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Erdoğan B, Meral EN, Topkarci Z, Hatipoğlu N, Kavak A. Langfristige Remission unter Rituximab-Therapie bei einer fünfjährigen Patientin mit Pemphigus vulgaris: Long-term remission with rituximab therapy in a five-year-old patient with pemphigus vulgaris. J Dtsch Dermatol Ges 2024; 22:292-294. [PMID: 38361186 DOI: 10.1111/ddg.15299_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/10/2023] [Indexed: 02/17/2024]
Affiliation(s)
- Bilgen Erdoğan
- Department of Dermatology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Elif Nur Meral
- Department of Dermatology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Zeynep Topkarci
- Department of Dermatology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Nevin Hatipoğlu
- Department of Pediatric Infectious Diseases, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Ayşe Kavak
- Department of Dermatology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Erdoğan B, Meral EN, Topkarci Z, Hatipoğlu N, Kavak A. Long-term remission with rituximab therapy in a five-year-old patient with pemphigus vulgaris. J Dtsch Dermatol Ges 2024; 22:292-294. [PMID: 38009460 DOI: 10.1111/ddg.15299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/10/2023] [Indexed: 11/28/2023]
Affiliation(s)
- Bilgen Erdoğan
- Department of Dermatology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Elif Nur Meral
- Department of Dermatology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Zeynep Topkarci
- Department of Dermatology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Nevin Hatipoğlu
- Department of Pediatric Infectious Diseases, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Ayşe Kavak
- Department of Dermatology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Hundt JE, Sadik CD, van Beek N, Busch H, Caux F, Goebeler M, Hammers CM, Hartmann K, Hashimoto T, Ibrahim S, Kasperkiewicz M, Murrell DF, Recke A, Rose C, Schumacher N, Shimanovich I, Sitaru C, Terheyden P, Thaçi D, Ludwig RJ, Schmidt E. A life for autoimmune blistering diseases: in memoriam Detlef Zillikens. Front Immunol 2023; 14:1291590. [PMID: 38175817 PMCID: PMC10621786 DOI: 10.3389/fimmu.2023.1291590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 09/22/2023] [Indexed: 01/06/2024] Open
Abstract
Detlef Zillikens, MD, director and chair of the Department of Dermatology at the University of Lübeck, Lübeck, Germany, died in September 2022, aged only 64. He dedicated his professional life to autoimmune blistering diseases (AIBDs) and built his department into one of the world's leading centers for these diseases. Herein, his professional life and the impact on the field of AIBDs and the research landscape at the University of Lübeck are addressed. With his warm, integrative, open-minded, ever-optimistic attitude, he was a highly reliable colleague, mentor, and friend to many in the field including each of the authors. Combined with his in-depth knowledge of dermatology, interest in many fields of life science, and hard work, Detlef Zillikens initiated the founding of two independent research institutes, the Lübeck Institute of Experimental Dermatology and the Institute and Comprehensive Center for Inflammation Medicine. He was also instrumental in establishing the Center for Research on Inflammation of the Skin, where in a new research building, over 140 scientists pursue research questions related to skin inflammation. By inviting numerous researchers and clinicians to his department and hosting two large international meetings, he brought the field of AIBDs much closer together and inspired multiple national and international research initiatives. His ideas will live on and grow in many of his colleagues and mentees.
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Affiliation(s)
- Jennifer E. Hundt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | | | - Nina van Beek
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Hauke Busch
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Frédéric Caux
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP, Bobigny, France
| | - Matthias Goebeler
- Department of Dermatology, University of Würzburg, Würzburg, Germany
| | - Christoph M. Hammers
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Kiel, Kiel, Germany
| | | | - Takashi Hashimoto
- Department of Dermatology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Saleh Ibrahim
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- Khalifa University, Abu Dhabi, United Arab Emirates
| | - Michael Kasperkiewicz
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Dedee F. Murrell
- Department of Dermatology, St George Hospital, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Andreas Recke
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Christian Rose
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Dermatohistologisches Einsendelabor Lübeck, Lübeck, Germany
| | - Nina Schumacher
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | | | - Cassian Sitaru
- Department of Dermatology, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | | | - Diamant Thaçi
- Institute and Comprehensive Center for Inflammation Medicine (CCIM), University of Lübeck, Lübeck, Germany
| | - Ralf J. Ludwig
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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Singh S, Kirtschig G, Anchan VN, Chi CC, Taghipour K, Boyle RJ, Murrell DF. Interventions for bullous pemphigoid. Cochrane Database Syst Rev 2023; 8:CD002292. [PMID: 37572360 PMCID: PMC10421473 DOI: 10.1002/14651858.cd002292.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common autoimmune blistering disease. Oral steroids are the standard treatment. We have updated this review, which was first published in 2002, because several new treatments have since been tried. OBJECTIVES To assess the effects of treatments for bullous pemphigoid. SEARCH METHODS We updated searches of the following databases to November 2021: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched five trial databases to January 2022, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA RCTs of treatments for immunofluorescence-confirmed bullous pemphigoid. DATA COLLECTION AND ANALYSIS At least two review authors, working independently, evaluated the studies against the review's inclusion criteria and extracted data from included studies. Using GRADE methodology, we assessed the certainty of the evidence for each outcome in each comparison. Our primary outcomes were healing of skin lesions and mortality. MAIN RESULTS We identified 14 RCTs (1442 participants). The main treatment modalities assessed were oral steroids, topical steroids, and the oral anti-inflammatory antibiotic doxycycline. Most studies reported mortality but adverse events and quality of life were not well reported. We decided to look at the primary outcomes 'disease control' and 'mortality'. Almost all studies investigated different comparisons; two studies were placebo-controlled. The results are therefore based on a single study for each comparison except azathioprine. Most studies involved only small numbers of participants. We assessed the risk of bias for all key outcomes as having 'some concerns' or high risk, due to missing data, inappropriate analysis, or insufficient information. Clobetasol propionate cream versus oral prednisone Compared to oral prednisone, clobetasol propionate cream applied over the whole body probably increases skin healing at day 21 (risk ratio (RR 1.08, 95% confidence interval (CI) 1.03 to 1.13; 1 study, 341 participants; moderate-certainty evidence). Skin healing at 21 days was seen in 99.8% of participants assigned to clobetasol and 92.4% of participants assigned to prednisone. Clobetasol propionate cream applied over the whole body compared to oral prednisone may reduce mortality at one year (RR 0.73, 95% CI 0.53 to 1.01; 1 study, 341 participants; low-certainty evidence). Death occurred in 26.5% (45/170) of participants assigned to clobetasol and 36.3% (62/171) of participants assigned to oral prednisone. This study did not measure quality of life. Clobetasol propionate cream may reduce risk of severe complications by day 21 compared with oral prednisone (RR 0.65, 95% CI 0.50 to 0.86; 1 study, 341 participants; low-certainty evidence). Mild clobetasol propionate cream regimen (10 to 30 g/day) versus standard clobetasol propionate cream regimen (40 g/day) A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen probably does not change skin healing at day 21 (RR 1.00, 95% CI 0.97 to 1.03; 1 study, 312 participants; moderate-certainty evidence). Both groups showed complete healing of lesions at day 21 in 98% participants. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change mortality at one year (RR 1.00, 95% CI 0.75 to 1.32; 1 study, 312 participants; low-certainty evidence), which occurred in 118/312 (37.9%) participants. This study did not measure quality of life. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change adverse events at one year (RR 0.94, 95% CI 0.78 to 1.14; 1 study, 309 participants; low-certainty evidence). Doxycycline versus prednisolone Compared to prednisolone (0.5 mg/kg/day), doxycycline (200 mg/day) induces less skin healing at six weeks (RR 0.81, 95% CI 0.72 to 0.92; 1 study, 213 participants; high-certainty evidence). Complete skin healing was reported in 73.8% of participants assigned to doxycycline and 91.1% assigned to prednisolone. Doxycycline compared to prednisolone probably decreases mortality at one year (RR 0.25, 95% CI 0.07 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 14; 1 study, 234 participants; moderate-certainty evidence). Mortality occurred in 2.4% (3/132) of participants with doxycycline and 9.7% (11/121) with prednisolone. Compared to prednisolone, doxycycline improved quality of life at one year (mean difference 1.8 points lower, which is more favourable on the Dermatology Life Quality Index, 95% CI 1.02 to 2.58 lower; 1 study, 234 participants; high-certainty evidence). Doxycycline compared to prednisolone probably reduces severe or life-threatening treatment-related adverse events at one year (RR 0.59, 95% CI 0.35 to 0.99; 1 study, 234 participants; moderate-certainty evidence). Prednisone plus azathioprine versus prednisone It is unclear whether azathioprine plus prednisone compared to prednisone alone affects skin healing or mortality because there was only very low-certainty evidence from two trials (98 participants). These studies did not measure quality of life. Adverse events were reported in a total of 20/48 (42%) participants assigned to azathioprine plus prednisone and 15/44 (34%) participants assigned to prednisone. Nicotinamide plus tetracycline versus prednisone It is unclear whether nicotinamide plus tetracycline compared to prednisone affects skin healing or mortality because there was only very low-certainty evidence from one trial (18 participants). This study did not measure quality of life. Fewer adverse events were reported in the nicotinamide group. Methylprednisolone plus azathioprine versus methylprednisolone plus dapsone It is unclear whether azathioprine plus methylprednisolone compared to dapsone plus methylprednisolone affects skin healing or mortality because there was only very low-certainty evidence from one trial (54 participants). This study did not measure quality of life. A total of 18 adverse events were reported in the azathioprine group and 13 in the dapsone group. AUTHORS' CONCLUSIONS Clobetasol propionate cream applied over the whole body is probably similarly effective as, and may cause less mortality than, oral prednisone for treating bullous pemphigoid. Lower-dose clobetasol propionate cream applied over the whole body is probably similarly effective as standard-dose clobetasol propionate cream and has similar mortality. Doxycycline is less effective but causes less mortality than prednisolone for treating bullous pemphigoid. Other treatments need further investigation.
