efficacy of intralesional rituximab versus intralesional triamcinolone in the treatment refractory Pemphigus Vulgaris lesions: A randomized clinical trial. Int Immunopharmacol 2019; 73:94-97. [DOI: 10.1016/j.intimp.2019.04.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/14/2019] [Accepted: 04/15/2019] [Indexed: 12/13/2022]
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9
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Abstract
BACKGROUND Pemphigus diseases are a heterogeneous group of potentially life-threatening autoimmune bullous disorders. Therefore, rapidly acting and effective therapeutic approaches are essential. OBJECTIVES In this review, current therapeutic options in line with available guidelines are presented and new therapeutic approaches are discussed. METHODS A literature search was performed using PubMed. RESULTS Treatment of pemphigus is based on systemic glucocorticosteroids, frequently combined with potentially corticosteroid-sparing immunosuppressants such as azathioprine and mycophenolate mofetil/mycophenolic acid. Recently, the impressive efficacy of the anti-CD20 antibody rituximab has been shown in a prospective randomized trial. In severe or treatment-refractory cases, immunoadsorption or high-dose intravenous immunoglobulins (IVIG) are recommended. Adjuvant immunoadsorption also seems to be useful within the first 8-12 weeks of therapy in patients with very high autoantibody levels. A variety of new therapeutic approaches is currently evaluated in phase IIa studies. CONCLUSION Therapy of pemphigus has been greatly improved by the employment of rituximab. The use of glucocorticosteroids, associated with a high number of adverse events and elevated mortality, could be reduced by the additional use of rituximab. After approval of rituximab for the treatment of pemphigus by the US Food and Drug Administration in 2018, licensing in Europe is expected in 2019.
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Affiliation(s)
- N van Beek
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - D Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - E Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.,Lübecker Institut für Experimentelle Dermatologie (LIED), Universität zu Lübeck, Lübeck, Deutschland
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10
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Tavakolpour S, Mahmoudi H, Balighi K, Abedini R, Daneshpazhooh M. Sixteen-year history of rituximab therapy for 1085 pemphigus vulgaris patients: A systematic review. Int Immunopharmacol 2018; 54:131-138. [DOI: 10.1016/j.intimp.2017.11.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 10/12/2017] [Accepted: 11/05/2017] [Indexed: 12/16/2022]
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11
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Harman K, Brown D, Exton L, Groves R, Hampton P, Mohd Mustapa M, Setterfield J, Yesudian P, McHenry P, Gibbon K, Buckley D, Leslie T, Mallon E, Wakelin S, Ungureanu S, Hunasehally R, Cork M, Johnston G, Natkunarajah J, Worsnop F, Chiang N, Duarte Williamson C, Donnelly J, Saunders C, Brain A. British Association of Dermatologists’ guidelines for the management of pemphigus vulgaris 2017. Br J Dermatol 2017; 177:1170-1201. [DOI: 10.1111/bjd.15930] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2017] [Indexed: 12/11/2022]
Affiliation(s)
- K.E. Harman
- University Hospitals Leicester Leicester Royal Infirmary Infirmary Square Leicester LE1 5WW U.K
| | - D. Brown
- St John's Institute of Dermatology Guy's and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital Westminster Bridge Road London SE1 7EH U.K
| | - L.S. Exton
- British Association of Dermatologists Willan House, 4 Fitzroy Square London W1T 5HQ U.K
| | - R.W. Groves
- St. John's Institute of Dermatology King's College London Guy's Campus, Great Maze Pond London SE1 9RT U.K
| | - P.J. Hampton
- Royal Victoria Infirmary Queen Victoria Road Newcastle upon Tyne Tyne and Wear NE1 4LP U.K
| | - M.F. Mohd Mustapa
- British Association of Dermatologists Willan House, 4 Fitzroy Square London W1T 5HQ U.K
| | - J.F. Setterfield
- St. John's Institute of Dermatology King's College London Guy's Campus, Great Maze Pond London SE1 9RT U.K
- Mucosal & Salivary Biology Division King's College London Dental Institute Guy's Campus, Great Maze Pond London SE1 9RT U.K
| | - P.D. Yesudian
- Wrexham Maelor Hospital Croesnewydd Road Wrexham LL13 7TD U.K
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12
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Abstract
INTRODUCTION Pemphigus vulgaris (PV) is a chronic, autoimmune, vesiculobullous disease. As a result of the relative rarity of PV, published randomized controlled trials (RCTs) are limited, which makes it difficult to evaluate the efficacy of different treatment regimens in this disease. This also precludes conduct of a meta-analysis. METHODS English-language publications describing treatment outcomes of patients with PV were identified by searches of electronic databases through May 2015, and additionally by review of the bibliography of these publications. A total of 89 papers, which included 21 case reports, 47 case series, 8 RCTs, and 13 observational studies, were identified. The findings from these publications, including information on disease course and prognosis, medications used, treatment responses, and side effects, are summarized in the tables and text of this review. RESULTS Prior to availability of corticosteroid therapy, PV had a high fatality rate. Early publications from the 1970s reported high-dose, prolonged corticosteroid use and significant associated side effects. Later reports described use of corticosteroids along with steroid-sparing adjuvants, which allows a reduction in the total dose of corticosteroids and a reduction in observed mortality and morbidity. For the majority of patients in these reports, a long-term course on medications lasting about 5-10 years was observed; however, subgroups of patients requiring shorter courses or needing longer-term therapy have also been described. Early diagnosis of PV and early initiation of treatment were prognostic factors. In recent publications, commonly used initial regimens include corticosteroids in combination with mycophenolate or azathioprine; whereas, for patients with inadequate response to these regimens, adjuvants such as intravenous immunoglobulin (IVIg) or rituximab are used. CONCLUSION The review findings emphasize the importance of early diagnosis, early initiation of treatment, and use of steroid-sparing adjuvants to allow a reduced total dose and duration on corticosteroids. Also highlighted is the need for more RCTs.
