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Chen Z, Wang L, Ma L, Yang F, Chen S, Yang J, Gao H, Tang C, Zhao Y, Zhang Z, Tang L, Xue H, Ying J, Xu Y, Zhang W, Shao L, Liu H, Luo X. Epidemiological Insights into Autoimmune Bullous Diseases in China: A Comprehensive Analysis. J Epidemiol Glob Health 2024:10.1007/s44197-024-00277-7. [PMID: 39037699 DOI: 10.1007/s44197-024-00277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 07/08/2024] [Indexed: 07/23/2024] Open
Abstract
OBJECTIVE This study aims to conduct an extensive analysis of autoimmune bullous diseases, particularly pemphigus vulgaris and bullous pemphigoid, in Shanghai, China, from 2016 to 2023. It seeks to understand the demographic profiles, comorbidities, mortality rates, risk factors, and socioeconomic impacts associated with autoimmune bullous disease. METHODS A cross-sectional study design was employed, enrolling 1,072 patients. Diagnostic measures included clinical manifestations, histopathology, direct immunofluorescence, and serologic tests. The study also involved a detailed socioeconomic analysis and evaluation of occupational risks. RESULTS The findings highlight a significant occupational risk in industries requiring enhanced safety measures, with a notable prevalence of autoimmune bullous disease among workers in these sectors. A considerable portion of the patients were from low-income backgrounds with limited literacy, indicating the economic burden of autoimmune bullous disease. A key discovery of the study is the potential pathological link between autoimmune bullous disease and interstitial lung disease. CONCLUSION This research, one of the first comprehensive studies on autoimmune bullous disease in China, underscores the need for targeted healthcare strategies and further investigation into autoimmune bullous disease, particularly its relationship with interstitial lung disease.
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Affiliation(s)
- Zihua Chen
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Lanting Wang
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Li Ma
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Fanping Yang
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Shengan Chen
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Jin Yang
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Haiqing Gao
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Chang Tang
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Ying Zhao
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Zhen Zhang
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Lin Tang
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Haiyu Xue
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Jian Ying
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Yu Xu
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China
| | - Wenhong Zhang
- Department of Infectious Diseases, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Lingyun Shao
- Department of Infectious Diseases, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Hanqiu Liu
- Department of Radiology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Xiaoqun Luo
- Department of Allergy and Immunology, Department of Dermatology, Research Center of Allergy and Diseases, Huashan Hospital Affiliated to Fudan University, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, P.R. China.
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Tan AJ, Archila M, Barbieri JS, Mostaghimi A, Scherer AM, Perez-Chada LM, Asgari MM, Gelfand JM, Noe MH. Understanding patient perspectives on vaccine decision making in adults with autoimmune bullous diseases: a qualitative study. Arch Dermatol Res 2024; 316:125. [PMID: 38637431 PMCID: PMC11296352 DOI: 10.1007/s00403-024-02862-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 12/22/2023] [Accepted: 04/07/2024] [Indexed: 04/20/2024]
Abstract
Patients with autoimmune bullous diseases are at an increased risk of infection, both from the underlying skin disease and from immunosuppressive treatments. Limited information is available on vaccine beliefs and behaviors in dermatology patients and adults with autoimmune bullous diseases in particular. To understand vaccine decision making, identify perceived risks and benefits of vaccinations, and discuss individual experiences in patients with autoimmune bullous diseases in the United States. A qualitative study was performed utilizing semi-structured interviews, and analysis was conducted on NVivo. Patterns were identified in the coded data, and representative quotations were recorded for each major theme. Interviews were conducted between February 15, 2022 and September 15, 2022. Twenty patients with a diagnosis of bullous pemphigoid, mucous membrane pemphigoid, pemphigus vulgaris, or pemphigus foliaceous were interviewed. Of the 20 participants, 14 (70%) were female, with a mean (SD, range) age of 64.8 (13.2, 34-83) years. Key themes that emerged from qualitative analysis of the interviews included patient concerns regarding their increased susceptibility to infection, potential exacerbation of skin disease following vaccination, and the effect of immunosuppressive medications on humoral response to vaccines. Lack of appointment availability, difficulty accessing vaccines, and cost were commonly identified barriers to vaccination. These findings provide valuable knowledge for dermatologists in regard to providing counseling specific to patient concerns and to improve communication surrounding vaccination in the dermatology setting.
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Affiliation(s)
- Alice J Tan
- University of Massachusetts Medical School, Worcester, MA, USA
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA, 02215, USA
| | - Marjorie Archila
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA, 02215, USA
| | - John S Barbieri
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA, 02215, USA
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA, 02215, USA
| | - Aaron M Scherer
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Lourdes M Perez-Chada
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA, 02215, USA
| | - Maryam M Asgari
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
| | - Joel M Gelfand
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Megan H Noe
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA, 02215, USA.
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Chen T, Huang W, Loh C, Huang H, Chi C. Risk of Incident Venous Thromboembolism Among Patients With Bullous Pemphigoid or Pemphigus Vulgaris: A Nationwide Cohort Study With Meta-Analysis. J Am Heart Assoc 2023; 12:e029740. [PMID: 37642024 PMCID: PMC10547313 DOI: 10.1161/jaha.123.029740] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/15/2023] [Indexed: 08/31/2023]
Abstract
Background Bullous pemphigoid (BP) and pemphigus vulgaris (PV) share similar pathophysiology with venous thromboembolism (VTE) involving platelet activation, immune dysregulation, and systemic inflammation. Nevertheless, their associations have not been well established. Methods and Results To examine the risk of incident VTE among patients with BP or PV, we performed a nationwide cohort study using Taiwan's National Health Insurance Research Database and enrolled 12 162 adults with BP or PV and 12 162 controls. A Cox regression model considering stabilized inverse probability weighting was used to calculate the hazard ratios (HRs) for incident VTE associated with BP or PV. To consolidate the findings, a meta-analysis that incorporated results from the present cohort study with previous literature was also conducted. Compared with controls, patients with BP or PV had an increased risk for incident VTE (HR, 1.87 [95% CI, 1.55-2.26]; P<0.001). The incidence of VTE was 6.47 and 2.20 per 1000 person-years in the BP and PV cohorts, respectively. The risk for incident VTE significantly increased among patients with BP (HR, 1.85 [95% CI, 1.52-2.24]; P<0.001) and PV (HR, 1.99 [95% CI, 1.02-3.91]; P=0.04). In the meta-analysis of 8 studies including ours, BP and PV were associated with an increased risk for incident VTE (pooled relative risk, 2.17 [95% CI, 1.82-2.62]; P<0.001). Conclusions BP and PV are associated with an increased risk for VTE. Preventive approaches and cardiovascular evaluation should be considered particularly for patients with BP or PV with concomitant risk factors such as hospitalization or immobilization.