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Affiliation(s)
- Sanjay Singh
- Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Vinayak N Anchan
- Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ching-Chi Chi
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Kathy Taghipour
- Department of Dermatology, Whittington Health NHS Trust, London, UK
| | - Robert J Boyle
- National Heart & Lung Institute, Section of Inflammation and Repair, Imperial College London, London, UK
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital & University of New South Wales, Sydney, Australia
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Cole C, Amber KT. Off-Label Uses of Rituximab in Dermatology. CURRENT DERMATOLOGY REPORTS 2022; 11:209-220. [PMID: 36217351 PMCID: PMC9534735 DOI: 10.1007/s13671-022-00375-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review Rituximab has transformed the treatment of B-cell malignancies and rheumatoid arthritis in the past 2 decades. More recently, this anti-CD20 monoclonal antibody has seen increasing usage in the field of dermatology. This review highlights the evidence supporting its use in several important dermatologic conditions. Recent Findings Key recent findings include the 2018 FDA approval of rituximab for the treatment of moderate-to-severe pemphigus. Summary Data from randomized controlled trials have demonstrated the efficacy of rituximab in pemphigus, ANCA-associated vasculitis, and cryoglobulinemic vasculitis. More limited data suggests its use in recalcitrant cases of diseases such as pemphigoid, epidermolysis bullosa acquisita, and dermatomyositis. There is scarce evidence and mixed results for rituximab when studied in cutaneous polyarteritis nodosa and cutaneous lupus erythematosus.
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Affiliation(s)
- Connor Cole
- Division of Dermatology, Rush University Medical Center, Chicago, IL USA
| | - Kyle T. Amber
- Division of Dermatology, Rush University Medical Center, Chicago, IL USA
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL USA
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Dolenc‐Voljč M, Povšič K, Kučič AC, Gašperšič R. Pemphigus vulgaris with refractory gingival ulcerations, successfully treated with rituximab—A case report. Clin Case Rep 2022; 10:e6321. [PMID: 36177086 PMCID: PMC9475132 DOI: 10.1002/ccr3.6321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/19/2022] [Accepted: 08/24/2022] [Indexed: 11/15/2022] Open
Abstract
A patient presented with ulcerations of the buccal mucosae, palate and gingiva. A gingival biopsy confirmed the diagnosis as pemphigus vulgaris. Despite medication with systemic corticosteroids and mycophenolate mofetil, desquamative gingivitis persisted. Adjunct treatment with rituximab was therefore introduced. Regular follow‐ups revealed no inflammatory gingival changes even 6 years later.
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Affiliation(s)
- Mateja Dolenc‐Voljč
- Department of Dermatovenereology, Faculty of Medicine University of Ljubljana Ljubljana Slovenia
| | - Katja Povšič
- Department of Oral Medicine and Periodontology, Faculty of Medicine University of Ljubljana Ljubljana Slovenia
| | - Alja Cmok Kučič
- Department of Oral Medicine and Periodontology, Faculty of Medicine University of Ljubljana Ljubljana Slovenia
| | - Rok Gašperšič
- Department of Oral Medicine and Periodontology, Faculty of Medicine University of Ljubljana Ljubljana Slovenia
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Pieper J, Pollmann R, Eming R, Greene B, Hahmann M, Hertl M. Disease progression and response to therapy in pemphigus based on a registry. J Dtsch Dermatol Ges 2022; 20:461-467. [PMID: 35446493 DOI: 10.1111/ddg.14695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 11/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Pemphigus diseases are potentially life-threatening and rare autoimmune bullous disorders characterized by blisters and erosions of the skin and mucous membranes. These disorders can be largely divided into two major subtypes: pemphigus vulgaris (PV) and pemphigus foliaceus (PF). The objective of this study was to evaluate the autoantibody profile and response to therapy of PV and PF patients by analyzing the clinicopathological data from a registry for bullous autoimmune dermatoses. PATIENTS AND METHODS In a retrospective study, data from 69 patients with PV and PF were included in the analysis. The Autoimmune Bullous Skin Intensity Score (ABSIS) was used to assess the clinical course, remissions, relapses and severity of the disease at first manifestation and throughout the observation period. ELISA was performed to assess levels of anti-desmoglein (Dsg)-1 and anti-Dsg3 IgG serum autoantibodies. RESULTS The mean remission time in PV and PF patients was 63 weeks. PV patients with mucosal involvement showed a more favorable healing process. In PV patients with a moderate/high anti-Dsg1 IgG serum level at baseline, anti-Dsg3 IgG levels decreased during the observation period. CONCLUSIONS Our study provides additional insights into the clinical course of patients with PV and PF, revealing that a mucosal phenotype is associated with a higher tendency towards remission.
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Affiliation(s)
- Josquin Pieper
- Department of Dermatology and Allergology, University Hospital Marburg, Marburg, Germany
| | - Robert Pollmann
- Department of Dermatology and Allergology, University Hospital Marburg, Marburg, Germany
| | - Rüdiger Eming
- Department of Dermatology and Allergology, University Hospital Marburg, Marburg, Germany
| | - Brandon Greene
- Institute of Medical Bioinformatics and Biostatistics, Philipps-University Marburg, Marburg, Germany
| | - Maik Hahmann
- Coordination Center for Clinical Studies (KKS), Philipps-University Marburg, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, University Hospital Marburg, Marburg, Germany
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Pieper J, Pollmann R, Eming R, Greene B, Hahmann M, Hertl M. Register-Studie zu Krankheitsentwicklung und Therapieansprechen bei Pemphigus. J Dtsch Dermatol Ges 2022; 20:461-468. [PMID: 35446496 DOI: 10.1111/ddg.14695_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 11/16/2021] [Indexed: 11/30/2022]
Abstract
HINTERGRUND UND ZIELE Pemphigus gehört zu den seltenen, aber potentiell lebensbedrohlichen Autoimmunerkrankungen. Typisch sind Blasen und Erosionen der Haut und der Schleimhäute. Grundsätzlich unterscheiden wir zwei Subtypen: Pemphigus vulgaris (PV) und Pemphigus foliaceus (PF). In dieser Studie wurden die klinisch-pathologischen Daten aus einem Register für bullöse Autoimmundermatosen analysiert mit dem Ziel, das Autoantikörperprofil und das Therapieansprechen bei Patienten mit PV und PF genauer zu charakterisieren. PATIENTEN UND METHODEN In einer retrospektiven Studie wurden die Daten von 69 Patienten mit PV und PF analysiert. Zur Beurteilung des klinischen Verlaufs, der Remissionen und Rezidive sowie des Schweregrads der Krankheit bei Erstmanifestation und während des gesamten Beobachtungszeitraums diente der ABSIS (Autoimmune Bullous Skin Intensity Score) (ABSIS). Mittels ELISA wurden die Spiegel von Anti-Desmoglein (Dsg)-1- und Anti-Dsg- IgG-Autoantikörpern im Serum bestimmt. ERGEBNISSE Die mittlere Remissionszeit bei Patienten mit PV und PF betrug 63 Wochen. PV-Patienten mit Schleimhautbeteiligung zeigten eine schnellere Heilung. Bei PV-Patienten mit moderat oder stark erhöhten Anti-Dsg1-IgG-Autoantikörpern im Serum zu Beginn erfolgte im Lauf des Beobachtungszeitraums ein Absinken der Anti-Dsg3-IgG-Spiegel. SCHLUSSFOLGERUNGEN Unsere Studie liefert neue Erkenntnisse zum Krankheitsverlauf bei Patienten mit PV und PF und offenbart, dass ein Phänotyp mit Schleimhautbeteiligung eine stärkere Neigung zur Remission aufweist.