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Kanwar AJ, Vinay K, Sawatkar GU, Dogra S, Minz RW, Shear NH, Koga H, Ishii N, Hashimoto T. Clinical and immunological outcomes of high- and low-dose rituximab treatments in patients with pemphigus: a randomized, comparative, observer-blinded study. Br J Dermatol 2016; 170:1341-9. [PMID: 24640990 DOI: 10.1111/bjd.12972] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Rituximab is a promising therapy in pemphigus. However, there is no consensus on optimum dose. OBJECTIVES To compare the efficacy, in terms of clinical and immunological outcomes in patients with pemphigus, of a high (2 × 1000 mg) vs. a low dose (2 × 500 mg) of rituximab. METHODS This was a randomized, observer-blinded trial wherein 22 patients with pemphigus were randomized into two treatment groups. Patients received either two doses (day 0 and day 15) of 1000 mg rituximab or 500 mg rituximab, and were followed up for 48 weeks. Clinical activity was assessed by a blinded investigator. Indices of enzyme-linked immunosorbent assays (ELISAs) for desmoglein (Dsg)1 and Dsg3, and CD19 cell count were examined at regular intervals. RESULTS There was no statistically significant difference in early and late clinical end points, and total cumulative dose of corticosteroids between the two groups. At week 40, the fall in Ikeda severity score was significantly more in the 2 × 1000 mg group than in 2 × 500 mg group (P = 0·049). Patients in the 2 × 500 mg group received a significantly higher cumulative dose of azathioprine (P = 0·018). The ELISA indices of Dsg1 and Dsg3 showed a statistically significant decline in the 2 × 1000 mg group only. B cell repopulation occurred earlier in the 2 × 500 mg group by 8 weeks. CONCLUSIONS A few clinical and immunological study parameters have suggested improved outcomes in patients receiving high-dose (2 × 1000 mg) rituximab.
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Affiliation(s)
- A J Kanwar
- Department of Dermatology, Venereology and Leprology
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14
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Abstract
Pediatric pemphigus vulgaris (PV) is a rare autoimmune bullous dermatosis that poses a diagnostic and therapeutic challenge. Rituximab, an anti-CD20 monoclonal antibody, is an important medication in adult PV but has rarely been used to treat pediatric disease. We describe successful rituximab therapy in a 4-year-old, the youngest patient with PV ever reported to receive rituximab. A live attenuated vaccination was later given without incident. We also review rituximab clinical outcomes, toxicity, dosing protocols, and relapse in children with PV.
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Affiliation(s)
- Leah Kincaid
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Section of Dermatology, Division of Pediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Miriam Weinstein
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Section of Dermatology, Division of Pediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
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Bellodi-Schmidt F, Shah KN. Beyond Psoriasis: Novel Uses for Biologic Response Modifiers in Pediatric Dermatology. Pediatr Dermatol 2016; 33:18-27. [PMID: 26607958 DOI: 10.1111/pde.12707] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Dermatologists have witnessed the increasing availability of novel biologic response modifiers for the treatment of inflammatory and autoimmune diseases in recent years. The most common dermatologic indication for the use of biologic response modifiers in adults is psoriasis, but the U.S. Food and Drug Administration has not approved any of these agents for use in any dermatologic disease in children with the exception of omalizumab, and as such, use in this population is considered off-label. In this review, we focus on the use of these agents in children to treat inflammatory skin diseases other than psoriasis, including atopic dermatitis, hidradenitis suppurativa, pemphigus vulgaris, bullous pemphigoid, and toxic epidermal necrolysis, with an emphasis on the use of etanercept, infliximab, rituximab, omalizumab, and ustekinumab. By highlighting novel uses of these agents, particularly for the treatment of dermatologic conditions for which optimal therapies are yet to be established, we hope to raise awareness of the potential use of this class of medications to treat inflammatory skin diseases in children.
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Affiliation(s)
- Fernanda Bellodi-Schmidt
- Division of Dermatology, Cincinnati Children's Hospital, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Kara N Shah
- Division of Dermatology, Cincinnati Children's Hospital, Cincinnati, Ohio.,Department of Dermatology, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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16
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Kong YL, Lim YL, Chandran NS. Retrospective Study on Autoimmune Blistering Disease in Paediatric Patients. Pediatr Dermatol 2015; 32:845-52. [PMID: 26391853 DOI: 10.1111/pde.12684] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Autoimmune blistering diseases (AIBDs) are rare in children and their prevalence in Singapore is unclear. We aimed to investigate the clinical and immunopathologic characteristics of children diagnosed with AIBDs in Singapore. MATERIALS AND METHODS The clinical and histology databases at the National Skin Centre in Singapore were searched to identify patients younger than 18 years old diagnosed with an AIBD from January 1, 1998, through December 31, 2012. Patient demographic characteristics, presentation, triggers, investigations, treatments, and disease course were analyzed. RESULTS Twelve patients with AIBDs were identified; five (41.7%) had linear immunoglobulin A disease (LAD); two (16.7%) each had pemphigus vulgaris (PV), bullous pemphigoid, and bullous systemic lupus erythematosus; and one (8.3%) had pemphigus foliaceus. Four (33.3%) were female and eight (66.7%) male. The mean age of onset was 8.7 years (range 2-17 years). Most patients were treated with steroids and adjuvant immunosuppressants. Intravenous rituximab was used effectively in a patient with recalcitrant PV. The mean follow-up was 2.35 years (range 0.17-7.33 years). As of the last follow-up, four (33.3%) patients were in complete remission off therapy, two (16.7%) were in complete remission on therapy, four (33.3%) were in partial remission on therapy, and two (16.7%) were lost to follow-up. CONCLUSION Consistent with the existing literature, our study shows that LAD is the most common cause of AIBDs in children. Although common in the West, dermatitis herpetiformis was not identified in the current study. Intravenous rituximab may be considered in recalcitrant childhood PV, but vigilant monitoring for side effects is crucial. Immunohistopathologic evaluation is important and repeat biopsies may be of value in patients with atypical disease courses.
