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Buján-Bonino C, Bosch-Amate X, Hashimoto T, Ishii N, Mascaró JM. IgA-Anti-p200-Pemphigoid mit areolärem Tropismus. J Dtsch Dermatol Ges 2023; 21:1038-1040. [PMID: 37700423 DOI: 10.1111/ddg.15130_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/17/2023] [Indexed: 09/14/2023]
Affiliation(s)
- Cecilia Buján-Bonino
- Department of Dermatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Xavier Bosch-Amate
- Department of Dermatology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Takashi Hashimoto
- Department of Dermatology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Kurume, Japan
| | - José-Manuel Mascaró
- Department of Dermatology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
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Buján-Bonino C, Bosch-Amate X, Hashimoto T, Ishii N, Mascaró JM. IgA anti-p200 pemphigoid with areolar tropism. J Dtsch Dermatol Ges 2023; 21:1038-1040. [PMID: 37376797 DOI: 10.1111/ddg.15130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/17/2023] [Indexed: 06/29/2023]
Affiliation(s)
- Cecilia Buján-Bonino
- Department of Dermatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Xavier Bosch-Amate
- Department of Dermatology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Takashi Hashimoto
- Department of Dermatology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Kurume, Japan
| | - José-Manuel Mascaró
- Department of Dermatology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
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Xie YH, Wang SH, Li SZ, Zuo YG. Coexistence of Anti-p200 Pemphigoid and Psoriasis: A Systematic Review. Front Immunol 2022; 13:839094. [PMID: 35317170 PMCID: PMC8934418 DOI: 10.3389/fimmu.2022.839094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background A close association between psoriasis and anti-p200 pemphigoid has been demonstrated by numerous studies. However, the clinical characteristics of patients suffering from these two entities have not yet been well-elucidated. Objective This study aimed to review the case reports and case series, summarizing clinical features and therapeutic strategies in patients suffering from anti-p200 pemphigoid and psoriasis. Methods A systematic review was conducted by searching PubMed, EMBASE, and Web of Science databases for studies published in English involving patients with psoriasis and anti-p200 pemphigoid on 6 September 2021. All case reports and case series reporting patients diagnosed with anti-p200 pemphigoid and psoriasis were included in this systematic review. Results A total of 21 eligible studies comprising 26 anti-p200 pemphigoid patients with preceding psoriasis were included in the qualitative synthesis. The average age at blisters eruption was 62.5 years, and the mean duration between the two entities was 15.6 years. Twenty-four percent of patients developed bullous lesions during UV therapy. Clinical manifestation of bullae and/or vesicles was recorded in all patients, and the trunk (94.7%) was most frequently involved, with only 15.8% reporting mucosal involvement. Epitope spreading was detected by immunoblotting in 33.3% of patients. All the patients reached completed remission during the course of disease, with 36.8% experiencing at least one relapse. Monotherapy of prednisolone was the leading therapeutic approach (n=6, 31.6%) required for disease control, but 5 (83.3%) of them suffered from blister recurrence after tapering or ceasing corticosteroid. Conclusion Most of the clinical aspects of patients with anti-p200 pemphigoid and psoriasis were similar to what was demonstrated in previous articles on anti-p200 pemphigoid. Nevertheless, compared with other anti-p200 pemphigoid cases without psoriasis, a clinical manifestation pattern with more frequent involvement of the trunk and less mucosal involvement was illustrated in those with psoriasis. Generally, monotherapy is sufficient for a complete remission for such patients. However, one or more relapses have been recorded in a considerable portion of patients, especially those prescribed with prednisolone. It reminded us to be more cautious during a tapering of medication.