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Affiliation(s)
- Josquin Pieper
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Marburg
| | - Robert Pollmann
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Marburg
| | - Rüdiger Eming
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Marburg
| | - Brandon Greene
- Institut für Medizinische Bioinformatik und Biostatistik, Philipps- Universität Marburg
| | - Maik Hahmann
- Koordinierungszentrum für Klinische Studien (KKS), Philipps- Universität Marburg
| | - Michael Hertl
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Marburg
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Burns RD, Vetos D, Muraga R. A Case of Severe Bullous Dermatitis With Mixed Bullous Pemphigoid and Pemphigus Vulgaris Cutaneous Manifestations. Cureus 2021; 13:e20433. [PMID: 35047270 PMCID: PMC8759978 DOI: 10.7759/cureus.20433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 11/05/2022] Open
Abstract
Bullous dermatoses include the rare, chronic autoimmune diseases pemphigus vulgaris and bullous pemphigoid. These diseases are traditionally taught to be differentiated by the presence of mucosal lesions (pemphigus vulgaris) and bullae without mucosal involvement (bullous pemphigoid). In the clinical setting, however, these diseases often contain overlapping features that present challenges to care teams without access to dermatologic care and leave patients without a clear treatment pathway. The ability to differentiate these two diseases clinically is imperative as it determines treatment regimens which when applied can mitigate unnecessary morbidity and mortality. Identifying these conditions clinically for the correct treatment also allows providers to rely less on laboratory assessments which are often unavailable or may take considerable time to result. This report details the clinical course of a patient who presented with an undifferentiated bullous dermatitis with features of both pemphigus vulgaris and bullous pemphigoid and aims to highlight the features of presentation which overlap between pemphigus vulgaris and bullous pemphigoid and those which are more characteristic for one over the other.
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Kunadia A, Sami N. Combination Therapy of Plasma Exchange and Rituximab to Treat Cicatricial Pemphigoid and Bullous Pemphigoid. Cureus 2021; 13:e19932. [PMID: 34984113 PMCID: PMC8713951 DOI: 10.7759/cureus.19932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/27/2021] [Indexed: 11/30/2022] Open
Abstract
The pemphigoid group of subepidermal autoimmune blistering diseases can affect both cutaneous and mucosal tissues. Therapy of this group of diseases, including cicatricial pemphigoid (CP) and bullous pemphigoid (BP), consists of systemic steroids and immunomodulatory agents. Recalcitrant cases have typically been treated with plasmapheresis or rituximab individually. This report describes two patients with severe, rapidly progressive CP and BP refractory to high-dosage systemic steroids and immunomodulatory agents. Both patients were treated with a combination of plasmapheresis and rituximab. In addition to these cases, one retrospective study showed the effectiveness of other immunosuppressants in combination with plasmapheresis in 17 patients with pemphigus refractory to corticosteroids and immunosuppressants alone. No major adverse events occurred in the study. Similar studies employing immunoadsorption and rituximab with various combinations of intravenous immune globulin (IVIg), corticosteroids, and other conventional immunosuppressants have shown promising results in other autoimmune blistering diseases. The successful response in the patients described here, as well as those described in the literature who underwent similar management, provides a possible combination treatment option for patients with severe, recalcitrant pemphigoid. A further trial with a larger group of pemphigoid patients is warranted.
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Bozca BC, Bilgiç A, Uzun S. Long-term experience with rituximab therapy for treatment-resistant moderate-to-severe pemphigus. J DERMATOL TREAT 2021; 33:2102-2109. [PMID: 34027788 DOI: 10.1080/09546634.2021.1919288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Rituximab appears to be effective for treating pemphigus, although there are limited long-term data. METHODS This retrospective single-center study evaluated patients with conventional treatment-resistant pemphigus who received rituximab during September 2010-December 2019. The first rituximab cycle was based on the rheumatoid arthritis protocol in all patients except one patient, and additional single doses (500 mg or 1000 mg) were administered after clinical and/or serological relapse. The consensus definitions were used for complete remission off therapy, complete remission on minimal therapy, and clinical relapse. Serological relapse was defined as a progressive ≥2-fold increase in anti-desmoglein titers (vs. previous the measurement). RESULTS The study included 52 patients with pemphigus vulgaris and 1 patient with pemphigus foliaceus. The mean number of infusions was 5 and the average follow-up after the first infusion was 56 months. The average time to clinical and/or serological relapse was 12 months. Complete remission was achieved in 84.9% of patients, including after the first rituximab cycle in 25 patients (47.1%). Two patients died during the follow-up period. CONCLUSION Additional rituximab cycles may help achieve and prolong remission in patients with moderate-to-severe pemphigus resistant to conventional therapies. However, prospective trials are needed to identify the optimal dosing protocol.
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Affiliation(s)
- Burçin Cansu Bozca
- Dermatology and Venereology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Aslı Bilgiç
- Dermatology and Venereology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Soner Uzun
- Dermatology and Venereology, Akdeniz University School of Medicine, Antalya, Turkey
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Zian Z, Berry SPDG, Bahmaie N, Ghotbi D, Kashif A, Madkaikar M, Bargir UA, Abdullahi H, Khan H, Azizi G. The clinical efficacy of Rituximab administration in autoimmunity disorders, primary immunodeficiency diseases and malignancies. Int Immunopharmacol 2021; 95:107565. [PMID: 33773205 DOI: 10.1016/j.intimp.2021.107565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023]
Abstract
Rituximab (RTX), as a monoclonal antibody-based immunotherapeutic intervention targeting CD20 on B cells, has proven efficacy in the treatment of patients with some immune-mediated diseases. In the present review, we provided information on the immunobiological mechanisms of signaling for RTX and its clinical applications, according to the immune-pathophysiology involved in the microenvironment of multiple diseases. We highlighted combination therapy, dose schedules, and laboratory monitoring, as well as the associated common and rare side effects to avoid. We also discussed the efficacy and safety of RTX-based therapeutic strategies and whether RTX therapy can be used as a promising treatment regimen for autoimmune diseases, primary immunodeficiency diseases, and malignancies. Our review highlights and supports the importance of collaboration between basic medical researchers and clinical specialists when considering the use of RTX in the treatment of various immune-mediated disorders.
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Affiliation(s)
- Zeineb Zian
- Biomedical Genomics and Oncogenetics Research Laboratory, Faculty of Sciences and Techniques of Tangier, P.B. 416, Abdelmalek Essaadi University, Tetouan, Morocco
| | - S P Déo-Gracias Berry
- Centre de Recherches Médicales (CERMEL) de Lambaréné, B.P: 242, Gabon; Technical University of Munich, 80333, Germany
| | - Nazila Bahmaie
- Department of Allergy and Immunology, Faculty of Medicine, Graduate School of Health Science, Near East University (NEU), Nicosia, 99138, Northern Cyprus, Cyprus
| | - Dana Ghotbi
- Faculty of Biological Sciences, University of Kharazmi, Tehran 14911-15719, Iran
| | - Ali Kashif
- Department of Pharmacy, Abdul Wali Khan University, Mardan 23200, Pakistan
| | - Manisha Madkaikar
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology, Mumbai 400070, India
| | - Umair Ahmed Bargir
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology, Mumbai 400070, India
| | - Hamisu Abdullahi
- Department of Immunology, School of Medical Laboratory Sciences, Usmanu Danfodiyo University Sokoto, 840232, Nigeria
| | - Haroon Khan
- Department of Pharmacy, Abdul Wali Khan University, Mardan 23200, Pakistan
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj 3149779453, Iran.
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13
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Kridin K, Ahmed AR. The evolving role of rituximab in the treatment of pemphigus vulgaris: a comprehensive state-of-the-art review. Expert Opin Biol Ther 2021; 21:443-454. [PMID: 33455475 DOI: 10.1080/14712598.2021.1874915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Pemphigus vulgaris (PV) is a life-threatening autoimmune mucocutaneous blistering disease. Systemic corticosteroids (CS), while life-saving, have several serious side effects. To improve treatment and prognosis, recently rituximab (RTX), a chimeric monoclonal antibody against CD20 molecule on B cells, has become popular. This Expert Opinion discusses clinical and scientifically relevant aspects of RTX treating PV. AREA COVERED This presentation describes the mechanism of action, clinical efficacy, safety, adverse events, protocols used, and clinical outcomes. Concerns for infection, reactivation of latent or previous infections, and high relapse rate are discussed. EXPERT OPINION Use of RTX in PV is still a work in progress. There are many unanswered questions. FDA did not provide a protocol or guidelines. Whenever RTX is used, systemic corticosteroids are simultaneously used, albeit for a shorter duration and lower dose. Used in these doses for these durations they can cause immunosuppression. Would it be more appropriate if instead of 'First Line Therapy' it would be more advisable to use the term 'First Adjunctive Immunosuppressive Agent'?