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Affiliation(s)
- Yan Ling Kong
- Department of Dermatology, National Skin Centre, Singapore, Singapore
| | - Yen Loo Lim
- Department of Dermatology, National Skin Centre, Singapore, Singapore
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17
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Abstract
Rituximab is a chimeric monoclonal antibody that selectively binds to the CD20 molecule on B cells, resulting in their lysis. In autoimmune blistering diseases, the auto-antibody-producing B cells are destroyed and auto-antibody levels are reduced or eliminated. In the majority of patients, rituximab produces rapid clinical response and early resolution. In part, this accounts for the increased use of rituximab. Rituximab does not distinguish normal from pathologic B cells. Hence, shortly after its use, B-cell levels are zero and remain so for several months. In most patients, the use of systemic corticosteroids and immunosuppressive agents are continued after rituximab therapy, while their dosages are significantly decreased. In the majority of patients rituximab is used according to the protocol used in treating lymphoma patients or patients with rheumatoid arthritis. Approximately 50% of patients experience a relapse, requiring additional therapy. Serious adverse events and fatal outcomes have been reported, although their incidence is less than that observed with conventional therapy. Nonetheless, the causes, i.e. infections and septicemia, are similar. Several gaps exist in our understanding of how to optimally benefit from the use of this valuable biological agent. Future studies need to be targeted in designing and implanting protocols that maximize the benefit of rituximab and result in producing sustained prolonged remissions with minimal adverse events and a high quality of life.
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18
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Ahmed AR, Shetty S. A comprehensive analysis of treatment outcomes in patients with pemphigus vulgaris treated with rituximab. Autoimmun Rev 2015; 14:323-31. [DOI: 10.1016/j.autrev.2014.12.002] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 12/03/2014] [Indexed: 02/05/2023]
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19
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Amber K, Hertl M. An assessment of treatment history and its association with clinical outcomes and relapse in 155 pemphigus patients with response to a single cycle of rituximab. J Eur Acad Dermatol Venereol 2014; 29:777-82. [DOI: 10.1111/jdv.12678] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 03/07/2014] [Indexed: 12/11/2022]
Affiliation(s)
- K.T. Amber
- Department of Dermatology and Cutaneous Surgery; University of Miami Miller School of Medicine; Miami FL USA
| | - M. Hertl
- Department of Dermatology and Allergology; Philipps-Universität; Marburg Germany
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20
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Schmidt E, Goebeler M. CD20-directed therapy in autoimmune diseases involving the skin: role of rituximab. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.3.3.259] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Kamran B, Maryam D, Somayeh K, Mostafa MN, Mahsa HJ, Cheyda CD. Adjuvant rituximab in the treatment of pemphigus vulgaris: a phase II clinical trial. Int J Dermatol 2013; 52:862-7. [DOI: 10.1111/j.1365-4632.2012.5847.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Balighi Kamran
- From the Department of Dermatology; Tehran University of Medical Sciences; Tehran; Iran
| | - Daneshpazhooh Maryam
- From the Department of Dermatology; Tehran University of Medical Sciences; Tehran; Iran
| | - Khezri Somayeh
- From the Department of Dermatology; Tehran University of Medical Sciences; Tehran; Iran
| | - Mahdavi-nia Mostafa
- From the Department of Dermatology; Tehran University of Medical Sciences; Tehran; Iran
| | | | - Chams-Davatchi Cheyda
- From the Department of Dermatology; Tehran University of Medical Sciences; Tehran; Iran
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España A, Ornilla E, Panizo C. Rituximab in dermatology. ACTAS DERMO-SIFILIOGRAFICAS 2013; 104:380-92. [PMID: 23665436 DOI: 10.1016/j.adengl.2013.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 02/22/2012] [Indexed: 11/30/2022] Open
Abstract
Rituximab was introduced into clinical practice as a medication with considerable potential. Its use in patients with B-cell lymphoma and rheumatoid arthritis revealed numerous indications in autoimmune diseases, many of which involve the skin, thus requiring dermatologists to become familiar with both the characteristics of anti-CD20 antibodies and the role of B cells in multiple skin diseases. Thanks to these developments, we will be able to use rituximab more frequently and appropriately in our patients and draw up consensus guidelines based on large case series. In other words, establishing the indications for rituximab will make it possible to shorten disease course and reduce morbidity due to more specific drugs.
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Affiliation(s)
- A España
- Departamento de Dermatología, Clínica Universidad de Navarra. Facultad de Medicina, Universidad de Navarra, Spain.
