Bullous pemphigoid initially localized around a urostomy

Efficacy and safety of tetracyclines for pemphigoid: a systematic review and meta-analysis

The aim of this review was to evaluate the efficacy and safety of tetracyclines for treatment of pemphigoid. We searched PubMed, EMBASE, Ovid, Web of Science, and the Cochrane Library for studies involving pemphigoid patients treated with tetracyclines published in English before 29 February 2020. References of included studies were also screened to widen the scope of the literature search. Data regarding predefined clinical outcomes of 341 patients from 77 studies were extracted and analyzed. A meta-analysis was conducted on the basis of 4 studies including 2 randomized controlled trials and 2 comparative studies. The patients had a mean age of 74.60 ± 13.18 years, 45.4% were males, and 54.6% were females. There were 185 patients with mild-to-moderate and 143 patients with severe disease. The average initial doses were 1.62 ± 0.39 g/day for tetracycline, 0.20 ± 0.01 g/day for doxycycline, and 0.11 ± 0.05 g/day for minocycline. The average time on tetracyclines was 3.74 ± 5.99 months, and 261 (81.3%) patients reported partial or complete remission. Relapses occurred in 72 (28.3%) cases. Adverse effects were experienced by 130 (41.9%) patients. The pooled ORs for short-term effectiveness, relapse, adverse effects, and 1-year survival in patients treated with oral tetracyclines vs. systemic corticosteroids were 0.40 (95% CI, 0.22-0.76), 0.69 (95% CI, 0.44-1.10), 0.47 (95% CI, 0.27-0.82) and 2.02 (95% CI, 1.16-3.50), respectively. Compared to doxycycline and minocycline, tetracycline was significantly associated with better treatment outcomes and fewer adverse effects (p < 0.05). This review revealed tetracyclines' efficacy and safety in pemphigoid treatment and may offer support for clinical use of tetracyclines in pemphigoid.

Diagnosis and treatment of bullous pemphigoid that developed twice after total knee replacement arthroplasty: a case report

Background

Total knee replacement arthroplasty (TKA) is frequently performed in South Korea. Simple swelling-associated blistering around the periphery of the operative wound is a well-known adverse effect. However, in rare cases, the blisters are bullous pemphigoid (BP).

Case presentation

A 75-year-old male presented with knee pain that had not improved despite 5 years of medication. We performed TKA of the left knee, placing a Stryker posteriorly stabilized prosthesis. Three days later, blisters developed near the buttocks and thighs and, on day 10 after surgery, around the operative site. A skin biopsy revealed BP. Commencing on day 14 after surgery, prednisolone 10 mg was administered twice daily. The symptoms improved by 3 weeks after surgery and were healed at 4 months. After 1 year, we performed TKA of the right knee. On day 2 after surgery, as formerly, blisters developed on the buttocks and an immediate biopsy revealed BP. Commencing on day 3 after surgery, prednisolone 10 mg was administered twice daily. On day 10 after surgery, the blisters on the buttocks had improved and no blisters were observed at the surgical site. All symptoms had resolved by 2.5 months after surgery.

Conclusions

After TKA surgery, generalized BP may develop, diagnosed via skin biopsy. A quick diagnosis is important because early treatment can prevent symptom progression and shorten treatment.

Nickel and Skin: From Allergy to Autoimmunity

Introduction & Objectives:

Cutaneous and systemic reactions to various metal implants and medical devices have been well documented. The aim of this review was to focus on the probable common mechanisms of allergy and autoimmunity that may lead to similar clinical outcomes following the growing evidence in the literature of metal and nickel-related systemic, autoimmune or autoinflammatory disorders.

Methods:

Detailed search of the available electronic databases (PubMed-Medline) was conducted for review of the literature on that topic till the present moment.

Results:

Multiple reports on the immunological effects of metals including immunomodulation, allergy, or autoimmunity were identified. It was found that metals may act through immunosuppression, immunotoxicity, or as immune adjuvants thus provoking allergy and autoimmunity in susceptible individuals. Both external or internal exposure to metals was observed. Nickel has been identified as the most common sensitizer, and also the most studied one. The coexistence of both allergic and autoimmune symptoms, induced by nickel, has been published, suggesting the autoimmune potential of nickel compounds.

Conclusions:

Clinical experience and scientific literature together demonstrate that metals may play an important role in the development of autoimmune diseases. While metal implant allergies and complications are on the rise, they remain a diagnostic and therapeutic challenge. Elucidation of their possible mechanisms will contribute to the more successful and safer treatment of affected individuals.