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
| | - A Razzaque Ahmed
- Department of Dermatology, Tufts University School of Medicine, and the Center for Blistering Diseases, USA
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14
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Nosrati A, Hodak E, Mimouni T, Oren-Shabtai M, Levi A, Leshem YA, Mimouni D. Treatment of Pemphigus with Rituximab: Real-Life Experience in a Cohort of 117 Patients in Israel. Dermatology 2021; 237:450-456. [PMID: 33567432 DOI: 10.1159/000513515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A combined regimen of rituximab with corticosteroids for the treatment of pemphigus was effective in a prospective randomized controlled trial. OBJECTIVE To assess real-life response to rituximab in patients with pemphigus. METHODS A retrospective cohort of patients with pemphigus treated with ≥1 rituximab cycles (1,000 mg on days 0 and 14). The primary outcome was remission rate after 1 cycle. For efficacy analyses, a minimal 6-month follow-up was required. Adverse events were assessed in all patients. RESULTS The cohort included 117 patients for safety analysis, 108 for efficacy analysis (median follow-up of 33 months). All but one received concomitant corticosteroids, a third also received adjuvants. Overall, 80/108 patients (74%) achieved remission after the first rituximab cycle at a median of 5.5 months. Relapses occurred in 39 patients (49%) at a median of 18 months. Repeating treatment in relapsed patients increased remission rates to 75 and 88% after the second and third cycles, respectively. Adverse events were similar to those of previous publications. Two elderly patients died of infections attributable to rituximab combined with high-dose corticosteroids. CONCLUSION In a large real-life long-term cohort, rituximab with corticosteroids ± adjuvants induced remission in most patients with pemphigus, with relatively favorable safety. Repeating treatment following relapse or remission failure was beneficial.
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Affiliation(s)
- Adi Nosrati
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emmilia Hodak
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tomer Mimouni
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Meital Oren-Shabtai
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assi Levi
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael A Leshem
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Mimouni
- Division of Dermatology, Rabin Medical Center, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Salman S, Awad M, Sarsik S, Ibrahim AM, Fathi M, Agha NY, Anis R, El Ashal G, Salem ML. Treatment options for autoimmune bullous dermatoses other than systemic steroids: A systematic review and network meta-analysis. Dermatol Ther 2020; 33:e13861. [PMID: 32558137 DOI: 10.1111/dth.13861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/09/2020] [Accepted: 06/05/2020] [Indexed: 02/05/2023]
Abstract
Autoimmune blistering diseases can eventually cause life-threatening complications if left untreated. Although there is no cure for these bullous diseases; their therapy is based on suppressing the immune system to cease the de novo formation of the generated antibodies. The current study aimed to assess the safety and efficacy of using standing alone alternative therapies beyond systemic steroids for management of autoimmune bullous diseases. We searched six literature databases for both randomized and quasi-randomized clinical trials that assessed the efficacy of drugs other than systemic steroids in autoimmune bullous diseases. Outcomes were calculated as odds ratios with 95% confidence-interval. We used the R software to perform conventional and network meta-analyses with a frequentist approach. The network ranking order for 629 bullous pemphigoid patients, from the best to the worst was, clobetasol propionate cream (40 mg; (P-score = .87), clobetasol propionate cream (10-30 mg; P-score = .77), nicotinamide plus tetracycline (P-score = .56), steroids (P-score = .29) and doxycycline (P-score = .01). Limitations of this study are the small sample of the included studies except for blister trial and lack of randomization in most trials. To conclude, Combined doxycycline and nicotinamides are safer and more effective option for extensive bullous pemphigoid patients than the usual use of systemic steroids. For limited disease, topical corticosteroid (40 mg/d) use provides a safer and better response modality than the other proposed treatments.
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Affiliation(s)
- Samar Salman
- Department of Dermatology and Venereology, Tanta University Hospital, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mina Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sameh Sarsik
- Department of Dermatology and Venereology, Tanta University Hospital, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Mohamed Fathi
- Kasr Al-Ainy Medical School, Cairo University, Cairo, Egypt
| | - Nadim Y Agha
- Kasr Al-Ainy Medical School, Cairo University, Cairo, Egypt
| | - Ruba Anis
- Kasr Al-Ainy Medical School, Cairo University, Cairo, Egypt
| | - Gehad El Ashal
- Kasr Al-Ainy Medical School, Cairo University, Cairo, Egypt
| | - Mohamed L Salem
- Immunology and Biotechnology Division, Zoology Department, Faculty of Science, Tanta University, Tanta, Egypt
- Center of Excellence in Cancer Research, Tanta University, Tanta, Egypt
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16
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Effect of Rituximab on Expanded Disability Status Scale and Relapse Rate in Multiple Sclerosis Patients. J Mol Neurosci 2020; 70:1165-1168. [PMID: 32144724 DOI: 10.1007/s12031-020-01523-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022]
Abstract
The aim of this study was to investigate the efficacy of rituximab, a monoclonal antibody that depletes circulating CD20+ B lymphocytes, in relapsing remitting multiple sclerosis (RRMS) patients with inadequate response to disease-modifying therapies. This single group quasi-experimental study recruited RRMS patients who were referred to Sina Farshchian Hospital, Hamadan, Iran, from March 2018 until August 2019. After getting informed consent from the patients, demographic data and duration of disease were recorded. Patients received 500 to 1000 mg of intravenous rituximab every 6 months until 18 months. Relapse rate per year and expanded disability status scale (EDSS) were obtained at baseline and throughout the post treatment follow-up. A total of 70 RRMS patients with the mean age 40.25 ± 8.17 were studied. At baseline, the mean of EDSS and relapse rate was 5.3 ± 1.08 and 0.95 ± 0.64, respectively. After 18 months treatment with rituximab, the relapse rates were significantly reduced (p < 0.000), but the mean EDSS almost remained unchanged (5.7 ± 1.4). Infusion-related adverse effects occurred in 60% of patients in first infusion, and most of them were mild. This study has indicated that rituximab can markedly reduce relapse rates in RRMS patients. The effect of rituximab on EDSS appears to be inappreciable. Also according to our results, administration of rituximab is safe and well tolerated.
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17
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Bardazzi F, Loi C, Vara G, Patrizi A, Di Altobrando A. Efficacy and safety of biosimilar rituximab in the treatment of pemphigus vulgaris: a single center experience of 12 cases. J DERMATOL TREAT 2020; 33:580-582. [DOI: 10.1080/09546634.2020.1729955] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Federico Bardazzi
- Department of Experimental, Diagnostic and Specialty Medicine, Division of Dermatology, University of Bologna, Bologna, Italy
| | - Camilla Loi
- Department of Experimental, Diagnostic and Specialty Medicine, Division of Dermatology, University of Bologna, Bologna, Italy
| | - Giulio Vara
- Radiology Unit, S.Orsola-Malpighi Bologna University Hospital, Bologna, Italy
| | - Annalisa Patrizi
- Department of Experimental, Diagnostic and Specialty Medicine, Division of Dermatology, University of Bologna, Bologna, Italy
| | - Ambra Di Altobrando
- Department of Experimental, Diagnostic and Specialty Medicine, Division of Dermatology, University of Bologna, Bologna, Italy
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18
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Post-rituximab immunoglobulin M (IgM) hypogammaglobulinemia. Autoimmun Rev 2020; 19:102466. [PMID: 31917267 DOI: 10.1016/j.autrev.2020.102466] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 12/19/2022]
Abstract
Rituximab is a B cell depleting monoclonal antibody that targets the B cell-specific cell surface antigen CD20 and is currently used to treat several autoimmune diseases. The elimination of mature CD20-positive B lymphocytes committed to differentiate into autoantibody-producing plasma cells is considered to be the major effect of rituximab, that makes it a beneficial biological agent in treating autoimmune diseases. Hypogammaglobulinemia has been reported after rituximab therapy in patients with lymphoma and rheumatoid arthritis. Similar data are scarce for other autoimmune diseases. Low immunoglobulin G (IgG) or hypogammaglobulinemia has attracted the most attention because of its significant role in protective immunity. However, the incidence and clinical implications of low immunoglobulin M (IgM) or hypogammaglobulinemia have not been studied in detail. This review will focus on the frequency and the clinical concerns of low IgM levels that result as a consequence of the administration of rituximab. The etiopathogenic mechanisms underlying post-rituximab IgM hypogammaglobulinemia and its implications are presented. The long-term consequences, if any, are not known or documented. Multiple factors may be involved in whether IgG or IgM decreases secondary to rituximab therapy. It is possible that the autoimmune disease itself may be one of the important factors. The dose, frequency and number of infusions appear to be important variables. Post-rituximab therapy immunoglobulin levels return to normal. During this process. IgM levels take a longer time to return to normal levels when compared to IgG or other immunoglobulins. IgM deficiency persists after B cell repopulation to normal levels has occurred. Laboratory animals and humans deficient in IgM can have multiple infections. Specific pharmacologic agents or biologic therapy that address and resolve IgM deficiency are currently unavailable. If the clinical situation so warrants, then prophylactic antibiotics may be indicated and perhaps helpful. Research in this iatrogenic phenomenon will provide a better understanding of not only the biology of IgM, but also the factor(s) that control its production and regulation, besides its influence if any, on rituximab therapy.