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Feldman RJ, Ahmed AR. Relevance of rituximab therapy in pemphigus vulgaris: analysis of current data and the immunologic basis for its observed responses. Expert Rev Clin Immunol 2011; 7:529-41. [PMID: 21790294 DOI: 10.1586/eci.11.22] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Treatment of pemphigus vulgaris (PV) patients with rituximab therapy has not been critically evaluated. This article will provide in significant detail the available data to date, in order to provide a clinical and immunologic basis for clinicians to decide how best to treat recalcitrant PV patients with rituximab. PV is an autoimmune blistering disorder that affects the skin and mucous membranes. The immunopathology is well characterized, including the target antigens. PV patients have traditionally been treated with systemic corticosteroids and adjuvant immunosuppressive therapies. Clinical remission has been achieved in roughly 30% of patients. However, many patients experience severe side effects from this immunosuppression, including death. B-cell depletion therapy with rituximab therapy has been used to treat several autoimmune diseases including PV. In this article, we examined the data on 153 patients with PV who have been treated with rituximab. Our focus is on the clinical response of the patients with emphasis on adjuvant therapies, dosing regimens, potential adverse events and mechanism of action related to B-cell modulation during therapy. Importantly, the use of rituximab has increased clinical remission rates to 65% including many patients who were able to discontinue all systemic medications. Finally, an expert commentary is provided, which includes suggestions for optimizing current therapy and recommends the future direction of the field. The authors strongly endorse the use of rituximab in treatment of PV patients, particularly those nonresponsive to or who develop serious side effects to conventional therapy. Proper monitoring of patients including peripheral B-cell counts and overt signs of infection are warranted, given the potential for prolonged B-cell depletion.
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Affiliation(s)
- Ron J Feldman
- Center for Blistering Diseases, 70 Parker Hill Avenue, Boston, MA 02120, USA
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Abstract
Since its approval in 1997 by the US Food and Drug Administration, rituximab has been approved for use in certain B-cell lymphomas and treatment-resistant rheumatoid arthritis. Over the past 10 years, many published reports have suggested rituximab's efficacy in several inflammatory conditions in dermatology. This article includes a review of the mechanism of action, dosing, side-effect profile, and the current literature for various off-label uses of this CD20+ B-cell antagonist, rituximab.
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Affiliation(s)
- David R Carr
- Department of Dermatology, Wright State University, One Elizabeth Place, Suite 200, Dayton, OH 45408, USA
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Asarch A, Gürcan HM, Ahmed AR. A current review of juvenile pemphigus vulgaris: analysis of data on clinical outcomes. Am J Clin Dermatol 2010; 11:21-33. [PMID: 20000872 DOI: 10.2165/11310380-000000000-00000] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Forty-seven cases of juvenile pemphigus vulgaris have been reported in the English literature. Histology of lesional skin and direct immunofluorescence of perilesional skin are both necessary for a complete diagnosis. The autoimmune bullous condition can affect the skin and mucous membranes individually, but typically affects both concurrently. Disease characteristics in juvenile patients are similar to those in adults; however, a disruption of biologic and social development is of particular concern during adolescence. Although systemic corticosteroids have been used to successfully treat the disease in most cases, long-term use is often necessary for adequate control. Adverse effects from therapy can have devastating effects during this critical period of hormonal changes, physical and mental growth, and social and cultural development that occurs during adolescence. Newer therapies must be designed to adequately treat juvenile patients while also limiting serious adverse effects.
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Affiliation(s)
- Adam Asarch
- Tufts University School of Medicine, Boston, Massachusetts, USA
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Dörner T, Isenberg D, Jayne D, Wiendl H, Zillikens D, Burmester G. Current status on B-cell depletion therapy in autoimmune diseases other than rheumatoid arthritis. Autoimmun Rev 2009; 9:82-9. [PMID: 19716441 DOI: 10.1016/j.autrev.2009.08.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2009] [Indexed: 12/29/2022]
Abstract
Since the approval of the chimeric anti-CD20 antibody rituximab for the treatment of adults with severe-to-moderate rheumatoid arthritis after an inadequate response to TNF blockade, B-cell depletion therapy has been used for the treatment of a broad range of refractory autoimmune disorders. Based on current experiences and a literature search, a systematic review and evaluation of the current status of B-cell depletion therapy in autoimmune diseases other than rheumatoid arthritis, including rheumatic, nephrologic, dermatologic and neurologic autoimmune entities, was performed by an international group of experts based at several academic centres. Although important questions remain about the value and place of B-cell depletion in autoimmune diseases other than RA, preliminary data indicate the value of this therapeutic approach in otherwise refractory patients. However, given the lack of robust data from large randomised controlled trials, anti-CD20 therapy should be considered on an individual basis in otherwise refractory patients and its use based on a risk/benefit net calculation.
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Antonucci A, Negosanti M, Tabanelli M, Varotti C. Treatment of refractory pemphigus vulgaris with anti‐CD20 monoclonal antibody (rituximab): Five cases. J DERMATOL TREAT 2009; 18:178-83. [PMID: 17538808 DOI: 10.1080/09546630701286110] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pemphigus vulgaris is an autoimmune disease characterized by blisters and widespread erosions, involving skin and mucous membranes, caused by autoantibodies to desmoglein 1 and 3. This pathology is associated with increased morbidity and mortality if untreated. The treatment of pemphigus vulgaris requires multiple immunosuppressive agents, but often it is particularly resistant. OBJECTIVE To evaluate the efficacy and safety of rituximab therapy in refractory pemphigus vulgaris. METHODS Five patients diagnosed as having pemphigus vulgaris were treated with anti-CD20 monoclonal antibody (rituximab). Each patient was treated with rituximab intravenously at a dosage of 375 mg per square metre of body surface area once weekly for 4 weeks. RESULTS All the patients presented clinical resolution. No adverse effects were observed. It is important to observe the clinical evolution in the future, but our experience is still limited to a short lifetime and follow-up. CONCLUSION In our experience rituximab has been an effective and safe treatment for refractory pemphigus vulgaris.