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Affiliation(s)
- Tai‐Li Chen
- Department of DermatologyTaipei Veterans General HospitalTaipeiTaiwan
- Department of Medical Education, Medical Administration Office, Hualien Tzu Chi HospitalBuddhist Tzu Chi Medical FoundationHualienTaiwan
| | - Wan‐Ting Huang
- Epidemiology and Biostatistics Center, Hualien Tzu Chi HospitalBuddhist Tzu Chi Medical FoundationHualienTaiwan
| | - Ching‐Hui Loh
- Center for Aging and HealthHualien Tzu Chi Hospital, Buddhist Tzu Chi Medical FoundationHualienTaiwan
- School of MedicineTzu Chi UniversityHualienTaiwan
| | - Huei‐Kai Huang
- School of MedicineTzu Chi UniversityHualienTaiwan
- Department of Family MedicineHualien Tzu Chi HospitalBuddhist Tzu Chi Medical FoundationHualienTaiwan
- Department of Medical Research, Hualien Tzu Chi HospitalBuddhist Tzu Chi Medical FoundationHualienTaiwan
| | - Ching‐Chi Chi
- Department of DermatologyChang Gung Memorial Hospital, LinkouTaoyuanTaiwan
- School of MedicineCollege of Medicine, Chang Gung UniversityTaoyuanTaiwan
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Can Methotrexate Be Employed as Monotherapy for Bullous Pemphigoid? Analysis of Efficiency and Tolerance of Methotrexate Treatment in Patients with Bullous Pemphigoid. J Clin Med 2023; 12:jcm12041638. [PMID: 36836172 PMCID: PMC9967290 DOI: 10.3390/jcm12041638] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023] Open
Abstract
The European Academy of Dermatology and Venerology (EADV) consensus states that the treatment of choice for bullous pemphigoid is systemic glucocorticosteroid therapy. Bearing in mind that long-term steroid therapy is associated with numerous side effects, an effective and safer treatment regimen for these patients is still being sought. A retrospective analysis was performed of the medical reports of patients with diagnosed bullous pemphigoid. The study included 40 patients with moderate or severe disease, and who had continued ambulatory treatment for at least six months. The patients were divided into two groups: one treated with methotrexate in monotherapy, or with combined methotrexate and systemic steroid therapy. A slightly better survival rate was noted in the methotrexate group. No significant differences were observed between the groups in time to achieve clinical remission. The combination therapy group demonstrated more frequent disease recurrence and exacerbations during treatment, and a higher mortality rate. None of the patients in either group presented with severe side effects related to methotrexate treatment. The treatment of bullous pemphigoid with methotrexate in monotherapy is an effective and safe therapeutic method for elderly patients.
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Chen C, Wu C, Lyu Y, Chou Y, Chang Y, Wu C. Association between bullous pemphigoid and risk of venous thromboembolism: A nationwide population‐based cohort study. J Dermatol 2022; 49:753-761. [DOI: 10.1111/1346-8138.16412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/23/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Ching‐Li Chen
- Department of Medical Education National Taiwan University Hospital Taipei Taiwan
| | - Chun‐Ying Wu
- Division of Translational Research, Department of Medical Research Taipei Veterans General Hospital Taipei Taiwan
- Institute of Biomedical Informatics National Yang Ming Chiao Tung University Taipei Taiwan
- College of Public Health China Medical University Taichung Taiwan
| | - Ying‐Syuan Lyu
- Institute of Biomedical Informatics National Yang Ming Chiao Tung University Taipei Taiwan
| | - Yiing‐Jenq Chou
- Department of Public Health, Institute of Public Health National Yang Ming Chiao Tung University Taipei Taiwan
| | - Yun‐Ting Chang
- Department of Dermatology Taipei Veterans General Hospital Taipei Taiwan
- Department of Dermatology National Yang Ming Chiao Tung University Taipei Taiwan
| | - Chen‐Yi Wu
- Department of Public Health, Institute of Public Health National Yang Ming Chiao Tung University Taipei Taiwan
- Department of Dermatology Taipei Veterans General Hospital Taipei Taiwan
- Department of Dermatology National Yang Ming Chiao Tung University Taipei Taiwan
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Deotto ML, Spiller A, Sernicola A, Alaibac M. Bullous pemphigoid: An immune disorder related to aging (Review). Exp Ther Med 2021; 23:50. [PMID: 34934428 DOI: 10.3892/etm.2021.10972] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/29/2021] [Indexed: 01/09/2023] Open
Abstract
Bullous pemphigoid (BP) is the most frequent subepidermal autoimmune blistering disease and is caused by autoantibodies directed against two principal antigens of the hemidesmosome, BP antigen 180 and BP antigen 230. The pathogenesis of BP is dependent upon the interaction between genetic predisposition, physiological skin alterations due to aging and specific triggers. Several triggers have already been reported to induce this disease and include drugs, thermal or electrical burns, surgical procedures, trauma, UV radiation, radiotherapy, chemicals and infections. Data from the current literature support the hypothesis that alterations of the skin barrier associated with aging increase individual susceptibility to these aforementioned triggers. Consequently, this has been reported to lead to the attack of autoantibodies, demonstrating the predilection of BP for the elderly population. The identification of triggering factors and comorbidities may aid in understanding the pathogenesis of BP and improve clinical management by encouraging their prompt recognition and removal. Moreover, the present review has indicated that current management of BP should be aimed at counteracting the detrimental effects of aging on the skin by restoring skin barrier integrity and maintaining cutaneous homeostasis, for example with systematic applications of topical emollients and photoprotection. This strategy could prove even more beneficial in the elderly, in which frequent comorbidities associated with age often narrow available immunosuppressive treatment options. Furthermore, the safety of treatment regimens may significantly affect outcome and prognosis.