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19
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20
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Saschenbrecker S, Karl I, Komorowski L, Probst C, Dähnrich C, Fechner K, Stöcker W, Schlumberger W. Serological Diagnosis of Autoimmune Bullous Skin Diseases. Front Immunol 2019; 10:1974. [PMID: 31552014 PMCID: PMC6736620 DOI: 10.3389/fimmu.2019.01974] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/05/2019] [Indexed: 12/12/2022] Open
Abstract
Autoimmune bullous dermatoses (AIBD) encompass a variety of organ-specific autoimmune diseases that manifest with cutaneous and/or mucosal blisters and erosions. They are characterized by autoantibodies targeting structural proteins of the skin, which are responsible for the intercellular contact between epidermal keratinocytes and for adhesion of the basal keratinocytes to the dermis. The autoantibodies disrupt the adhesive functions, leading to splitting and blister formation. In pemphigus diseases, blisters form intraepidermally, whereas in all other disease types they occur subepidermally. Early identification of autoimmune bullous dermatoses is crucial for both treatment and prognosis, particularly as regards tumor-associated disease entities. The diagnosis is based on clinical symptoms, histopathology, direct immunofluorescence to detect antibody/complement deposits, and the determination of circulating autoantibodies. The identification of various target antigens has paved the way for the recent development of numerous specific autoantibody tests. In particular, optimized designer antigens and multiplex test formats for indirect immunofluorescence and ELISA have enhanced and refined the laboratory analysis, enabling highly efficient serodiagnosis and follow-up. This review elaborates on the current standards in the serological diagnostics for autoimmune bullous dermatoses.
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Affiliation(s)
| | - Ingolf Karl
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Christian Probst
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Cornelia Dähnrich
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Kai Fechner
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Winfried Stöcker
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
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21
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Thomas RM, Colon A, Motaparthi K. Rituximab in autoimmune pemphigoid diseases: Indications, optimized regimens, and practice gaps. Clin Dermatol 2019; 38:384-396. [PMID: 32563354 DOI: 10.1016/j.clindermatol.2019.07.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Rituximab is a monoclonal antibody targeting CD20 on B cells with proven efficacy for pemphigus vulgaris, now an FDA-approved indication. Other autoimmune bullous diseases can be challenging to treat and have significant associated morbidity and mortality, but data supporting the use of rituximab in pemphigoid group diseases remain limited. Although rituximab demonstrates efficacy for clinical improvement and remission in pemphigoid, concern for adverse events may also limit the use of this medication. We review the current evidence fo rthe use of rituximab in pemphigoid diseases, pertinent dosing schedules and laboratory monitoring, and the associated common and rare adverse events. Review of the literature to date not only supports consideration of rituximab for treatment of refractory pemphigoid group diseases but also reflects tolerability and an acceptable safety profile.
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Affiliation(s)
- Renee M Thomas
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Alysha Colon
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA.
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22
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Amber KT, Maglie R, Solimani F, Eming R, Hertl M. Targeted Therapies for Autoimmune Bullous Diseases: Current Status. Drugs 2019; 78:1527-1548. [PMID: 30238396 DOI: 10.1007/s40265-018-0976-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Autoimmune bullous skin disorders are rare but meaningful chronic inflammatory diseases, many of which had a poor or devastating prognosis prior to the advent of immunosuppressive drugs such as systemic corticosteroids, which down-regulate the immune pathogenesis in these disorders. Glucocorticoids and adjuvant immunosuppressive drugs have been of major benefit for the fast control of most of these disorders, but their long-term use is limited by major side effects such as blood cytopenia, osteoporosis, diabetes mellitus, hypertension, and gastrointestinal ulcers. In recent years, major efforts were made to identify key elements in the pathogenesis of autoimmune bullous disorders, leading to the identification of their autoantigens, which are mainly located in desmosomes (pemphigus) and the basement membrane zone (pemphigoids). In the majority of cases, immunoglobulin G, and to a lesser extent, immunoglobulin A autoantibodies directed against distinct cutaneous adhesion molecules are directly responsible for the loss of cell-cell and cell-basement membrane adhesion, which is clinically related to the formation of blisters and/or erosions of the skin and mucous membranes. We describe and discuss novel therapeutic strategies that directly interfere with the production and regulation of pathogenic autoantibodies (rituximab), their catabolism (intravenous immunoglobulins), and their presence in the circulation and extravascular tissues such as the skin (immunoadsorption), leading to a significant amelioration of disease. Moreover, we show that these novel therapies have pleiotropic effects on various proinflammatory cells and cytokines. Recent studies in bullous pemphigoid suggest that targeting of immunoglobulin E autoantibodies (omalizumab) may be also beneficial. In summary, the introduction of targeted therapies in pemphigus and pemphigoid holds major promise because of the high efficacy and fewer side effects compared with conventional global immunosuppressive therapy.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of Illinois at Chicago, 808 Wood St. Room 377, Chicago, IL, 60612, USA.
| | - Roberto Maglie
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany.,Department of Surgery and Translational Medicine, Section of Dermatology, University of Florence, Florence, Italy
| | - Farzan Solimani
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany
| | - Rüdiger Eming
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany.
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23
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Didona D, Maglie R, Eming R, Hertl M. Pemphigus: Current and Future Therapeutic Strategies. Front Immunol 2019; 10:1418. [PMID: 31293582 PMCID: PMC6603181 DOI: 10.3389/fimmu.2019.01418] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022] Open
Abstract
Pemphigus encompasses a heterogeneous group of autoimmune blistering diseases, which affect both mucous membranes and the skin. The disease usually runs a chronic-relapsing course, with a potentially devastating impact on the patients' quality of life. Pemphigus pathogenesis is related to IgG autoantibodies targeting various adhesion molecules in the epidermis, including desmoglein (Dsg) 1 and 3, major components of desmosomes. The pathogenic relevance of such autoantibodies has been largely demonstrated experimentally. IgG autoantibody binding to Dsg results in loss of epidermal keratinocyte adhesion, a phenomenon referred to as acantholysis. This in turn causes intra-epidermal blistering and the clinical appearance of flaccid blisters and erosions at involved sites. Since the advent of glucocorticoids, the overall prognosis of pemphigus has largely improved. However, mortality persists elevated, since long-term use of high dose corticosteroids and adjuvant steroid-sparing immunosuppressants portend a high risk of serious adverse events, especially infections. Recently, rituximab, a chimeric anti CD20 monoclonal antibody which induces B-cell depletion, has been shown to improve patients' survival, as early rituximab use results in higher disease remission rates, long term clinical response and faster prednisone tapering compared to conventional immunosuppressive therapies, leading to its approval as a first line therapy in pemphigus. Other anti B-cell therapies targeting B-cell receptor or downstream molecules are currently tried in clinical studies. More intriguingly, a preliminary study in a preclinical mouse model of pemphigus has shown promise regarding future therapeutic application of Chimeric Autoantibody Receptor T-cells engineered using Dsg domains to selectively target autoreactive B-cells. Conversely, previous studies from our group have demonstrated that B-cell depletion in pemphigus resulted in secondary impairment of T-cell function; this may account for the observed long-term remission following B-cell recovery in rituximab treated patients. Likewise, our data support the critical role of Dsg-specific T-cell clones in orchestrating the inflammatory response and B-cell activation in pemphigus. Monitoring autoreactive T-cells in patients may indeed provide further information on the role of these cells, and would be the starting point for designating therapies aimed at restoring the lost immune tolerance against Dsg. The present review focuses on current advances, unmet challenges and future perspectives of pemphigus management.
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Affiliation(s)
- Dario Didona
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Roberto Maglie
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany.,Surgery and Translational Medicine, Section of Dermatology, University of Florence, Florence, Italy.,Section of Dermatology, Departement of Health Sciences, University of Florence, Florence, Italy
| | - Rüdiger Eming
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
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24
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Barbach Y, Baybay H, Mrabat S, Chaouche M, Elloudi S, Mernissi FZ. [Unexpected positive outcome following rituximab treatment in a patient with pemphigus vegetans resistant to conventional therapies: a case report]. Pan Afr Med J 2019; 32:101. [PMID: 31223391 PMCID: PMC6560954 DOI: 10.11604/pamj.2019.32.101.16743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 08/14/2018] [Indexed: 11/29/2022] Open
Abstract
Le pemphigus végétant est une variété rare de pemphigus. Il n'y représente que 2%. Plusieurs traitements sont de mise pour traiter cette entité, on retrouve les corticostéroïdes topiques et/ou oraux en 1ère intension, les immunosuppresseurs tels que l'Azathioprine, la Cyclosporine, le Méthotrexate, le Cyclophosphamide et le Mycophénolate mofétil pour remédier au effet secondaires des stéroides. Certains cas restent réfractaires à tous ces traitements, l'utilisation du Rituximab a fait révolutionner la prise en charge du pemphigus, en particulier sa forme végétante. Nous rapportons le cas d'une patiente de 42ans, admise pour prise en charge d'un pemphigus végétant confirmé histologiquement et mise initialement sous corticothérapie en association avec immunosuppresseur sans amélioration, puis fut mise sous Rituximab avec une évolution spectaculaire.