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Affiliation(s)
- Angela Antonucci
- Department of Specialistic and Experimental Clinical Medicine, Division of Dermatology, University of Bologna, Bologna, Italy.
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31
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Barrera MV, Mendiola MV, Bosch RJ, Herrera E. Prolonged treatment with rituximab in patients with refractory pemphigus vulgaris. J DERMATOL TREAT 2009; 18:312-4. [PMID: 17852643 DOI: 10.1080/09546630701323988] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Recent reports have documented swift responses in refractory pemphigus vulgaris to rituximab, a monoclonal anti-CD20 antibody. Nevertheless, no standard protocol has yet been established for the administration of rituximab in patients with pemphigus vulgaris. We report the results of prolonged treatment with rituximab therapy in two patients with refractory pemphigus vulgaris. METHODS A 22- and a 27-year-old man were diagnosed with pemphigus vulgaris according to clinical, histopathological and immunofluorescence criteria. They failed to respond after several years of steroid and immunosuppressive treatment and experienced adverse effects. Rituximab was administered intravenously at a dose of 375 mg/m2 once weekly for 4 weeks. RESULTS Single infusions of rituximab 375 mg/m2 were repeated at 2-monthly intervals four times because of a delayed response. The treatment was well tolerated, no side effects were observed and the previous corticosteroid therapy could be progressively withdrawn. CONCLUSIONS The good response of our patients suggests that rituximab may be a valuable treatment option for refractory pemphigus vulgaris. It is important that clinicians are aware that the response to rituximab in pemphigus may be delayed, and that prolonged treatment may have a good outcome.
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Abstract
The basic understanding of inflammatory dermatoses and autoimmune-mediated skin disorders has greatly advanced and broadened our understanding of underlying immune mechanisms that shape the complex network of chronic inflammation and autoimmunity. The new treatment options for psoriasis exemplify how new insights into (auto)immune responses, especially the role and function of various immune cells and proinflammatory cytokines, may lead to new therapeutic strategies. The concept of targeting B cells in autoimmune-mediated disorders is closely related to the discovery of autoantibodies and their cellular origin. However, the appreciation of B cells in autoimmunity has significantly changed and is not limited to their role as progenitors of autoantibody secreting plasma cells. Recent investigations of various inflammatory skin diseases, that is, autoimmune blistering disorders, collagen vascular diseases, and atopic dermatitis, actually support the concept that B cells might be as important as T cells in the etiopathogenesis of these disorders. The striking clinical improvement seen in patients with rheumatoid arthritis following B-cell depletion with the anti-CD20 mAb rituximab has tremendously catalyzed the interest in B-cell-targeted therapies in different autoimmune diseases. Future translational and clinical investigations are mandatory to precisely define the role and the contribution of impaired B-cell function in (auto)immune-mediated skin diseases.
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Pemphigus vulgaire de l’enfant. Ann Dermatol Venereol 2008; 135:843-7. [DOI: 10.1016/j.annder.2007.11.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Accepted: 11/23/2007] [Indexed: 01/25/2023]
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Alexandroff AB, Harman KE. Blistering skin disorders: an evidence-based update. Conference report. Br J Dermatol 2008; 160:502-4. [PMID: 18945308 DOI: 10.1111/j.1365-2133.2008.08857.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Evidence-based update meetings are held annually by the Centre of Evidence Based Dermatology, University of Nottingham. Past topics have included important themes such as eczema, psoriasis, hair disorders and skin cancers. This year, the seventh Evidence Based Update meeting focused on blistering disorders and took place in Loughborough University on 5 June 2008. The latest data on incidence and mortality, therapeutic trials and management of bullous pemphigoid, pemphigus and epidermolysis bullosa (EB) were presented by an international panel of renowned speakers. The highlights of the meeting included an informal atmosphere, an international perspective, a practical question and answer session and hearing first-hand a patient and carer's perspective of living with EB.
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Affiliation(s)
- A B Alexandroff
- Department of Dermatology, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.
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Abstract
Pemphigus defines a group of rare mucocutaneous autoimmune diseases of which pemphigus vulgaris (PV) is the most common. The aetiology and pathogenesis of PV are not completely clear, but there is a fairly strong genetic background: ethnic groups such as Ashkenazi Jews and people of Mediterranean and Indian origin are particularly susceptible and there is a link to HLA class II alleles. The initiating event in PV is not clear, but circulating IgG autoantibodies develop, directed particularly against the intercellular cadherin desmoglein 3 (Dsg3) in desmosomes of stratified squamous epithelium. Oral lesions often herald the disease and are initially vesiculobullous, but they rupture readily to leave ulcers. Involvement of other mucosa and skin is almost inevitable and PV is potentially life threatening. The diagnosis is confirmed by biopsy with histological examination and immunostaining. Management is largely by systemic immunosuppression with corticosteroids, usually azathioprine or other agents, but newer treatments with potentially fewer adverse effects look promising.
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Affiliation(s)
- Crispian Scully
- University College London, Eastman Dental Institute, London, UK.