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Affiliation(s)
- Maria Ludovica Deotto
- Dermatology Unit, Department of Medicine, University of Padova, I-35121 Padua, Italy
| | - Alice Spiller
- Dermatology Unit, Department of Medicine, University of Padova, I-35121 Padua, Italy
| | - Alvise Sernicola
- Dermatology Unit, Department of Medicine, University of Padova, I-35121 Padua, Italy
| | - Mauro Alaibac
- Dermatology Unit, Department of Medicine, University of Padova, I-35121 Padua, Italy
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Chronic Systemic Inflammatory Skin Disease as a Risk Factor for Cardiovascular Disease. Curr Probl Cardiol 2021; 46:100799. [PMID: 33607473 DOI: 10.1016/j.cpcardiol.2021.100799] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 01/10/2021] [Indexed: 11/24/2022]
Abstract
Chronic systemic skin disease and cardiovascular disease are multisystem disorders which have been associated with each other for centuries. Recent research has strengthened this association, particularly in systemic inflammatory disease. Here we explore the current literature on psoriasis, hidradenitis suppurativa, lupus erythematosus, acanthosis nigricans, atopic dermatitis, and bullous pemphigoid. Psoriasis is a chronic inflammatory disorder that has been labeled as a risk-modifier for hyperlipidemia and coronary artery disease by the American College of Cardiology ACC lipid guidelines. Cardiovascular disease is also found at a significantly higher rate in patients with hidradenitis suppurativa and lupus erythematosus. Some associations have even been noted between cardiovascular disease and acanthosis nigricans, atopic dermatitis, and bullous pemphigoid. While many of these associations have been attributed to a shared underlying disease process such as chronic systemic inflammation and shared underlying risk factors, these dermatologic manifestations can help to identify patients at higher risk for cardiovascular disease.
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Moro F, Fania L, Sinagra JLM, Salemme A, Di Zenzo G. Bullous Pemphigoid: Trigger and Predisposing Factors. Biomolecules 2020; 10:E1432. [PMID: 33050407 PMCID: PMC7600534 DOI: 10.3390/biom10101432] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/01/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022] Open
Abstract
Bullous pemphigoid (BP) is the most frequent autoimmune subepidermal blistering disease provoked by autoantibodies directed against two hemidesmosomal proteins: BP180 and BP230. Its pathogenesis depends on the interaction between predisposing factors, such as human leukocyte antigen (HLA) genes, comorbidities, aging, and trigger factors. Several trigger factors, such as drugs, thermal or electrical burns, surgical procedures, trauma, ultraviolet irradiation, radiotherapy, chemical preparations, transplants, and infections may induce or exacerbate BP disease. Identification of predisposing and trigger factors can increase the understanding of BP pathogenesis. Furthermore, an accurate anamnesis focused on the recognition of a possible trigger factor can improve prognosis by promptly removing it.
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Affiliation(s)
- Francesco Moro
- Correspondence: (F.M.); (L.F.); Tel.: +39-(342)-802-0004 (F.M.)
| | - Luca Fania
- Correspondence: (F.M.); (L.F.); Tel.: +39-(342)-802-0004 (F.M.)
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Chen J, Mao X, Zhao W, Zhang B, Chen X, Yu C, Zheng Z, Jin H, Li L. Assessment of the Characteristics and Associated Factors of Infectious Complications in Bullous Pemphigoid. Front Immunol 2020; 11:1607. [PMID: 32793235 PMCID: PMC7390841 DOI: 10.3389/fimmu.2020.01607] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/16/2020] [Indexed: 12/13/2022] Open
Abstract
Objectives: The clinical outcome of bullous pemphigoid appears worse in patients with infectious complications, and assessment of the prevalence and risk factors of infectious complications could be necessary to plan preventative strategies and to instruct the treatment plans. We sought to determine the risk factors of infection and compare associated factors in inpatients and outpatients with different system infections. Design: This is a single-centered retrospective study on the medical records of 252 patients from 2010 to 2018 at the dermatology department, Peking Union Medical College. Medical profiles of medical history, diagnosis, infectious complications, and treatment plans were analyzed. The associated factors were compared between the subgroups, including inpatients and outpatients, different body sites of infection. Results: Of the total 252 patients with bullous pemphigoid (BP), 81 patients (81/252, 32.1%) had infectious complications. Forty-eight patients died from pulmonary infections (11/48, 22.9%), cardiovascular diseases (6/48, 12.5%), and other diseases. Infections were most frequently found in skin/mucosa (44/252, 17.5%), respiratory system (32/252, 12.7%), and blood (10/252, 4.0%). On multivariate analysis, risk factors of infections in BP were maximal control dose of corticosteroids (OR 2.539, 95% CI 1.456-4.430, p = 0.001), low serum albumin level (OR 2.557, 95% CI 1.283, 5.092, p = 0.007), hospitalization (OR 4.025, 95% CI 2.289, 7.079, p < 0.001), comorbidities including respiratory disease (OR 4.060, 95% CI, 1.861, 8.858, p < 0.001), eye disease (OR 4.431, 95% CI 1.864, 10.532, p < 0.001), and diabetes (OR 2.667, 95% CI 1.437, 4.949, p = 0.002). The rate of infection was significantly higher in inpatients compared to that in outpatients (54.0 vs. 20.6%, p < 0.001), with diverse risk factors. Mucocutaneous infections were associated with a maximal control dose of corticosteroid and other dermatoses. Respiratory infections were related to respiratory disease and old age, and hematologic infection was associated with low serum hemoglobin levels and mucosal involvement of BP. Both of them were associated with mucosal involvement of BP and high titer anti-BP180 antibody. Conclusions: Infectious complications of bullous pemphigoid are common and are associated with mucosal involvement of BP, more comorbidities, the higher dose of corticosteroids, and the lower level of serum albumin.