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Affiliation(s)
| | | | | | - Ya-Gang Zuo
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
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Koneczny I. Update on IgG4-mediated autoimmune diseases: New insights and new family members. Autoimmun Rev 2020; 19:102646. [PMID: 32801046 DOI: 10.1016/j.autrev.2020.102646] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/08/2020] [Indexed: 12/23/2022]
Abstract
Antibodies of IgG4 subclass are exceptional players of the immune system, as they are considered to be immunologically inert and functionally monovalent, and as such may be part of classical tolerance mechanisms. IgG4 antibodies are found in a range of different diseases, including IgG4-related diseases, allergy, cancer, rheumatoid arthritis, helminth infection and IgG4 autoimmune diseases, where they may be pathogenic or protective. IgG4 autoimmune diseases are an emerging new group of diseases that are characterized by pathogenic, antigen-specific autoantibodies of IgG4 subclass, such as MuSK myasthenia gravis, pemphigus vulgaris and thrombotic thrombocytopenic purpura. The list of IgG4 autoantigens is rapidly growing and to date contains 29 candidate antigens. Interestingly, IgG4 autoimmune diseases are restricted to four distinct organs: 1) the central and peripheral nervous system, 2) the kidney, 3) the skin and mucous membranes and 4) the vascular system and soluble antigens in the blood circulation. The pathogenicity of IgG4 can be validated using our classification system, and is usually excerted by functional blocking of protein-protein interaction.
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Affiliation(s)
- Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Währingergürtel 18-20, 1090 Vienna, Austria.
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Laufer Britva R, Amber K, Cohen A, Kridin K. Treatment and clinical outcomes in anti‐p200 pemphigoid: a systematic review. J Eur Acad Dermatol Venereol 2019; 34:465-472. [DOI: 10.1111/jdv.15961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/18/2019] [Indexed: 01/05/2023]
Affiliation(s)
- R. Laufer Britva
- Department of Dermatology Rambam Health Care Campus Haifa Israel
| | - K.T. Amber
- Department of Dermatology University of Illinois at Chicago Chicago IL USA
| | - A.D. Cohen
- Siaal Research Center for Family Medicine and Primary Care Faculty of Health Sciences Ben‐Gurion University of the Negev Beer‐Sheva Israel
| | - K. Kridin
- Department of Dermatology Rambam Health Care Campus Haifa Israel
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Kridin K, Ahmed AR. Anti-p200 Pemphigoid: A Systematic Review. Front Immunol 2019; 10:2466. [PMID: 31695695 PMCID: PMC6817563 DOI: 10.3389/fimmu.2019.02466] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/03/2019] [Indexed: 12/25/2022] Open
Abstract
The many clinical aspects of anti-p200 pemphigoid are not well-characterized. We aimed to analyze and correlate known existing data on the epidemiological, clinical, histological, and immunological features of anti-p200 pemphigoid. We performed a review using Medline, Embase, and Web of Science databases (1900–2018). Case reports and series of patients were included. A total of 68 eligible studies that comprised 113 anti-p200 pemphigoid patients were included in the qualitative analysis, where there was a mean age of onset of 65.5 years. All patients presented with bullae/vesicles, and 54.3% had urticarial plaques. A similarity to bullous pemphigoid was reported in 66.1% of cases, but palmoplantar (51.4%), cephalic (40.3%), and mucosal (38.5%) involvement, besides frequent development of scars/milia (15.7%), were reported. Autoantibodies against recombinant laminin γ1 were detected in the sera of 73.1% of patients. Psoriasis was present in 28.3% of anti-p200 pemphigoid patients, particularly among Japanese patients (56.4%). The incidence of pustular psoriasis in this subgroup, was significantly greater than in the normal population. In conclusion, the diagnosis of anti-p200 pemphigoid may be suspected when a subepidermal autoimmune blistering disease develops in a younger age group, along with significant acral and cephalic distribution and mucosal involvement.