Localised bullous pemphigoid overlying knee arthroplasty: a diagnostic challenge

An elderly Caucasian woman developed bullous pemphigoid (BP) overlying the site of total knee arthroplasty for osteoarthritis 2 days after surgery. The clinical findings were consistent with blistering due to soft tissue swelling, bullous impetigo or allergic contact dermatitis. The blistering spread over weeks to months down the ipsilateral leg and then to the other leg and hips. A biopsy for H&E and direct immunofluorescence established the diagnosis of BP. A concomitantly occurring wound infection was identified and treated. The blistering responded well to superpotent topical steroids and local care.

Bullous Pemphigoid Triggered by Thermal Burn Under Medication With a Dipeptidyl Peptidase-IV Inhibitor: A Case Report and Review of the Literature

Bullous pemphigoid (BP) is a common autoimmune blistering disease in which autoantibodies mainly target the hemidesmosomal component BP180 (also known as type XVII collagen) in basal keratinocytes. Various triggering factors are known to induce BP onset, including radiotherapy, burns, ultraviolet exposure, surgery, and the use of dipeptidyl peptidase-IV inhibitors (DPP4i), which are widely used antihyperglycemic drugs. Here, we present a case of BP triggered by a thermal burn under medication with DPP4i. A 60-year-old man with type II diabetes had been treated with the DPP4i linagliptin for 1 year. After the right forearm experienced a thermal burn, blisters developed around the burned area and gradually spread over the whole body with the production of autoantibodies targeting the non-NC16A domain of BP180. The diagnosis of BP was confirmed by immunohistopathological examination. Upon withdrawal of linagliptin and treatment with topical steroid and minocycline, complete remission was achieved after 4 months. Previously, 13 cases of BP that developed after thermal burns have been reported, and our case shared some of the clinical features of these thermal burn-induced BP cases. Interestingly, the present case also showed the typical clinical, histopathological, and immunological features of the non-inflammatory type of DPP4i-associated BP (DPP4i-BP). Although the pathogenesis of BP remains uncertain, the present case suggests that DPP4i may trigger the onset of BP similarly to a thermal burn. In addition, the clinical and histopathological features of DPP4i-BP may be distinct from other types of BP.

Role of physical factors in the pathogenesis of bullous pemphigoid: Case report series and a comprehensive review of the published work

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disease affecting mainly the elderly. The subtype of the disease induced by physical agents represents a rare and, therefore, insufficiently characterized form. In the present study, we aimed to contribute to a better understanding of the pathogenetic mechanisms involved in the onset of BP induced by different trigger factors. We have retrospectively analyzed nine cases of BP. All patients were characterized based on clinical, epidemiological and immunological parameters. For each case, the trigger factor involved was specified. In addition to our retrospective analysis, a comprehensive review of the 59 published cases was conducted, regarding the involvement of trigger factor in BP, and clinical, epidemiological and immunological data were collected. In the local study, conducted on nine patients diagnosed with BP, various trigger factors were identified: contrast substance injection, surgical procedure, mechanical trauma, insect bite, thermal burn, radiotherapy and ultraviolet exposure associated with pre-existing psoriasis. The autoantibodies from all patients were shown to activate granulocytes and induce dermal-epidermal split. Different hypotheses regarding the pathogenetic mechanism involving the trigger factors have been discussed. In regard of the pathogenetic mechanism, we believe that the most reliable hypothesis is that BP patients already have low titers of anti-basement membrane autoantibodies which activate the granulocytes. However, more studies are needed for a better understanding of the pathogenetic mechanism of the intervention of trigger factors.

Molecular diagnosis in autoimmune skin blistering conditions

Blister formation in skin and mucous membranes results from a loss of cell-cell or cell-matrix adhesion and is a common outcome of pathological events in a variety of conditions, including autoimmune and genetic diseases, viral and bacterial infections, or injury by physical and chemical factors. Autoantibodies against structural components maintaining cell-cell and cell-matrix adhesion induce tissue damage in autoimmune blistering diseases. Detection of these autoantibodies either tissue-bound or circulating in serum is essential to diagnose the autoimmune nature of disease. Various immunofluorescence methods as well as molecular immunoassays, including enzyme-linked immunosorbent assay and immunoblotting, belong to the modern diagnostic algorithms for these disorders. There is still a considerable need to increase awareness of the rare autoimmune blistering diseases, which often show a severe, chronic-relapsing course, among physicians and the public. This review article describes the immunopathological features of autoimmune bullous diseases and the molecular immunoassays currently available for their diagnosis and monitoring.