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Affiliation(s)
- Jia Chen
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuming Mao
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Wenling Zhao
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Dermatology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Bingjie Zhang
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinyi Chen
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenyang Yu
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zehui Zheng
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongzhong Jin
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Li
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Persson MSM, Harman KE, Vinogradova Y, Langan SM, Hippisley-Cox J, Thomas KS, Gran S. Validation study of bullous pemphigoid and pemphigus vulgaris recording in routinely collected electronic primary healthcare records in England. BMJ Open 2020; 10:e035934. [PMID: 32665386 PMCID: PMC7365488 DOI: 10.1136/bmjopen-2019-035934] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/12/2020] [Accepted: 06/03/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES The validity of bullous pemphigoid and pemphigus vulgaris recording in routinely collected healthcare data in the UK is unknown. We assessed the positive predictive value (PPV) for bullous pemphigoid and pemphigus vulgaris primary care Read codes in the Clinical Practice Research Datalink (CPRD) using linked inpatient data (Hospital Episode Statistics (HES)) as the diagnostic benchmark. SETTING Adult participants with bullous pemphigoid or pemphigus vulgaris registered with HES-linked general practices in England between January 1998 and December 2017. Code-based algorithms were used to identify patients from the CPRD and extract their benchmark blistering disease diagnosis from HES. PRIMARY OUTCOME MEASURE The PPVs of Read codes for bullous pemphigoid and pemphigus vulgaris. RESULTS Of 2468 incident cases of bullous pemphigoid and 431 of pemphigus vulgaris, 797 (32.3%) and 85 (19.7%) patients, respectively, had a hospitalisation record for a blistering disease. The PPV for bullous pemphigoid Read codes was 93.2% (95% CI 91.3% to 94.8%). Of the bullous pemphigoid cases, 3.0% had an HES diagnosis of pemphigus vulgaris and 3.8% of another blistering disease. The PPV for pemphigus vulgaris Read codes was 58.5% (95% CI 48.0% to 68.9%). Of the pemphigus vulgaris cases, 24.7% had an HES diagnosis of bullous pemphigoid and 16.5% of another blistering disease. CONCLUSIONS The CPRD can be used to study bullous pemphigoid, but recording of pemphigus vulgaris needs to improve in primary care.
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Affiliation(s)
- Monica S M Persson
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Karen E Harman
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | - Sinead M Langan
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Sciences, University of Oxford, Oxford, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Sonia Gran
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Genovese G, Di Zenzo G, Cozzani E, Berti E, Cugno M, Marzano AV. New Insights Into the Pathogenesis of Bullous Pemphigoid: 2019 Update. Front Immunol 2019; 10:1506. [PMID: 31312206 PMCID: PMC6614376 DOI: 10.3389/fimmu.2019.01506] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/17/2019] [Indexed: 12/19/2022] Open
Abstract
There are several lines of evidence indicating that the physiopathological bases of bullous pemphigoid (BP), the most common subepidermal autoimmune bullous disease, are hallmarked by the production of autoantibodies directed against the hemidesmosomal anchoring proteins BP180 and BP230. In contrast to the robustness of the latter assumption, the multifaceted complexity of upstream and downstream mechanisms implied in the pathogenesis of BP remains an area of intense speculation. So far, an imbalance between T regulatory cells and autoreactive T helper (Th) cells has been regarded as the main pathogenic factor triggering the autoimmune response in BP patients. However, the contributory role of signaling pathways fostering the B cell stimulation, such as Toll-like receptor activation, as well as that of ancillary inflammatory mechanisms responsible for blister formation, such as Th17 axis stimulation and the activation of the coagulation cascade, are still a matter of debate. In the same way, the pathomechanisms implied in the loss of dermal-epidermal adhesion secondary to autoantibodies binding are not fully understood. Herein, we review in detail the current concepts and controversies on the complex pathogenesis of BP, shedding light on the most recent theories emerging from the literature.
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Affiliation(s)
- Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Di Zenzo
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell'Immacolata (IDI) IRCCS, Rome, Italy
| | - Emanuele Cozzani
- DISSAL Section of Dermatology, Università degli Studi di Genova, Genoa, Italy
| | - Emilio Berti
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Massimo Cugno
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Internal Medicine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Cugno M, Borghi A, Garcovich S, Marzano AV. Coagulation and Skin Autoimmunity. Front Immunol 2019; 10:1407. [PMID: 31281319 PMCID: PMC6596352 DOI: 10.3389/fimmu.2019.01407] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/04/2019] [Indexed: 12/16/2022] Open
Abstract
Several lines of evidence indicate that the immune system, inflammation, and coagulation are simultaneously activated in autoimmune and immune-mediated skin diseases. Pro-inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha induce the expression of the main initiator of coagulation, i.e., tissue factor. The proteases of coagulation in turn act on protease-activated receptors inducing the expression of various pro-inflammatory cytokines triggering inflammation. The cross-talk among immune system, inflammation, and coagulation amplifies and maintains the activation of all three pathways. This review focuses on three skin disorders as chronic spontaneous urticaria (CSU), angioedema, and bullous pemphigoid (BP), in which the relationships among the three systems have been investigated or their clinical consequences are relevant. Markers of thrombin generation, fibrinolysis, and inflammation have been reported to be increased in the plasma during flares of CSU and angioedema, as well as in the active phase of BP, with the marker levels reverting to normal during remission. The coagulation activation seems to be important only at local level in CSU and angioedema while both at local and systemic levels in BP which is the only condition associated with an increased thrombotic risk. The prothrombotic state in autoimmune skin diseases raises the question of the indication of anticoagulant treatment, particularly in the presence of other cardiovascular risk factors.
