Bullous pemphigoid following radiotherapy

Subepithelial autoimmune blistering dermatoses: Clinical features and diagnosis

Subepithelial autoimmune blistering dermatoses are a group of rare skin disorders that are characterized by the disruption of the dermal-epidermal junction through the action of autoantibodies. The third article in this continuing medical education series explores the background, epidemiology, clinical features, and diagnostic criteria of each of the major subepithelial autoimmune blistering dermatoses, including bullous pemphigoid, pemphigoid gestationis, lichen planus pemphigoides, mucous membrane pemphigoid, linear IgA bullous dermatosis, and dermatitis herpetiformis.

Dermatologic Sequelae Associated with Radiation Therapy

Radiation therapy is a mainstay for the treatment of primary malignancies and metastatic disease and is associated with several dermatological adverse events that are underreported in the literature. The objective of this paper was to review the literature regarding cutaneous manifestations associated with radiation therapy in order to promote awareness of the cutaneous radiation therapy-associated adverse effects. This extensive literature review was performed using the Pubmed and Embase databases. Studies were reviewed for relevance and critical evidence pertaining to cutaneous manifestations of radiation therapy. The most commonly reported cutaneous sequelae associated with radiation therapy include radiation dermatitis, non-melanoma skin cancer, radiation-associated angiosarcoma, morphea, bullous pemphigoid, lymphangioma circumscriptum, and pseudosclerodermatous panniculitis. For many of these conditions, only case reports or case series exist and there is an absence of large-scale cohort studies. Despite these limitations, this review describes the wide range of dermatological adverse events associated with radiation therapy.

Autoimmune bullous diseases associations

The presence of one autoimmune disorder helps lead to the discovery of other autoimmune conditions. It is thought that diseases in which autoimmunity is a feature tend to be associated together more often than one can ascribe to chance. A variety of diseases have been implicated in the onset of intraepidermal and subepidermal autoimmune diseases. The presence of one autoimmune disease should alert the physician to watch for a second immunologic disorder. A list of autoimmune bullous diseases associations includes autoimmune bullous diseases, pemphigus, pemphigoid, epidermolysis bullosa acquisita, dermatitis herpetiformis (Duhring), linear immunoglobulin A disease, and multiple autoimmune syndrome.

Localized bullous pemphigoid induced by photodynamic therapy

Topical photodynamic therapy (PDT) causes localized phototoxicity and has been shown both in vitro and in humans to have immunomodulatory and immunosuppressive effects. We report a case of localized bullous pemphigoid (BP) developing after PDT. Although BP has been reported to develop following cutaneous insults such as surgery, radiotherapy, psoralen ultraviolet A (PUVA) and ultraviolet B phototherapy, PDT has not previously been reported as a trigger. Possible mechanisms include direct mechanical injury to the basement membrane and subsequent autoantibody formation, an indirect immunomodulatory effect of PDT, or most likely, precipitation of BP in individuals with pre-existing low titres of epidermal autoantibodies (so-called subclinical BP). PDT should be added to the list of possible exogenous triggers for BP and this condition should be considered if blistering develops following PDT.

Radiation-induced bullous pemphigoid: a systematic review of an unusual radiation side effect

BACKGROUND

Percutaneous radiotherapy (RT) may cause a range of acute and late side effects of the skin within the irradiated area. In rare cases radiotherapy can cause bullous pemphigoid (BP). BP is reported to occur mainly within irradiated fields following radiation treatment. Exceptionally, BP may arise during RT. It is unclear which mechanism exactly triggers BP following megavoltage irradiation and whether there is a potential association with hormonal anticancer treatment.

METHODS

A systematic literature based review was performed. Publications reporting histologically confirmed BP and a treatment with RT were retrieved based on a standardized query using electronic databases. A standardized quality assessment was applied.

RESULTS

Out of 306 potentially relevant publications 21 were identified to be relevant and included in this review. An association between RT and BP was reported in 27 patients. The majority developed BP after RT and a median dose of 50 Gy. Four patients developed BP during RT after a minimal dose of 20 Gy.

CONCLUSIONS

BP induced by RT was observed predominantly in patients with breast cancer. In all reported cases, there is a clear relationship with RT. Therefore, BP may be considered as RT-induced side effect. RT can induce a BP following a minimal dose of 20 Gy. New biological agents may play a role in the future treatment of BP.

A bullous pemphigoid-like skin eruption after a chemical burn

Bullous pemphigoid is a blistering disorder characterized by antibody deposition in the lamina lucida of the basement membrane zone. In addition to the idiopathic form, there are many agents that have been implicated in inducing bullous pemphigoid or bullous pemphigoid-like lesions. We describe a patient who developed a bullous pemphigoid-like eruption after a chemical burn.

Bullous pemphigoid and multiple sclerosis: a report of three cases and review of the literature

Three patients with longstanding multiple sclerosis (MS) who developed bullous pemphigoid (BP) are reported. All patients had immunological features of typical BP as determined by immunofluorescence and Western immunoblotting studies. The clinical features, however, differed from those observed in typical BP. In two the BP started near an indwelling catheter and two had striking involvement of the soles. None of our patients, or a further nine cases reported in the literature, had mucous membrane involvement. In MS patients BP appears to develop at a younger age. Multiple drugs were taken by the MS patients; these, however, appear not to play a role in triggering their BP. The course of BP in patients with MS is moderate, although the majority require systemic treatment.