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Affiliation(s)
| | | | - Samia Mrabat
- Service de Dermatologie, CHU Hassan II, Fès, Maroc
| | | | - Sara Elloudi
- Service de Dermatologie, CHU Hassan II, Fès, Maroc
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25
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Bilgic Temel A, Murrell DF. Pharmacological advances in pemphigus. Curr Opin Pharmacol 2019; 46:44-49. [PMID: 30974409 DOI: 10.1016/j.coph.2019.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/26/2018] [Accepted: 01/07/2019] [Indexed: 02/06/2023]
Abstract
This is an updated review of the literature on the emerging therapeutic options for the treatment of pemphigus to provide better care for patients. There is an increasing range of molecules targeted for pemphigus therapy against CD20, Bruton tyrosine kinase, chimeric antigen receptor, T-cell immune components, B-cell activating factor, proliferation-inducing ligand (APRIL), CD25, p38 mitogen-activated protein kinase (p38MAPK) and cytokine modulation therapies (anti-IL-4, anti-IL-6). The main aim of the current new therapies is to provide specific pathology-focused therapeutic options which have long-term sustainable therapeutic effects on disease progress, cause less side effects without systemic immunosuppression, and have less risk of getting antibodies against the medication during treatment.
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Affiliation(s)
- Asli Bilgic Temel
- St George Hospital, UNSW Department of Dermatology, Kogarah, Sydney, NSW 2217, Australia
| | - Dedee F Murrell
- St George Hospital, UNSW Department of Dermatology, Kogarah, Sydney, NSW 2217, Australia.
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26
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Abstract
Mucous membrane pemphigoid (MMP) is a pemphigoid disease defined by the presence of autoantibodies against the dermal-epidermal junction and predominant involvement of mucous membranes. Diagnosis is made by the clinical presentation and linear deposits of IgG and/or IgA and/or C3 at the dermal-epidermal junction by direct immunofluorescence microscopy of a perilesional biopsy. Circulating autoantibodies can be detected in most patients by indirect immunofluorescence microscopy on salt-split human skin as well as ELISA and immunoblotting with recombinant and cell-derived target antigens. For systemic treatment of MMP, corticosteroids, dapsone, mycophenolates, and azathioprine are applied. In severe cases and in cases with rapid disease progression cyclophosphamide, rituximab, high-dose intravenous immunoglobulins, and immunoadsorption are used. For the successful management of MMP patients, close cooperation with dentists, ophthalmologists, ENT specialists, gynecologists, and gastroenterologists is essential.
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Abstract
BACKGROUND Pemphigus diseases are a heterogeneous group of potentially life-threatening autoimmune bullous disorders. Therefore, rapidly acting and effective therapeutic approaches are essential. OBJECTIVES In this review, current therapeutic options in line with available guidelines are presented and new therapeutic approaches are discussed. METHODS A literature search was performed using PubMed. RESULTS Treatment of pemphigus is based on systemic glucocorticosteroids, frequently combined with potentially corticosteroid-sparing immunosuppressants such as azathioprine and mycophenolate mofetil/mycophenolic acid. Recently, the impressive efficacy of the anti-CD20 antibody rituximab has been shown in a prospective randomized trial. In severe or treatment-refractory cases, immunoadsorption or high-dose intravenous immunoglobulins (IVIG) are recommended. Adjuvant immunoadsorption also seems to be useful within the first 8-12 weeks of therapy in patients with very high autoantibody levels. A variety of new therapeutic approaches is currently evaluated in phase IIa studies. CONCLUSION Therapy of pemphigus has been greatly improved by the employment of rituximab. The use of glucocorticosteroids, associated with a high number of adverse events and elevated mortality, could be reduced by the additional use of rituximab. After approval of rituximab for the treatment of pemphigus by the US Food and Drug Administration in 2018, licensing in Europe is expected in 2019.
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Affiliation(s)
- N van Beek
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - D Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - E Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.,Lübecker Institut für Experimentelle Dermatologie (LIED), Universität zu Lübeck, Lübeck, Deutschland
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Wittenberg M, Worm M. Severe Refractory Paraneoplastic Mucous Membrane Pemphigoid Successfully Treated With Rituximab. Front Med (Lausanne) 2019; 6:8. [PMID: 30761304 PMCID: PMC6362419 DOI: 10.3389/fmed.2019.00008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 01/11/2019] [Indexed: 12/15/2022] Open
Abstract
Mucous membrane pemphigoid (MMP) is a rare autoimmune bullous disease of the mucous membranes, which can cause irreversible scarring and is discussed to be associated with cancer, if laminin-332-autoantibodies are present. MMP with severe ocular and laryngeal involvement is difficult to treat and can be treatment-refractory to conventional immunosuppressant therapy. A 67-year-old man with a history of prostate cancer presented to our clinic with sore throat, intraoral bullae, odynophagia, dysphonia, exertional dyspnea, and erosions of the glans penis. Clinical examination confirmed a laryngo-pharyngitis with involvement of the epiglottis and bilateral symblepharon. Diagnostics comprising multiple biopsies, direct and indirect immunofluorescence, serology analysis, and immunoblotting confirmed the diagnosis of a paraneoplastic MMP by showing a subepithelial split in histology and the presence of anti-laminin-332-antibodies. Despite combined systemic treatment with prednisolone and either dapsone or azathioprine, a progress of the disease occurred leading to severe ocular and laryngeal complications. Two month after rituximab treatment, complete disease control was achieved. This case report shows a severe ocular and life threatening laryngeal involvement of therapy-refractory paraneoplastic MMP highlighting the importance of interdisciplinary management and difficulty of diagnosing MMP despite repeated diagnostic testing.
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Affiliation(s)
- Marcel Wittenberg
- Department of Dermatology, Venerology and Allergology, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Margitta Worm
- Department of Dermatology, Venerology and Allergology, Charité- Universitätsmedizin Berlin, Berlin, Germany
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Loi C, Magnano M, Ravaioli GM, Sacchelli L, Patrizi A, Bardazzi F. Rituximab therapy in pemphigus: A long-term follow-up. Dermatol Ther 2018; 32:e12763. [DOI: 10.1111/dth.12763] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/10/2018] [Accepted: 09/29/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Camilla Loi
- Department of Specialized, Clinical and Experimental Medicine, Division of Dermatology; University of Bologna; Bologna Italy
| | - Michela Magnano
- Department of Specialized, Clinical and Experimental Medicine, Division of Dermatology; University of Bologna; Bologna Italy
| | - Giulia Maria Ravaioli
- Department of Specialized, Clinical and Experimental Medicine, Division of Dermatology; University of Bologna; Bologna Italy
| | - Lidia Sacchelli
- Department of Specialized, Clinical and Experimental Medicine, Division of Dermatology; University of Bologna; Bologna Italy
| | - Annalisa Patrizi
- Department of Specialized, Clinical and Experimental Medicine, Division of Dermatology; University of Bologna; Bologna Italy
| | - Federico Bardazzi
- Department of Specialized, Clinical and Experimental Medicine, Division of Dermatology; University of Bologna; Bologna Italy
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Feliciani C, Cozzani E, Marzano AV, Caproni M, Di Zenzo G, Calzavara-Pinton P. Italian Guidelines in Pemphigus - adapted from the European Dermatology Forum (EDF) and European Academy of Dermatology and Venerology (EADV). GIORN ITAL DERMAT V 2018; 153:599-608. [DOI: 10.23736/s0392-0488.18.06073-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Pemphigus vulgaris (PV) is a life-threatening disease belonging to the pemphigus group of autoimmune intra-epidermal bullous diseases of the skin and mucosae. The therapeutic management of PV remains challenging and, in some cases, conventional therapy is not adequate to induce clinical remission. The cornerstone of PV treatment remains systemic corticosteroids. Although very effective, long-term corticosteroid administration is characterized by substantial adverse effects. Corticosteroid-sparing adjuvant therapies have been employed in the treatment of PV, aiming to reduce the necessary cumulative dose of corticosteroids. Specifically, immunosuppressive agents such as azathioprine and mycophenolate mofetil are widely used in PV. More recently, high-dose intravenous immunoglobulins, immunoadsorption, and rituximab have been established as additional successful therapeutic options. This review covers both conventional and emerging therapies in PV. In addition, it sheds light on potential future treatment strategies for this disease.