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
| | - A Razzaque Ahmed
- Department of Dermatology, Center for Blistering Diseases, Tufts University School of Medicine, Boston, MA, United States
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Abstract
Anti-p200 pemphigoid is a rare autoimmune blistering disease. It belongs to the group of pemphigoid diseases and was first described in 1996. The diagnostic gold standard is the combination of (1) linear deposits of immunoreactants at the dermal epidermal junction by direct immunofluorescence microscopy of a perilesional skin biopsy, (2) detection of circulating autoantibodies binding to the dermal side (blister floor) of human salt split skin by indirect immunofluorescence microscopy, and reactivity with a 200 kDa protein (p200) in extract of human dermis by immunoblotting. In 2009, laminin γ1 was described as an additional target antigen in 90% of anti-p200 pemphigoid patients. Since ex vivo and in vivo studies have shown no direct pathogenic relevance for laminin γ1 antibodies and the preadsorption of patient sera against laminin γ1 does not reduce their reactivity with p200, the molecular identity of p200 still remains to be elucidated. The clinical phenotype of the disease is heterogeneous; in most cases, however, it resembles bullous pemphigoid. Anti-p200 patients are younger and skin lesions more often appear on palms of the hands and soles of the feet than in bullous pemphigoid. Therapy consists of topical and systemic corticosteroids. In addition, the use of daspone and immunosuppressants has been reported.
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Amber KT, Murrell DF, Schmidt E, Joly P, Borradori L. Autoimmune Subepidermal Bullous Diseases of the Skin and Mucosae: Clinical Features, Diagnosis, and Management. Clin Rev Allergy Immunol 2018; 54:26-51. [PMID: 28779299 DOI: 10.1007/s12016-017-8633-4] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Autoimmune subepidermal blistering diseases of the skin and mucosae constitute a large group of sometimes devastating diseases, encompassing bullous pemphigoid, gestational pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, and anti-p200 pemphigoid. Their clinical presentation is polymorphic. These autoimmune blistering diseases are associated with autoantibodies that target distinct components of the basement membrane zone of stratified epithelia. These autoantigens represent structural proteins important for maintenance of dermo-epidermal integrity. Bullous pemphigoid (BP) is the most common subepidermal autoimmune blistering disease of the skin and mucosae. Although the disease typically presents with a generalized blistering eruption associated with itch, atypical variants with either localized bullous lesions or "non-bullous" presentations are observed in approximately 20% of patients. A peculiar form of BP typically associated with pregnancy is pemphigoid gestationis. In anti-p200 pemphigoid, patients present with tense blisters on erythematosus or normal skin resembling BP, with a predilection for acral surfaces. These patients have antibodies targeting the 200-kDa basement membrane protein. Epidermolysis bullosa is a rare autoimmune blistering disease associated with autoantibodies against type VII collagen that can have several phenotypes including a classical form mimicking dystrophic epidermolysis bullosa, an inflammatory presentation mimicking BP, or mucous membrane pemphigoid-like lesions. Mucous membrane pemphigoid (MMP) is the term agreed upon by international consensus for an autoimmune blistering disorder, which affects one or more mucous membrane and may involve the skin. The condition involves a number of different autoantigens in the basement membrane zone. It may result in severe complications from scarring, such as blindness and strictures. Diagnosis of these diseases relies on direct immunofluorescence microscopy studies and immunoserological assays. Management of affected patients is often challenging. We will here review the clinical and immunopathological features as well as the pathophysiology of this group of organ-specific autoimmune diseases. Finally, we will discuss the diagnostic approach and the principles of management in clinical practice.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of California Irvine Health, 118 Med Surg 1, Irvine, CA, 92697, USA.