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Affiliation(s)
- Massimo Cugno
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.,Medicina Interna, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Borghi
- Sezione di Dermatologia e Malattie Infettive, Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy
| | - Simone Garcovich
- Istituto di Dermatologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Angelo Valerio Marzano
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.,UOC Dermatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Ren Z, Narla S, Hsu DY, Silverberg JI. Association of serious infections with pemphigus and pemphigoid: analysis of the Nationwide Inpatient Sample. J Eur Acad Dermatol Venereol 2018; 32:1768-1776. [PMID: 29575160 DOI: 10.1111/jdv.14961] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 03/06/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pemphigus and pemphigoid are blistering disorders associated with barrier disruption, immune dysregulation and use of immunosuppressing systemic therapy, all of which may predispose towards serious infections. OBJECTIVES To determine whether pemphigus and pemphigoid are associated with increased likelihood of serious infections and the impact of such infections on mortality and cost of care. METHODS We analysed data from the 2002 to 2012 Nationwide Inpatient Sample, including a representative 20% sample of all hospitalizations in the US (total n = 72 108 077 adults). RESULTS Overall, 54.6% (95% CI: 53.6-55.6%) and 50.4% (49.0-51.8%) of inpatients with either pemphigoid or pemphigus had a diagnosis of serious infection, respectively, compared with 25.4% (25.2-25.6%) in those without either diagnosis. In multivariable logistic regression models controlling for gender, age, race/ethnicity and insurance status, pemphigoid or pemphigus was associated with 26 or 21 of 48 infections examined, respectively. In particular, both pemphigoid and pemphigus were associated with higher odds of infections of the skin, bones, respiratory, gastrointestinal, genitourinary and central nervous system, septicaemia and antibiotic-resistant infections. Pemphigus was also associated with aspergillus, pharyngitis and Pneumocystis Carinii pneumonia. Associations of any serious infection in both pemphigoid and pemphigus patients were older age, non-White race, lower median household income, government or no insurance, higher number of chronic conditions, and those with a diagnosis of Cushing's syndrome, diabetes, cancer or autoimmune disease. The diagnosis of any serious infection vs. no infection was associated with increased inpatient mortality and costs in both pemphigoid (mortality: 7.85% vs. 2.84%; cost: $16 115 vs. $10 653) and pemphigus (mortality: 6.78% vs. 1.88%; cost: $17 707 vs. $11 545) inpatients (P < 0.0001 for all). CONCLUSIONS Adults with pemphigus or pemphigoid had increased cutaneous, respiratory, multi-organ and systemic infections, which were associated with considerable inpatient mortality and cost burden. Moreover, there were significant clinical and healthcare disparities with respect to infections in patients with pemphigus or pemphigoid.
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Affiliation(s)
- Z Ren
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - S Narla
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - D Y Hsu
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - J I Silverberg
- Departments of Dermatology, Preventive Medicine and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Ungprasert P, Wijarnpreecha K, Thongprayoon C. Risk of venous thromboembolism in patients with bullous pemphigoid: A systematic review and meta-analysis. Indian J Dermatol Venereol Leprol 2018; 84:22-26. [DOI: 10.4103/ijdvl.ijdvl_827_16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Ren Z, Hsu D, Brieva J, Silverberg N, Langan S, Silverberg J. Hospitalization, inpatient burden and comorbidities associated with bullous pemphigoid in the U.S.A. Br J Dermatol 2016; 176:87-99. [DOI: 10.1111/bjd.14821] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Z. Ren
- Department of Dermatology Northwestern University Feinberg School of Medicine Chicago IL 60611 U.S.A
- The Graduate School Northwestern University Chicago IL 60611 U.S.A
| | - D.Y. Hsu
- Department of Dermatology Northwestern University Feinberg School of Medicine Chicago IL 60611 U.S.A
| | - J. Brieva
- Department of Dermatology Northwestern University Feinberg School of Medicine Chicago IL 60611 U.S.A
| | - N.B. Silverberg
- Department of Dermatology Icahn School of Medicine at Mount Sinai New York NY U.S.A
| | - S.M. Langan
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London U.K
| | - J.I. Silverberg
- Department of Dermatology Northwestern University Feinberg School of Medicine Chicago IL 60611 U.S.A
- Departments of Preventive Medicine and Medical Social Sciences Northwestern University Feinberg School of Medicine Chicago IL 60611 U.S.A
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16
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Murrell DF. Screening for infections prior to initiating immunosuppressive treatment for patients with autoimmune blistering diseases. Br J Dermatol 2016; 171:1285-6. [PMID: 25523248 DOI: 10.1111/bjd.13451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- D F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Gray Street, Kogarah, Sydney, NSW, 2217, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
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Tissue Factor in Dermatitis Herpetiformis and Bullous Pemphigoid: Link between Immune and Coagulation System in Subepidermal Autoimmune Bullous Diseases. Mediators Inflamm 2015; 2015:870428. [PMID: 27057091 PMCID: PMC4709721 DOI: 10.1155/2015/870428] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 11/27/2015] [Accepted: 12/10/2015] [Indexed: 01/19/2023] Open
Abstract
Dermatitis herpetiformis (DH) and bullous pemphigoid (BP) are skin diseases associated with eosinophilic and neutrophilic infiltrations. Although chemokines are critical for the selective accumulation and activation of various leukocyte subsets in the inflammatory process, there are few findings concerning inflammatory cells and production of coagulation factors in blistering diseases. Skin biopsies were taken from 14 patients with DH, 27 with BP, and 20 control subjects. The localization and expression of tissue factor (TF) in skin lesions and perilesional skin were studied by immunohistochemistry and confirmed by Western Blot. Moreover the plasma concentrations of TF were measured by immunoassays. D dimers, fibrinogen, and selected coagulation parameters were measured by routine methods. Expression of TF in the epidermis and in inflammatory influxed cells in dermis was detected in skin biopsies from BP patients. Examined TF expression was detected in perilesional skin of all BP patients too. The expression of TF was not observed in biopsies from healthy people and DH patients. The findings of the study show an increased expression of tissue factor in the lesional and perilesional skin of patients with bullous pemphigoid. The difference in chemokine pattern expression and variations in the cellular infiltration in BP and DH cause variable expression of TF.