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
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32
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Rituximab impedes natural killer cell function in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis patients: A pilot in vitro investigation. BMC Pharmacol Toxicol 2018; 19:12. [PMID: 29587879 PMCID: PMC5870391 DOI: 10.1186/s40360-018-0203-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 03/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A recent in vitro pilot investigation reported Rituximab significantly reduced natural killer (NK) cell cytotoxicity in healthy donors. Chronic fatigue syndrome/Myalgic encephalomyelitis (CFS/ME) is a debilitating disorder of unknown etiology. A consistent finding is a significant reduction in NK cell cytotoxicity. Rituximab has been reported having questionable potential therapeutic benefits for the treatment of CFS/ME, however, the potential effects of Rituximab on NK cell cytotoxicity in CFS/ME patients are yet to be determined. METHODS A total of eight CFS/ME patients (48.63 ± 15.69 years) and nine non-fatigued controls (NFC) (37.56 ± 11.06 years) were included using the Fukuda case definition. Apoptotic function, lytic proteins and degranulation markers were measured on isolated NK cells using flow cytometry following overnight incubation with Rituximab at 10 μg/ml and 100 μg/ml. RESULTS There was a significant reduction in NK cell lysis between CFS/ME patients and NFC following incubation with Rituximab at 100 μg/ml at 12.5:1 and 6.25:1 effecter-target (E:T) ratios (p < 0.05). However, there was no significant difference for NFC following incubation with Rituximab at 10 μg/ml and 100 μg/ml. There was no significant difference between CFS/ME patients and NFC for granzyme A and granzyme B prior to incubation with Rituximab and following overnight incubation with Rituximab at 10 μg/ml. There was a significant decrease in granzyme B in CFS/ME patients compared to NFC with 100 μg/ml of Rituximab prior to K562 cells stimulation (p < 0.05). There was a significant increase in CD107a (p < 0.05) and CD107b expression (p < 0.01) in NFC after stimulation with K562 cells prior to incubation with Rituximab. There was a significant increase in CD107b expression between CFS/ME patients and NFC prior to incubation with Rituximab and without stimulation of K562 cells (p < 0.01). Importantly, there was a significant increase in CD107b following overnight incubation with 100 μg/ml of Rituximab in NFC prior to K562 cells stimulation (p < 0.01). CONCLUSION This study reports significant decreases in NK cell lysis and a significant increase in NK cell degranulation following Rituximab incubation in vitro in CFS/ME patients, suggesting Rituximab may be toxic for NK cells. Caution should be observed in clinical trials until further investigations in a safe and controlled in vitro setting are completed.
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Tavakolpour S, Mahmoudi H, Balighi K, Abedini R, Daneshpazhooh M. Sixteen-year history of rituximab therapy for 1085 pemphigus vulgaris patients: A systematic review. Int Immunopharmacol 2018; 54:131-138. [DOI: 10.1016/j.intimp.2017.11.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 10/12/2017] [Accepted: 11/05/2017] [Indexed: 12/16/2022]
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35
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Albers LN, Liu Y, Bo N, Swerlick RA, Feldman RJ. Developing biomarkers for predicting clinical relapse in pemphigus patients treated with rituximab. J Am Acad Dermatol 2017; 77:1074-1082. [DOI: 10.1016/j.jaad.2017.07.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/06/2017] [Accepted: 07/12/2017] [Indexed: 01/16/2023]
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Paraneoplastic Pemphigus: Insight into the Autoimmune Pathogenesis, Clinical Features and Therapy. Int J Mol Sci 2017; 18:ijms18122532. [PMID: 29186863 PMCID: PMC5751135 DOI: 10.3390/ijms18122532] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/09/2017] [Accepted: 11/24/2017] [Indexed: 11/17/2022] Open
Abstract
Paraneoplastic pemphigus is a rare autoimmune skin disease that is always associated with a neoplasm. Usually, oral, skin, and mucosal lesions are the earliest manifestations shown by paraneoplastic pemphigus patients. The pathogenesis of paraneoplastic pemphigus is not yet completely understood, although some immunological aspects have been recently clarified. Because of its rarity, several diagnostic criteria have been proposed. Besides, several diagnostic procedures have been used for the diagnosis, including indirect immunofluorescence, direct immunofluorescence, and ELISA. We reviewed the most recent literature, searching on PubMed "paraneoplastic pemphigus". We included also papers in French, German, and Spanish. We found 613 papers for "paraneoplastic pemphigus". Among them, 169 were review papers. Because of its varying clinical features, paraneoplastic pemphigus still represents a challenge for clinicians. Furthermore, diagnosis and management of paraneoplastic pemphigus requires close collaboration between physicians, including dermatologist, oncologist, and otorhinolaryngologist.
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37
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Bağcı IS, Horváth ON, Ruzicka T, Sárdy M. Bullous pemphigoid. Autoimmun Rev 2017; 16:445-455. [DOI: 10.1016/j.autrev.2017.03.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 11/27/2022]
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38
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Wei K, Wang Y, Wang W, Chen W. Fatal infection of Pneumocystis jiroveci pneumonia
in a pemphigus patient treated with rituximab. J Eur Acad Dermatol Venereol 2017; 31:e350-e351. [DOI: 10.1111/jdv.14144] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- K.C. Wei
- Department of Dermatology; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - Y.H. Wang
- Department of Dermatology; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
- Department of Internal Medicine; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - W.H. Wang
- Department of Internal Medicine; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - W. Chen
- IZZ-Immunologie Zentrum Zürich; Zurich Switzerland
- Department of Dermatology and Allergy; Technische Universität München; Munich Germany
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39
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Vassallo C, Grassi S, Tagliabue E, Piccolo A, Brazzelli V. Pregnancy outcome after rituximab treatment before conception in patients affected by severe pemphigus vulgaris/superficialis. J Eur Acad Dermatol Venereol 2017; 31:e331-e333. [DOI: 10.1111/jdv.14119] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- C. Vassallo
- Clinica Dermatologica; University of Pavia; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
| | - S. Grassi
- Clinica Dermatologica; University of Pavia; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
| | - E. Tagliabue
- Clinica Dermatologica; University of Pavia; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
| | - A. Piccolo
- Clinica Dermatologica; University of Pavia; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
| | - V. Brazzelli
- Clinica Dermatologica; University of Pavia; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
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40
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Combined Use of Rituximab and Intravenous Immunoglobulin for Severe Autoimmune Cicatricial Conjunctivitis—An Interventional Case Series. Cornea 2016; 35:1611-1614. [DOI: 10.1097/ico.0000000000001024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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41
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Kim M, Borradori L, Murrell DF. Autoimmune Blistering Diseases in the Elderly: Clinical Presentations and Management. Drugs Aging 2016; 33:711-723. [DOI: 10.1007/s40266-016-0402-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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42
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Bambauer R, Latza R, Burgard D, Schiel R. Therapeutic Apheresis in Hematologic, Autoimmune and Dermatologic Diseases With Immunologic Origin. Ther Apher Dial 2016; 20:433-452. [PMID: 27633388 DOI: 10.1111/1744-9987.12474] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Indexed: 01/04/2023]
Abstract
The process of curing a patient by removing his illness by extracting blood is a very old one. Many years ago, phlebotomy was practiced to cure illness. Now, this old process, placed on a rational basis with therapeutic apheresis (TA), is being followed in clinical practice. Therapeutic plasma exchange (TPE) with hollow fiber modules has been used in different severe diseases for more than 40 years. Based on many years of experience with the extracorporeal circulation in end-stage renal disease, the authors herein give an overview of TA in immunological diseases, especially in hematologic, autoimmune and dermatologic diseases. Updated information on immunology and molecular biology of different immunological diseases is discussed in relation to the rationale for apheresis therapy and its place in combination with other modern therapies. With the introduction of novel and effective biologic agents, TA is indicated only in severe cases, such as in rapid progression despite immunosuppressive therapy and/or biologic agents. In mild forms of autoimmune disease, treatment with immunosuppressive therapies and/or biologic agents seems to be sufficient. The prognosis of autoimmune diseases with varying organ manifestations has improved in recent years, due in part to very aggressive therapy schemes. For the immunological diseases that can be treated with TA, the guidelines of the German Working Group of Clinical Nephrology and of the Apheresis Applications Committee of the American Society for Apheresis are cited. TA has been shown to effectively remove the autoantibodies from blood and lead to rapid clinical improvement.
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Affiliation(s)
- Rolf Bambauer
- Formerly: Institute for Blood Purification, 66424, Homburg, Germany.
| | | | | | - Ralf Schiel
- Inselklinik Heringsdorf GmbH, 17424, Seeheilbad Heringsdorf, Germany
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Abstract
BACKGROUND Pemphigus is a severe bullous autoimmune dermatosis that represents a clinical challenge despite high-dose immunosuppressive therapy due to the therapy-related comorbidities and the lack of long-term control of disease activity. OBJECTIVES Which targeted therapies are currently used in pemphigus and which innovative therapeutic strategies are in clinical development? MATERIALS AND METHODS A review of the literature in PubMed was performed under consideration of the current guideline for the treatment of pemphigus as well as of our own results. Discussion of basic findings and results of targeted therapies in autoantibody-mediated autoimmune disorders were taken into account. RESULTS Immunapheresis and high-dose intravenous immunoglobulins with the aim of reducing circulating autoantibodies have been successfully used in the treatment of pemphigus. Depletion of autoreactive B-lymphocytes provides the rationale for the use of the monoclonal anti-CD20 antibody rituximab which demonstrated long-term clinical remission of pemphigus in clinical trials. Current developments include the investigation of humanised B-cell depleting antibodies in other B-cell driven autoimmune disorders as well as the identification of new cellular and molecular target structures that are essential in the humoral autoimmune cascade and exert important immune regulatory functions, respectively. CONCLUSIONS The well-characterised basic pathogenesis of pemphigus results in targeted therapies. Currently, therapies aiming at rapid reduction of circulating autoantibodies and the depletion of autoreactive B-cells are in clinical use. More cellular and molecular target structures are being investigated in other autoantibody-driven autoimmune disorders and they provide promising candidates for innovative pathogenesis-related therapeutic strategies in pemphigus in the future.