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36
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Hertl M, Zillikens D, Borradori L, Bruckner-Tuderman L, Burckhard H, Eming R, Engert A, Goebeler M, Hofmann S, Hunzelmann N, Karlhofer F, Kautz O, Lippert U, Niedermeier A, Nitschke M, Pfütze M, Reiser M, Rose C, Schmidt E, Shimanovich I, Sticherling M, Wolff-Franke S. Recommendations for the use of rituximab (anti-CD20 antibody) in the treatment of autoimmune bullous skin diseases. J Dtsch Dermatol Ges 2008; 6:366-73. [DOI: 10.1111/j.1610-0387.2007.06602.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Guhl G, Díaz-Ley B, Fernández-Herrera J. Uso de fármacos biológicos en dermatosis fuera de la indicación aprobada. Segunda parte: etanercept, efalizumab, alefacept, rituximab, daclizumab, basiliximab, omalizumab y cetuximab. ACTAS DERMO-SIFILIOGRAFICAS 2008; 99:5-33. [DOI: 10.1016/s0001-7310(08)74612-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Off-Label Use of Biologic Agents in the Treatment of Dermatosis, Part 2: Etanercept, Efalizumab, Alefacept, Rituximab, Daclizumab, Basiliximab, Omalizumab, and Cetuximab. ACTAS DERMO-SIFILIOGRAFICAS 2008. [DOI: 10.1016/s1578-2190(08)70191-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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39
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Abstract
Pemphigus is an uncommon but potentially life-threatening chronic autoimmune bullous disorder. Antibodies are directed against antigens (desmoglein 1 and 3) in the desmosomes linking keratinocytes and against acetylcholine receptors. Conventional treatment with high-dose corticosteroids, sometimes with adjuvant immunosuppressive agents, may be associated with very serious adverse effects. There is an urgent need to establish the evidence for the safest and most effective form of treatment. A literature review has revealed 11 controlled (9 randomized) trials of treatment for pemphigus. The numbers of participants in the individual trials are small and the data cannot be pooled as they evaluate different forms of treatment. The results of these trials suggest that very high doses of corticosteroids, either as pulse therapy or in daily dosage, are not superior to moderate daily doses. Based on evidence from the available trials, addition of an immunosuppressive agent generally does not appear to offer substantial benefit in terms of clinical response. However, a recent study demonstrated a significant reduction in corticosteroid requirements among patients receiving immunosuppressive agents. Newer therapies, such as biologic agents (in particular rituximab), calcineurin inhibitors, or immunoadsorption appear promising but there are inadequate controlled trials to establish their role clearly. Initial open-label studies suggest that specific peptide immunotherapy may offer a safe and novel approach to the treatment of pemphigus in the future. At present, treatment of an individual patient with pemphigus requires clinical judgment and should not be based purely on guidelines or on the inadequate available evidence alone. There is an urgent need for large randomized, controlled, multicenter trials of treatment in patients with pemphigus.
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Affiliation(s)
- Sue Jessop
- Division of Dermatology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa.
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Shimanovich I, Nitschke M, Rose C, Grabbe J, Zillikens D. Treatment of severe pemphigus with protein A immunoadsorption, rituximab and intravenous immunoglobulins. Br J Dermatol 2007; 158:382-8. [DOI: 10.1111/j.1365-2133.2007.08358.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Joly P, Mouquet H, Roujeau JC, D'Incan M, Gilbert D, Jacquot S, Gougeon ML, Bedane C, Muller R, Dreno B, Doutre MS, Delaporte E, Pauwels C, Franck N, Caux F, Picard C, Tancrede-Bohin E, Bernard P, Tron F, Hertl M, Musette P. A single cycle of rituximab for the treatment of severe pemphigus. N Engl J Med 2007; 357:545-52. [PMID: 17687130 DOI: 10.1056/nejmoa067752] [Citation(s) in RCA: 292] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The combination of multiple cycles of rituximab and intravenous immune globulins has been reported to be effective in patients with severe pemphigus. The aim of this study was to assess the efficacy of a single cycle of rituximab in severe types of pemphigus. METHODS We studied 21 patients with pemphigus whose disease had not responded to an 8-week course of 1.5 mg of prednisone per kilogram of body weight per day (corticosteroid-refractory disease), who had had at least two relapses despite doses of prednisone higher than 20 mg per day (corticosteroid-dependent disease), or who had severe contraindications to corticosteroids. The patients were treated with four weekly infusions of 375 mg of rituximab per square meter of body-surface area. The primary end point was complete remission 3 months after the end of rituximab treatment; complete remission was defined as epithelialization of all skin and mucosal lesions. RESULTS Eighteen of 21 patients (86%; 95% confidence interval, 64 to 97%) had a complete remission at 3 months. The disease relapsed in nine patients after a mean of 18.9+/-7.9 months. After a median follow-up of 34 months, 18 patients (86%) were free of disease, including 8 who were not receiving corticosteroids; the mean prednisone dose decreased from 94.0+/-10.2 to 12.0+/-7.5 mg per day (P=0.04) in patients with corticosteroid-refractory disease and from 29.1+/-12.4 to 10.9+/-16.5 mg per day (P=0.007) in patients with corticosteroid-dependent disease. Pyelonephritis developed in one patient 12 months after rituximab treatment, and one patient died of septicemia 18 months after rituximab treatment. These patients had a profound decrease in the number of circulating B lymphocytes but normal serum levels of IgG. CONCLUSIONS A single cycle of rituximab is an effective treatment for pemphigus. Because of its potentially severe side effects, its use should be limited to the most severe types of the disease. (ClinicalTrials.gov number, NCT00213512 [ClinicalTrials.gov].).