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Cugno M, Marzano AV, Bucciarelli P, Balice Y, Cianchini G, Quaglino P, Calzavara Pinton P, Caproni M, Alaibac M, De Simone C, Patrizi A, Cozzani E, Papini M, Tedeschi A, Berti E, Rosendaal FR. Increased risk of venous thromboembolism in patients with bullous pemphigoid. The INVENTEP (INcidence of VENous ThromboEmbolism in bullous Pemphigoid) study. Thromb Haemost 2015; 115:193-9. [PMID: 26245987 DOI: 10.1160/th15-04-0309] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/19/2015] [Indexed: 01/24/2023]
Abstract
Activation of blood coagulation has been demonstrated in bullous pemphigoid (BP), a rare autoimmune blistering disease, potentially leading to a prothrombotic state. In order to evaluate the incidence of venous thromboembolism (VTE) in BP, a cohort study was carried out on 432 BP patients (59% females; median age 76 years, interquartile range [IQR]: 68-82). At diagnosis, autoimmune bullous skin disorder intensity score (ABSIS) was calculated. VTE incidence was standardised with rates of the general population. Multivariable Cox proportional hazard model was used to estimate the hazard ratio of VTE according to ABSIS and concomitant risk factors. During a median follow-up of 4.2 years, 31 objectively-diagnosed VTE events were recorded. The incidence rate of VTE (per 1000 patient-years) was 17.2 overall (95% confidence interval [CI]: 11.1-23.2), 56.7 (95%CI: 33.0-80.4) during acute phase (22 VTE) and 6.3 (95%CI: 2.8-11.3) during remission (9 VTE). The standardised incidence ratio was 4.06 (95%CI: 2.73-5.65), higher during the acute phase (14.86, 95%CI: 9.20-21.88) than during remission (1.48, 0.66-2.63). The adjusted hazard ratio of VTE was 2.74 (95%CI: 1.07-7.04) for ABSIS > 48 vs ABSIS < 28, and 2.56 (95%CI: 1.00-6.70) in patients with ≥ 2 concomitant risk factors. In conclusion, BP patients have a 15-fold increased VTE risk during acute phase, proportional to disease severity and heightened by concomitant risk factors.
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Affiliation(s)
- Massimo Cugno
- Massimo Cugno, MD, Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, Via Pace 9, 20122 Milano, Italy, Tel.: +39 02 55036340, Fax: +39 02 50320742, E-mail:
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Phoon YW, Fook-Chong SM, Koh HY, Thirumoorthy T, Pang SM, Lee HY. Infectious complications in bullous pemphigoid: An analysis of risk factors. J Am Acad Dermatol 2015; 72:834-9. [DOI: 10.1016/j.jaad.2015.01.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 01/07/2015] [Accepted: 01/19/2015] [Indexed: 11/29/2022]
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Cugno M, Marzano AV, Lorini M, Carbonelli V, Tedeschi A. Enhanced tissue factor expression by blood eosinophils from patients with hypereosinophilia: a possible link with thrombosis. PLoS One 2014; 9:e111862. [PMID: 25375118 PMCID: PMC4222944 DOI: 10.1371/journal.pone.0111862] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/05/2014] [Indexed: 12/30/2022] Open
Abstract
Thrombotic risk is increased in eosinophil-mediated disorders, and several hypotheses have been proposed to link eosinophilia and thrombosis. In particular, eosinophils have been described as source of tissue factor (TF), the main initiator of blood coagulation; however, this aspect is still controversial. This study was aimed to evaluate whether TF expression varies in eosinophils isolated from normal subjects and patients with different hypereosinophilic conditions. Eosinophils were immunologically purified from peripheral blood samples of 9 patients with different hypereosinophilic conditions and 9 normal subjects. Western blot analysis and real-time polymerase chain reaction (RT-PCR) were performed to test eosinophil TF expression. For comparison, TF expression was evaluated in monocytes from blood donors and in human endothelial (ECV304) and fibroblast (IMR90) cell lines. Western blot analysis revealed a major band of 47,000 corresponding to native TF in homogenates of purified eosinophils with a higher intensity in the 9 patients than in the 9 controls (p<0.0001). According to RT-PCR cycle threshold (Ct), TF gene expression was higher in eosinophils from patients than in those from controls, median (range) 35.10 (19.45-36.50) vs 37.17 (35.33-37.87) (p = 0.002), and was particularly abundant in one patient with idiopathic hypereosinophilic syndrome and ischemic heart attacks (Ct: 19.45). TF gene expression was moderate in monocytes, Ct: 31.32 (29.82-33.49) and abundant in endothelial cells, Ct: 28.70 (27.79-29.57) and fibroblasts, Ct: 22.77 (19.22-25.05). Our results indicate that human blood eosinophils contain variable amounts of TF. The higher TF expression in patients with hypereosinophilic disorders may contribute to increase the thrombotic risk.