| | - Dedee F Murrell
- Department of Dermatology, St. George Hospital, Gray Street, Kogarah, Sydney, NSW, Australia
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Pascal Joly
- Department of Dermatology, INSERM U901, University of Rouen, Rouen, France
| | - Luca Borradori
- Department of Dermatology, University of Bern, Bern, Switzerland
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Didona D, Di Zenzo G. Humoral Epitope Spreading in Autoimmune Bullous Diseases. Front Immunol 2018; 9:779. [PMID: 29719538 PMCID: PMC5913575 DOI: 10.3389/fimmu.2018.00779] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/28/2018] [Indexed: 12/15/2022] Open
Abstract
Autoimmune blistering diseases are characterized by autoantibodies against structural adhesion proteins of the skin and mucous membranes. Extensive characterization of their autoantibody targets has improved understanding of pathogenesis and laid the basis for the study of antigens/epitopes diversification, a process termed epitope spreading (ES). In this review, we have reported and discussed ES phenomena in autoimmune bullous diseases and underlined their functional role in disease pathogenesis. A functional ES has been proposed: (1) in bullous pemphigoid patients and correlates with the initial phase of the disease, (2) in pemphigus vulgaris patients with mucosal involvement during the clinical transition to a mucocutaneous form, (3) in endemic pemphigus foliaceus, underlining its role in disease pathogenesis, and (4) in numerous cases of disease transition associated with an intermolecular diversification of immune response. All these findings could give useful information to better understand autoimmune disease pathogenesis and to design antigen/epitope specific therapeutic approaches.
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Affiliation(s)
- Dario Didona
- Clinic for Dermatology and Allergology, University Hospital Marburg, University of Marburg, Marburg, Germany
| | - Giovanni Di Zenzo
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
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Usefulness of a Simple Immunohistochemical Staining Technique to Differentiate Anti-p200 Pemphigoid From Other Autoimmune Blistering Diseases: A Report of 2 Cases. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2016.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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11
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Autoimmunity against laminins. Clin Immunol 2016; 170:39-52. [PMID: 27464450 DOI: 10.1016/j.clim.2016.07.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/30/2016] [Accepted: 07/22/2016] [Indexed: 12/12/2022]
Abstract
Laminins are ubiquitous constituents of the basement membranes with major architectural and functional role as supported by the fact that absence or mutations of laminins lead to either lethal or severely impairing phenotypes. Besides genetic defects, laminins are involved in a wide range of human diseases including cancer, infections, and inflammatory diseases, as well as autoimmune disorders. A growing body of evidence implicates several laminin chains as autoantigens in blistering skin diseases, collagenoses, vasculitis, or post-infectious autoimmunity. The current paper reviews the existing knowledge on autoimmunity against laminins referring to both experimental and clinical data, and on therapeutic implications of anti-laminin antibodies. Further investigation of relevant laminin epitopes in pathogenic autoimmunity would facilitate the development of appropriate diagnostic tools for thorough characterization of patients' antibody specificities and should decisively contribute to designing more specific therapeutic interventions.
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García-Díez I, Martínez-Escala ME, Ishii N, Hashimoto T, Mascaró Galy JM, Pujol RM, Herrero-González JE. Usefulness of a Simple Immunohistochemical Staining Technique to Differentiate Anti-p200 Pemphigoid From Other Autoimmune Blistering Diseases: A Report of 2 Cases. ACTAS DERMO-SIFILIOGRAFICAS 2016; 108:e1-e5. [PMID: 27095685 DOI: 10.1016/j.ad.2015.10.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/17/2015] [Accepted: 10/04/2015] [Indexed: 10/21/2022] Open
Abstract
Anti-p200 pemphigoid is a rare autoimmune subepidermal blistering disease characterized by the presence of circulating immunoglobulin G antibodies directed against laminin gamma-1, a 200-kDa protein located in the lamina lucida of the basement membrane. We review the clinical, histopathological and immunological characteristics of the first 2 cases described in Spain. Anti-p200 pemphigoid shares histopathological and immunopathological findings with epidermolysis bullosa acquisita, the main entity in the differential diagnosis. However, its management follows the same guidelines as those used for bullous pemphigoid. The diagnosis is confirmed by immunoblotting, which is a complex technique available in few centers. We propose the immunohistochemical detection of collagen type IV on the floor of the blister, combined with standard immunofluorescence techniques, as a simple, accessible alternative to differentiate anti-p200 pemphigoid from epidermolysis bullosa acquisita.