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Iranzo P, Alsina MM, Martínez-De Pablo I, Segura S, Mascaró JM, Herrero C. Gold: an old drug still working in refractory pemphigus. J Eur Acad Dermatol Venereol 2007; 21:902-7. [PMID: 17658998 DOI: 10.1111/j.1468-3083.2006.02074.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The mainstay of treatment for pemphigus is systemic corticosteroids. Different adjuvants have been used to reduce side-effects of long-term corticotherapy. Gold is an anti-inflammatory drug used in autoimmune diseases, whose use has waned with the advent of new immunosuppressive agents. OBJECTIVE To study the outcome of the use of intramuscular gold treatment of pemphigus vulgaris refractory to previous therapies. METHODS Thirteen patients with pemphigus vulgaris who had failed to respond to several prior therapies were treated with aurothiomalate, as a steroid-sparing agent. Patients were monitored to assess disease activity and gold toxicity. RESULTS Seven patients achieved complete remission. Four patients were able to taper prednisone doses, although pemphigus flared when prednisone was discontinued or reduced. Toxicity was observed in the other two patients. CONCLUSIONS In 53.4% of the patients, the use of chrysotherapy resulted in the complete clearing of the disease, discontinuation of all systemic therapies and induced a long-term clinical remission. Prednisone doses were able to be reduced in the remaining 46.6%. Any side-effects were reversible with drug discontinuation. Gold therapy showed efficacy as a secondary line treatment in refractory pemphigus vulgaris.
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Affiliation(s)
- P Iranzo
- Department of Dermatology, Hospital Clínic, Barcelona 08036, Spain.
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Connelly EA, Aber C, Kleiner G, Nousari C, Charles C, Schachner LA. Generalized erythrodermic pemphigus foliaceus in a child and its successful response to rituximab treatment. Pediatr Dermatol 2007; 24:172-6. [PMID: 17461818 DOI: 10.1111/j.1525-1470.2007.00369.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pemphigus foliaceus is an autoimmune disease that clinically manifests with cutaneous blisters of the superficial skin. The nonendemic or sporadic form of this entity is rare in children and typically presents with a milder, more localized rash that usually follows a benign course of short duration. We describe an affected patient atypical in both her young age and the severity of skin findings. Our patient presented with a full body exfoliative erythroderma at 21 months of age. After an extensive work-up to determine the etiology of her exfoliative erythroderma, direct and indirect immunofluorescence studies confirmed the diagnosis of pemphigus foliaceus. Rituximab therapy was initiated based on the patient's refractory disease course to multiple immunosuppressive agents. Rituximab is a therapeutic monoclonal antibody targeting CD20, an integral membrane protein highly expressed on the surface of pre-B lymphocytes and activated mature B lymphocytes. The patient's skin exhibited marked clinical improvement after the start of rituximab infusions over 12 weeks. Her initial desmoglein 1 antibody level was greater than 1:1280, which decreased to 1:16 after seven rituximab treatments. She has had no skin flares since initiating treatment with rituximab therapy. Based on this clinical and serologic response, the use of rituximab may be helpful in the treatment of pediatric pemphigus foliaceus refractory to mainstays of therapy.
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Affiliation(s)
- Elizabeth Alvarez Connelly
- Department of Dermatology and Cutaneous Surgery, Division of Pediatric Dermatology, University of Miami Miller School of Medicine, Miami, Florida 33125, USA
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Schmidt E, Seitz CS, Benoit S, Bröcker EB, Goebeler M. Rituximab in autoimmune bullous diseases: mixed responses and adverse effects. Br J Dermatol 2007; 156:352-6. [PMID: 17223877 DOI: 10.1111/j.1365-2133.2006.07646.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Intolerably high doses of systemic corticosteroids and additional immunosuppressants may be required to control disease activity in autoimmune bullous skin diseases. New therapeutic options are needed for such patients. OBJECTIVES To determine the efficacy and adverse effects of adjuvant rituximab. METHODS Seven patients with refractory autoimmune blistering diseases (pemphigus vulgaris, PV, n = 4; bullous pemphigoid, BP, n = 2; mucous membrane pemphigoid, MMP, n = 1) were treated four times with rituximab at an individual dose of 375 mg m(-2) at weekly intervals. RESULTS All lesions cleared in three patients (two PV, one BP), while they were reduced by more than 50% in three others (two PV, one BP). The concomitant immunosuppressive medication was reduced in five patients (four PV, one BP). The patient with MMP developed bilateral blindness while nasopharyngeal lesions resolved. Three patients (two BP, one PV) experienced severe adverse events including fatal pneumonia. CONCLUSIONS Adjuvant B-cell depletion by rituximab is effective in otherwise therapy-resistant bullous autoimmune disorders but may be associated with substantial adverse effects including fatal outcomes.