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Affiliation(s)
- Massimo Cugno
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
- Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
- * E-mail:
| | - Angelo V. Marzano
- Unità Operativa di Dermatologia, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Maurizio Lorini
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - Vincenzo Carbonelli
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - Alberto Tedeschi
- Unità Operativa di Allergologia e Immunologia Clinica, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
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Cai SCS, Allen JC, Lim YL, Chua SH, Tan SH, Tang MBY. Mortality of bullous pemphigoid in Singapore: risk factors and causes of death in 359 patients seen at the National Skin Centre. Br J Dermatol 2014; 170:1319-26. [PMID: 24372558 DOI: 10.1111/bjd.12806] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common autoimmune-mediated subepidermal blistering skin disease and is associated with significant morbidity and mortality. OBJECTIVES To determine the 3-year mortality rate, risk factors and causes of death in patients with BP in Singapore, compared with the general population. METHODS We conducted a retrospective cohort study of all newly diagnosed patients with BP seen at the National Skin Centre from 1 April 2004 to 31 December 2009. Demographic and clinical data on comorbidities and treatment were recorded. Mortality information was obtained from the National Registry of Diseases. RESULTS In total 359 patients were included in our study. The 1-, 2-, 3-year mortality rates were 26·7%, 38·4% and 45·7%, respectively. The 3-year standardized mortality risk for patients with BP was 2·74 (95% confidence interval 2·34-3·19) times higher than for the age- and sex-matched general population. Parkinson disease, heart failure and chronic renal disease were associated with increased mortality, while combination treatment with low-to-moderate-dose corticoste-roids and immunomodulatory agents such as doxycycline and/or nicotinamide was associated with lower mortality. Overall, infections were the most common cause of death (59·8%), with the main causes of death being pneumonia (42·7%), cardiovascular disease (14·6%) and stroke (11·6%). CONCLUSIONS This study confirms an increased 3-year mortality rate for patients with BP in Singapore. Risk factors for increased mortality include medical comorbidities, especially neurological, cardiac and renal diseases. Treatment with combination therapy, including the use of low-to-moderate-dose corticosteroid, appeared to decrease mortality risk in patients with BP.
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Affiliation(s)
- S C S Cai
- Duke-NUS Graduate Medical School, 8 College Road, Singapore, 169857, Singapore
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Tedeschi A, Marzano AV, Lorini M, Balice Y, Cugno M. Eosinophil cationic protein levels parallel coagulation activation in the blister fluid of patients with bullous pemphigoid. J Eur Acad Dermatol Venereol 2014; 29:813-7. [PMID: 24650303 DOI: 10.1111/jdv.12464] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 02/17/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune blistering disease due to autoantibodies against two hemidesmosomal antigens, namely BP180 and BP230, and characterized by coagulation activation both at cutaneous and systemic levels. Skin-infiltrating eosinophils contribute to bulla formation and, upon activation, are supposed to initiate the coagulation cascade. OBJECTIVE The aim of this study was to investigate whether the activation of eosinophils and coagulation are linked in BP. METHODS We evaluated the correlation between eosinophil cationic protein (ECP) levels and concentrations of the prothrombotic markers F1 + 2 and D-dimer in blister fluid and blood samples of 30 BP patients. Thirty healthy subjects were used as normal controls. RESULTS ECP, F1 + 2 and D-dimer plasma levels were significantly higher in BP patients than in normal subjects. A significant correlation was found between ECP plasma levels and blood eosinophil count (r = 0.54, P = 0.002). F1 + 2 plasma levels positively correlated with disease severity, expressed as the percentage of body surface area involved (r = 0.36, P = 0.048). A striking increase in ECP (288.8 ± 45.2 ng/mL), F1 + 2 (31 409.9 ± 2929.4 pmol/L) and D-dimer levels (342 798.3 ± 44 206 ng/mL) was found in blister fluid from BP patients. In blister fluid, ECP levels were significantly higher than in peripheral blood (P < 0.0001) and were positively correlated with the levels of both F1 + 2 (r = 0.4, P = 0.02) and D-dimer (r = 0.5, P = 0.0045). CONCLUSIONS ECP levels are strikingly elevated in blister fluids from BP patients and correlate with markers of coagulation activation, supporting the view that eosinophils initiate the coagulation cascade at skin level.
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Affiliation(s)
- A Tedeschi
- Unità Operativa di Allergologia e Immunologia Clinica, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
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Ruocco E, Wolf R, Caccavale S, Brancaccio G, Ruocco V, Lo Schiavo A. RETRACTED: Bullous pemphigoid: Associations and management guidelines. Clin Dermatol 2013; 31:400-412. [DOI: 10.1016/j.clindermatol.2013.01.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Lehman JS, Khunger M, Lohse CM. Infection in autoimmune bullous diseases: A retrospective comparative study. J Dermatol 2013; 40:613-9. [DOI: 10.1111/1346-8138.12175] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 03/21/2013] [Indexed: 12/27/2022]
Affiliation(s)
- Julia S. Lehman
- Division of Dermatopathology and Cutaneous Immunopathology; Department of Dermatology; Mayo Clinic; Rochester; Minnesota; USA
| | - Monica Khunger
- All India Institute of Medical Sciences; New Delhi; India
| | - Christine M. Lohse
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Rochester; Minnesota; USA
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Schulze F, van Beek N, Terheyden P, Zillikens D, Schmidt E. Concomitant bullous pemphigoid and dermatitis herpetiformis. Dermatology 2013; 226:217-21. [PMID: 23775006 DOI: 10.1159/000349982] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 02/04/2013] [Indexed: 11/19/2022] Open
Abstract
Dermatitis herpetiformis and bullous pemphigoid are bullous autoimmune diseases of the skin microscopically characterized by subepidermal blisters. We present a 77-year-old patient with an 18-month history of disseminated pruritic papular lesions. Direct immunofluorescence microscopy revealed linear deposition of IgG at the basement membrane zone as well as granular deposits of IgA in the papillary dermis. Circulating IgG antibodies against BP180, BP230 and gliadin as well as IgA reactivity against endomysium, tissue transglutaminase, and gliadin were detected compatible with both bullous pemphigoid and dermatitis herpetiformis. Here, we review the English literature on all previously reported patients with co-occurrence of both entities. Interestingly, in previous cases, tissue-bound and serum autoantibodies against the respective target antigens had not yet been completely characterized.