Bullous pemphigoid: etiology, pathogenesis, and inducing factors: facts and controversies

The term pemphigoids includes a group of autoimmune bullous diseases characterized by subepidermal blistering. Bullous pemphigoid (BP) is not only the most common disorder within the pemphigoid group, but also represents the most frequent autoimmune blistering disease in general. The onset and course of BP depend on a variable interaction between predisposing and inducing factors. HLA genes are the most significant genetic predisposition factor to autoimmunity mechanisms. Many studies show an association between HLA-DQβ1*0301 and distinct clinical pemphigoid variants. Imbalance between autoreactive T helper (Th) and T regulatory cells, toll-like receptor activation, and Th17/IL-17 pathway are the three possible autoimmunity triggers underlying BP. The pathomechanism of BP hinges on an autoantibody response toward structural components of the hemidesmosome (BP180 and BP230). The binding of autoantibodies leads to complement activation, recruitment of inflammatory cells, and release of proteolytic enzymes. The inflammatory cascade also may be directly triggered by activation of Th17 cells with no intervention of autoantibodies. The intervention of inducing factors in BP can be identified in no more than 15% of patients. Facilitating factors in genetically predisposed individuals are various (drug intake, physical agents, and viral infections). Drugs may act as triggers by either modifying the immune response or altering the antigenic properties of the epidermal basement membrane. Cases of induction of BP by physical agents (eg, radiation therapy, ultraviolet radiation, thermal or electrical burns, surgical procedures, transplants) are rare, but well-documented events. A contributing role in inducing BP has been suggested for infections, in particular human herpes virus (HHV) infections (cytomegalovirus, Epstein-Barr virus, and HHV-6), but also hepatitis B and C viruses, Helicobacter pylori, and Toxoplasma gondii. Unlike pemphigus, no dietary triggers have been suspected of being involved in the induction of BP. In all patients who have a diagnosis of BP, an environmental agent as a potential cause should always be considered, because the prompt discontinuation of it might result in rapid improvement or even cure of the disease.

Bullous pemphigoid and percutaneous endoscopic gastrostomy

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disorder. It is rare in the general population but the prevalence was reported to be relatively high among the elderly in nursing homes. The aim of the study was to analyze the clinical characteristics and risk factor for BP in elderly patients with a long hospital stay.

METHODS

This was a retrospective survey with 36 hospitalized patients, aged 64 to 101 years, staying more than 2 years from July 2005 to April 2009. We encountered 5 newly occurring BP cases during this survey period and the remaining 31 patients were non-BP cases. All of these subjects were disabled elderly patients because of cerebral stroke, etc. We assessed the clinical variables as follows: age, sex, underling disease of hospitalization, length of hospital stay, feeding method, medication, tracheal tube indwelling and frequency of death and compared these 2 groups.

RESULTS

All of the patients underwent enteral feeding by percutaneous endoscopic gastrostomy (PEG) or nasogastric (NG) tube. In the univariate analysis, PEG and tube feeding (PEG and NG) were associated with BP (p<0.05). The multivariate logistic and Cox proportional hazard regression analysis were performed with age, sex (elderly female is well known feature of BP) and PEG or tube feeding, demonstrating only PEG was significantly and independently associated with BP (p<0.05).

CONCLUSION

We found that PEG was significant risk factor for BP. Since the sample size was small in this survey, further study is required. Greater awareness of BP is needed for physicians managing institutionalized elderly patients with PEG.

Reactive eccrine syringofibroadenoma arising in peristomal skin: An unusual presentation of a rare lesion

We report the third case of eccrine syringofibroadenoma (ESFA) arising in peristomal skin. A 55-year-old man presented with a 15- x 10-cm pale pink verrucous, exophytic, intermittently tender plaque involving his ileostomy site. He had undergone proctocolectomy with ileostomy creation 33 years prior for ulcerative colitis. The clinical differential diagnosis included granulomatous dermatitis, infection (fungus or atypical mycobacterium), or neoplasm. A punch biopsy specimen was performed and showed ESFA. Although ESFA is considered to be benign, recent reports have demonstrated an association of ESFA with malignancy or malignant transformation of ESFA. Furthermore, ESFA and reported cases of ileostomy carcinoma share similar clinical symptoms at presentation including pain, irritation, ulceration, bleeding, and the presence of a fungating mass. The lesion was, therefore, excised in toto and the excisional specimen showed no evidence of malignancy. We speculate that ESFA is a reaction to chronic irritation and, analogous to other long-standing reactive processes such as lichen sclerosis or burn scar ulcers, may be associated with malignant transformation. Because of this possibility and the clinical overlap with ileostomy carcinoma, peristomal ESFA should be treated with complete excision. If it is not amenable to complete excision because of lesion size or anatomic complexity, generous sampling and close clinical follow-up are recommended.