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Affiliation(s)
- E Schmidt
- Department of Dermatology, University of Würzburg, Josef-Schneider-Strasse 2, D-97080 Würzburg,
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Watanabe R, Fujimoto M, Yazawa N, Nakashima H, Asashima N, Kuwano Y, Tada Y, Maruyama N, Okochi H, Tamaki K. Increased serum levels of a proliferation-inducing ligand in patients with bullous pemphigoid. J Dermatol Sci 2007; 46:53-60. [PMID: 17250993 DOI: 10.1016/j.jdermsci.2006.12.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2006] [Revised: 12/10/2006] [Accepted: 12/15/2006] [Indexed: 12/23/2022]
Abstract
BACKGROUND B cells have been demonstrated to have critical roles in developing autoimmune bullous diseases. Recently identified tumor necrosis factor-like molecules, B cell-activating factor of the TNF family (BAFF) and a proliferation-inducing ligand (APRIL) are essential molecules for B cell development, survival, and proliferation. Although the functions of APRIL have not been fully evaluated, recent studies suggest that circulating levels of APRIL are increased in various autoimmune diseases, including systemic lupus erythematosus and rheumatoid arthritis. OBJECTIVES To determine serum APRIL levels in patients with pemphigus vulgaris (PV) and bullous pemphigoid (BP), and compare those with clinical findings and laboratory findings. PATIENTS/METHODS Sera from 15 PV patients, 43 BP patients, and 15 normal controls were subjected to ELISA assays to measure serum APRIL, BAFF, Dsg3, and BP180 levels. RESULTS AND CONCLUSIONS Circulating APRIL levels were significantly elevated in BP patients but not in PV patients, and correlated with serum BAFF levels. Our study revealed that serum APRIL levels tended to be increased in the quite early stage of disease. In conclusion, circulating APRIL levels may be a useful marker for early activation of autoimmune diathesis, and furthermore, an effective therapeutic target molecule in patients with BP.
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Affiliation(s)
- R Watanabe
- Department of Dermatology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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Graves JE, Nunley K, Heffernan MP. Off-label uses of biologics in dermatology: Rituximab, omalizumab, infliximab, etanercept, adalimumab, efalizumab, and alefacept (Part 2 of 2). J Am Acad Dermatol 2007; 56:e55-79. [PMID: 17190618 DOI: 10.1016/j.jaad.2006.07.019] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2006] [Revised: 06/30/2006] [Accepted: 07/22/2006] [Indexed: 12/28/2022]
Abstract
Recently, dermatologists have witnessed a revolution in our therapeutic armamentarium with the development of several novel biologic immunomodulators. Although psoriasis remains the only condition in dermatology for which the use of biologic immunomodulators has been approved by the Food and Drug Administration, these drugs have the potential to significantly impact the treatment of several inflammatory conditions in dermatology. This article includes a review of the mechanism of action, dosing, and side-effect profile, as well as a review of the current literature on off-label uses of the CD20-positive B-cell antagonist rituximab, the IgE antagonist omalizumab, the tumor necrosis factor-alpha antagonists infliximab, etanercept, and adalimumab, and the T-cell response modifiers efalizumab and alefacept.
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Affiliation(s)
- Julia E Graves
- Division of Dermatology, Washington University, St Louis, Missouri, USA
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Cummins DL, Mimouni D, Tzu J, Owens N, Anhalt GJ, Meyerle JH. Lichenoid paraneoplastic pemphigus in the absence of detectable antibodies. J Am Acad Dermatol 2007; 56:153-9. [PMID: 17097371 DOI: 10.1016/j.jaad.2006.06.007] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 05/20/2006] [Accepted: 06/04/2006] [Indexed: 11/20/2022]
Abstract
Paraneoplastic pemphigus (PNP) has been described as an antibody-mediated mucocutaneous disease occurring almost exclusively in patients with lymphocytic neoplasms. We describe 4 patients with the clinical features of the lichenoid variant of PNP in the absence of detectable autoantibodies. On the basis of these findings, we conclude that the spectrum of PNP likely includes patients with disease predominantly or exclusively mediated by cytotoxic T cells rather than autoantibodies. The pathophysiology and range of PNP disease are likely more complex than was initially believed.
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MESH Headings
- Aged
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antibody Formation/drug effects
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Autoantibodies/blood
- B-Lymphocytes/drug effects
- Combined Modality Therapy
- Cyclophosphamide/administration & dosage
- Doxorubicin/administration & dosage
- Esophageal Diseases/diagnosis
- Esophageal Diseases/etiology
- Esophageal Diseases/immunology
- Etoposide/administration & dosage
- Female
- Hematopoietic Stem Cell Transplantation
- Humans
- Immunity, Cellular
- Interleukin-2/administration & dosage
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/radiotherapy
- Leukemia, Lymphocytic, Chronic, B-Cell/surgery
- Lichenoid Eruptions/diagnosis
- Lichenoid Eruptions/etiology
- Lichenoid Eruptions/immunology
- Lymphoma, Follicular/complications
- Lymphoma, Follicular/drug therapy
- Lymphoma, Follicular/radiotherapy
- Lymphoma, Non-Hodgkin/complications
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/radiotherapy
- Male
- Middle Aged
- Mucositis/complications
- Paraneoplastic Syndromes/etiology
- Paraneoplastic Syndromes/immunology
- Pemphigus/diagnosis
- Pemphigus/etiology
- Pemphigus/immunology
- Prednisone/administration & dosage
- Recurrence
- Rituximab
- T-Lymphocytes/immunology
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
- Vincristine/administration & dosage
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Affiliation(s)
- Deborah L Cummins
- Department of Dermatology, Johns Hopkins Hospital, Baltimore, MD 21205, USA
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Kerns MJJ, Graves JE, Smith DI, Heffernan MP. Off-Label Uses of Biologic Agents in Dermatology: A 2006 Update. ACTA ACUST UNITED AC 2006; 25:226-40. [PMID: 17174843 DOI: 10.1016/j.sder.2006.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The introduction of a number of biologic therapies into the market has revolutionized the practice of dermatology. These therapies include adalimumab, alefacept, efalizumab, etanercept, infliximab, IVIg, omalizumab, and rituximab. Most dermatologists are familiar with the indications of these medications that have been approved by the Food and Drug Administration; however, numerous off-label uses have evolved. To update the reader on more recent uses of the biologics for off-label dermatologic use, this article will emphasize more recent published data from 2005 through the date of submission in May 2006.
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