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Badia M, Serviá L, Casanova JM, Montserrat N, Vilanova J, Vicario E, Rodriguez A, Trujillano J. Classification of dermatological disorders in critical care patients: a prospective observational study. J Crit Care 2012; 28:220.e1-8. [PMID: 22835424 DOI: 10.1016/j.jcrc.2012.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 12/11/2011] [Accepted: 06/11/2012] [Indexed: 01/14/2023]
Abstract
PURPOSE The objective of this study was to identify dermatological disorders detected in the intensive care unit (ICU), to analyze their specific characteristics, and to define a useful classification for intensive care physicians. MATERIALS AND METHODS This was a prospective, observational study over a 3-year period (2006-2009) in a mixed ICU. This included all patients presenting with dermatological disorders that were detected at the time of ICU admission or developed along the ICU stay. We recorded the specific characteristics of the disorders and its evolution and treatment, which enabled us to classify the different observed conditions. As general variables, we analyzed demographic factors, the principal diagnosis, ICU procedures, the severity score (Acute Physiology and Chronic Health Evaluation II), length of stay, and mortality. RESULTS One hundred thirty-three patients showed at least one dermatological disorder (9.3%) and were classified into (1) preexisting dermatological disorders, (2) life-threatening dermatologic disorders, (3) systemic dermatological disorders, (4) infectious dermatological disorders, (5) reactive dermatological disorders, and (6) others. CONCLUSIONS Dermatological disorders are a frequent problem in the ICU, and their recognition is key to set up an appropriate care plan. We propose a classification and description of the different types of dermatological disorders that are most commonly found in ICUs.
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Affiliation(s)
- Mariona Badia
- Intensive Care Unit, Hospital Universitario Arnau de Vilanova, 25198 Lleida, Spain
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Johannesdottir SA, Schmidt M, Horváth-Puhó E, Sørensen HT. Autoimmune skin and connective tissue diseases and risk of venous thromboembolism: a population-based case-control study. J Thromb Haemost 2012; 10:815-21. [PMID: 22353382 DOI: 10.1111/j.1538-7836.2012.04666.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Systemic inflammation is associated with vessel wall damage, upregulation of procoagulants, downregulation of anticoagulants, and suppression of fibrinolysis. Autoimmune diseases may therefore increase the risk of venous thromboembolism (VTE). OBJECTIVES To examine whether autoimmune skin and connective tissue diseases are associated with increased VTE risk. METHODS We conducted this population-based case-control study in northern Denmark, using administrative databases. From 1999 to 2009, we identified 14,721 VTE cases and 147,210 birth year-matched, sex-matched and county-matched population controls. The date of diagnosis/matching was considered to be the index date for cases and controls. For all study subjects, we identified hospital diagnoses of autoimmune skin or connective tissue diseases between 1977 and the index date. We used conditional logistic regression with adjustment for VTE risk factors to calculate odds ratios and 95% confidence intervals (CIs) for patients with vs. without autoimmune disease. Given the risk-set sampling design, odds ratios estimate incidence rate ratios (IRRs). RESULTS Autoimmune skin disease was not associated with VTE (IRR 1.0; 95% CI 0.9-1.2). Patients with connective tissue disease had an increased VTE risk within 90 days (IRR 2.3; 95% CI 1.5-3.7) and 91-365 days (IRR 2.0; 95% CI 1.5-2.8) after diagnosis, but not thereafter (IRR 1.1; 95% CI 1.0-1.2). Among connective tissue diseases, the greatest overall risk increases were found for juvenile rheumatoid arthritis (IRR 3.0; 95% CI 1.4-6.4) and systemic lupus erythematosus (IRR 2.8; 95% CI 1.7-4.7). CONCLUSIONS Autoimmune connective tissue disease was associated with an increased risk of VTE within 1 year after diagnosis, whereas skin diseases were not.
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Affiliation(s)
- S A Johannesdottir
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
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Du-Thanh A, Merlet S, Maillard H, Bernard P, Joly P, Estève E, Richard M, Pauwels C, Ingen-Housz-Oro S, Guillot B, Dereure O. Combined treatment with low-dose methotrexate and initial short-term superpotent topical steroids in bullous pemphigoid: an open, multicentre, retrospective study. Br J Dermatol 2011; 165:1337-43. [DOI: 10.1111/j.1365-2133.2011.10531.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lehman JS, Murrell DF, Camilleri MJ, Kalaaji AN. Infection and Infection Prevention in Patients Treated with Immunosuppressive Medications for Autoimmune Bullous Disorders. Dermatol Clin 2011; 29:591-8. [DOI: 10.1016/j.det.2011.06.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Yang YW, Chen YH, Xirasagar S, Lin HC. Increased risk of stroke in patients with bullous pemphigoid: a population-based follow-up study. Stroke 2010; 42:319-23. [PMID: 21164122 DOI: 10.1161/strokeaha.110.596361] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Although previous research reveals that cardiovascular events and thromboembolic diseases are important causes of death in patients with bullous pemphigoid (BP), the risk of stroke after the diagnosis of BP relative to the general population remains unknown. Using a randomly selected nationwide population-based sample, this study investigates the risk of stroke in patients with BP compared with unaffected individuals of a similar age. METHODS This study analyzes data from Taiwan's National Health Insurance Research Database. This sample included 390 patients with BP and 1950 matched subjects as a comparison group. Stratified Cox proportional hazard regressions were used to calculate the 3-year stroke risk for these 2 groups after adjusting for patient's age, sex, and comorbid medical disorders at baseline. RESULTS Of the 2340 patients in the sample, 312 patients (13.3%) had strokes during the 3-year follow-up period, 89 (22.8% of the patients with BP) in the study group and 223 (11.4% of patients without BP) in the comparison group (P<0.001). The hazard ratio for stroke for patients with BP was 2.37 (95% CI, 1.78 to 3.15; P<0.001) times as high that for patients without BP within the 3-year follow-up period after adjusting for hypertension, diabetes, hyperlipidemia, heart failure, atrial fibrillation, and coronary heart disease. CONCLUSIONS Patients with BP have an increased risk of stroke and particularly ischemic stroke.
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Affiliation(s)
- Ya-Wen Yang
- School of Health Care Administration, Taipei Medical University, Taipei 110, Taiwan
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