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Affiliation(s)
- I García-Díez
- Departamento de Dermatología, Hospital del Mar, Parc de Salut Mar, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, España.
| | - M E Martínez-Escala
- Departamento de Dermatología, Hospital del Mar, Parc de Salut Mar, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, España
| | - N Ishii
- Departamento de Dermatología, Facultad de Medicina de la Universidad de Kurume, Fukuoka, Japón
| | - T Hashimoto
- Departamento de Dermatología, Facultad de Medicina de la Universidad de Kurume, Fukuoka, Japón
| | - J M Mascaró Galy
- Departamento de Dermatología, Hospital Clínic, Barcelona, España
| | - R M Pujol
- Departamento de Dermatología, Hospital del Mar, Parc de Salut Mar, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, España
| | - J E Herrero-González
- Departamento de Dermatología, Hospital del Mar, Parc de Salut Mar, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, España
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McCarty M, Zillikens D, Fivenson D. Anti-p200 pemphigoid (anti-laminin-γ1 pemphigoid) demonstrating pathergy. Int J Womens Dermatol 2015; 1:173-174. [PMID: 28491985 PMCID: PMC5419765 DOI: 10.1016/j.ijwd.2015.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 09/04/2015] [Accepted: 09/15/2015] [Indexed: 10/27/2022] Open
Abstract
Anti-p200 pemphigoid, also called anti-laminin-γ1 pemphigoid, is a recently defined entity. First reported in 1996, the incidence is relatively rare, with approximately 70 reports in the literature. Clinical presentation is heterogeneous, but the disease most commonly mimics bullous pemphigoid with urticarial papules, plaques, or tense bullae on the trunk or extremities. Described here is a case with additional features of pathergy that have not yet been reported in the literature.
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Affiliation(s)
- Morgan McCarty
- St. Joseph Mercy Health System, Dermatology Residency Program, Ypsilanti, MI
| | - Deltef Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein-Campus Lübeck, Lübeck, Germany
| | - David Fivenson
- St. Joseph Mercy Health System, Dermatology Residency Program, Ypsilanti, MI.,David Fivenson, MD, Dermatology PLLC, Ann Arbor, MI
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Goletz S, Hashimoto T, Zillikens D, Schmidt E. Anti-p200 pemphigoid. J Am Acad Dermatol 2014; 71:185-91. [PMID: 24767733 DOI: 10.1016/j.jaad.2014.02.036] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 02/17/2014] [Accepted: 02/19/2014] [Indexed: 11/18/2022]
Abstract
Anti-p200 pemphigoid is a rare subepidermal blistering skin disease. Patients' autoantibodies label the dermal side of 1 mol/L NaCl-split human skin by indirect immunofluorescence microscopy and recognize a 200-kd protein by immunoblotting of human dermal extract. Clinically, anti-p200 pemphigoid is characterized by tense blisters and vesicles, erosions, and urticarial plaques, closely resembling bullous pemphigoid and the inflammatory variant of epidermolysis bullosa acquisita. Recently, 90% of anti-p200 pemphigoid sera were shown to recognize laminin γ1. The C-terminus of laminin γ1 was identified as an immunodominant region and in its recombinant form was used by immunoblotting and enzyme-linked immunosorbent assay for the serologic diagnosis of this disease. Subsequent ex vivo and in vivo studies were, however, unable to show pathogenic activity of antilaminin γ1 antibodies. Both patients' sera and sera depleted from antilaminin γ1 antibodies induced subepidermal splitting in an ex vivo model of autoantibody-mediated leukocyte-dependent neutrophil activation. Antilaminin γ1 antibodies appear to be useful biomarkers that will further facilitate the diagnosis of anti-p200 pemphigoid. The true identity of the pathogenetically relevant autoantigen of this disease, which may either be a yet unknown isoform of laminin γ1 or even another 200-kd protein of the dermoepidermal junction, still needs to be elucidated.
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Affiliation(s)
- Stephanie Goletz
- Department of Dermatology, University of Luebeck, Luebeck, Germany
| | - Takashi Hashimoto
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - Detlef Zillikens
- Department of Dermatology, University of Luebeck, Luebeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Luebeck, Luebeck, Germany.
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