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Affiliation(s)
- R Eming
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Baldingerstraße, 35043, Marburg, Deutschland,
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Eming R, Sticherling M, Hofmann SC, Hunzelmann N, Kern JS, Kramer H, Pfeiffer C, Schuster V, Zillikens D, Goebeler M, Hertl M, Nast A, Orzechowski HD, Sárdy M, Schmidt E, Sitaru C, Sporbeck B, Worm M. S2k guidelines for the treatment of pemphigus vulgaris/foliaceus and bullous pemphigoid. J Dtsch Dermatol Ges 2016. [PMID: 26213827 DOI: 10.1111/ddg.12606] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Rüdiger Eming
- Department of Dermatology and Allergology, Philipps-Universität Marburg
| | | | - Silke C Hofmann
- Helios Hospital Wuppertal, Department of Dermatology, Allergology and Dermatosurgery, Wuppertal, Germany
| | | | - Johannes S Kern
- Department of Dermatology, Medical Center, University of Freiburg, Germany
| | | | | | - Volker Schuster
- Pediatric Immunology and Rheumatology, University Hospital and Outpatient Clinic for Pediatrics, Leipzig, Germany
| | - Detlef Zillikens
- Department of Dermatology, Allergology, and Venereology, Campus Luebeck, University Hospital Schleswig-Holstein (UKSH), Luebeck, Germany
| | - Matthias Goebeler
- Department of Dermatology, Venereology, and Allergology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps-Universität Marburg
| | - Alexander Nast
- Division of Evidence-based Medicine (dEBM), Department of Dermatology, Charité - University Hospital Berlin, Germany
| | | | - Miklós Sárdy
- Department of Dermatology and Venereology, University Hospital Munich (LMU), Munich, Germany
| | - Enno Schmidt
- Department of Dermatology, Allergology, and Venereology, Campus Luebeck, University Hospital Schleswig-Holstein (UKSH), Luebeck, Germany
| | - Cassian Sitaru
- Department of Dermatology, Medical Center, University of Freiburg, Germany
| | - Birte Sporbeck
- Division of Evidence-based Medicine (dEBM), Department of Dermatology, Charité - University Hospital Berlin, Germany
| | - Margitta Worm
- Allergy Center, Department of Dermatology, Charité - University Hospital Berlin, Germany
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Gregoriou S, Efthymiou O, Stefanaki C, Rigopoulos D. Management of pemphigus vulgaris: challenges and solutions. Clin Cosmet Investig Dermatol 2015; 8:521-7. [PMID: 26543381 PMCID: PMC4622091 DOI: 10.2147/ccid.s75908] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The main objective in the treatment of pemphigus vulgaris is to control the disease, prevent relapses, and avoid adverse events associated with the prolonged use of steroids and immunosuppressive agents. Systemic corticosteroids remain the gold standard treatment for pemphigus vulgaris. Azathioprine and mycophenolate mofetil are the first line of steroid-sparing treatment. Rituximab is extremely effective in recalcitrant pemphigus, when other treatments fail to control the disease. The European Dermatology Forum recommends tapering prednisolone by 25% every 2 weeks after the consolidation phase, and a 5 mg reduction every 4 weeks when the dose is reduced to <20 mg. If the patient relapses, options include increasing steroids back to the previous dose, adding an immunosuppressant if using steroid monotherapy, or replacing a first-line immunosuppressant by another if already on combination therapy.
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Affiliation(s)
- Stamatis Gregoriou
- 2nd Department of Dermatology and Venereology, University of Athens Medical School, Attikon Hospital, Athens, Greece
| | - Ourania Efthymiou
- 2nd Department of Dermatology and Venereology, University of Athens Medical School, Attikon Hospital, Athens, Greece
| | - Christina Stefanaki
- 2nd Department of Dermatology and Venereology, University of Athens Medical School, Attikon Hospital, Athens, Greece
| | - Dimitris Rigopoulos
- 2nd Department of Dermatology and Venereology, University of Athens Medical School, Attikon Hospital, Athens, Greece
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46
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Eming R, Sticherling M, Hofmann SC, Hunzelmann N, Kern JS, Kramer H, Pfeiffer C, Schuster V, Zillikens D, Goebeler M, Hertl M, Nast A, Orzechowski HD, Sárdy M, Schmidt E, Sitaru C, Sporbeck B, Worm M. S2k-Leitlinie zur Therapie des Pemphigus vulgaris/foliaceus und des bullösen Pemphigoid. J Dtsch Dermatol Ges 2015. [DOI: 10.1111/ddg.140_12606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Rüdiger Eming
- Klinik für Dermatologie und Allergologie, Philipps-Universität; Marburg
| | | | - Silke C. Hofmann
- Helios Klinikum Wuppertal; Zentrum für Dermatologie, Allergologie und Dermatochirurgie; Wuppertal
| | - Nicolas Hunzelmann
- Klinik und Poliklinik für Dermatologie und Venerologie; Universität zu Köln
| | - Johannes S. Kern
- Klinik für Dermatologie und Venerologie; Universitätsklinikum Freiburg
| | | | | | - Volker Schuster
- Pädiatrische Immunologie und Rheumatologie; Universitätsklinik und Poliklinik für Kinder und Jugendliche; Leipzig
| | - Detlef Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie; Universitätsklinikum Schleswig-Holstein; Campus Lübeck
| | - Matthias Goebeler
- Klinik und Poliklinik für Dermatologie; Venerologie und Allergologie, Universitätsklinikum Würzburg; Würzburg
| | - Michael Hertl
- Klinik für Dermatologie und Allergologie, Philipps-Universität; Marburg
| | - Alexander Nast
- Division of Evidence Based Medicine (dEBM); Klinik für Dermatologie, Charité - Universitätsmedizin Berlin
| | | | - Miklós Sárdy
- Klinik und Poliklinik für Dermatologie und Allergologie; Klinikum der Universität München (LMU); München
| | - Enno Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie; Universitätsklinikum Schleswig-Holstein; Campus Lübeck
| | - Cassian Sitaru
- Klinik für Dermatologie und Venerologie; Universitätsklinikum Freiburg
| | - Birte Sporbeck
- Division of Evidence Based Medicine (dEBM); Klinik für Dermatologie, Charité - Universitätsmedizin Berlin
| | - Margitta Worm
- Allergie-Centrum, Klinik für Dermatologie; Charité - Universitätsmedizin Berlin
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Hertl M, Jedlickova H, Karpati S, Marinovic B, Uzun S, Yayli S, Mimouni D, Borradori L, Feliciani C, Ioannides D, Joly P, Kowalewski C, Zambruno G, Zillikens D, Jonkman MF. Pemphigus. S2 Guideline for diagnosis and treatment--guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol 2014; 29:405-14. [PMID: 25338479 DOI: 10.1111/jdv.12772] [Citation(s) in RCA: 175] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 09/10/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pemphigus encompasses a group of life-threatening autoimmune bullous diseases characterized by blisters and erosions of the mucous membranes and skin. Before the era of immunosuppressive treatment, the prognosis of pemphigus was almost fatal. Due to its rarity, only few prospective controlled therapeutic trials are available. OBJECTIVES For this reason, a group of European dermatologists with a long-standing interest and expertise in basic and clinical pemphigus research has sought to define diagnostic and therapeutic guidelines for the management of patients with pemphigus. RESULTS This group identified the statements of major agreement or disagreement regarding the diagnostic and therapeutic management of pemphigus. The revised final version of the pemphigus guideline was finally passed on to the European Dermatology Forum (EDF) for a final consensus with the European Academy of Dermatology and Venereology (EADV) and the European Union of Medical Specialists (UEMS).
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Affiliation(s)
- M Hertl
- Department of Dermatology, Philipps-University Marburg, Marburg, Germany
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48
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Porro AM, Caetano LDVN, Maehara LDSN, Enokihara MMDS. Non-classical forms of pemphigus: pemphigus herpetiformis, IgA pemphigus, paraneoplastic pemphigus and IgG/IgA pemphigus. An Bras Dermatol 2014; 89:96-106. [PMID: 24626654 PMCID: PMC3938360 DOI: 10.1590/abd1806-4841.20142459] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 02/14/2013] [Indexed: 12/13/2022] Open
Abstract
The pemphigus group comprises the autoimmune intraepidermal blistering diseases
classically divided into two major types: pemphigus vulgaris and pemphigus
foliaceous. Pemphigus herpetiformis, IgA pemphigus, paraneoplastic pemphigus and
IgG/IgA pemphigus are rarer forms that present some clinical, histological and
immunopathological characteristics that are different from the classical types. These
are reviewed in this article. Future research may help definitively to locate the
position of these forms in the pemphigus group, especially with regard to pemphigus
herpetiformis and the IgG/ IgA pemphigus.
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Affiliation(s)
- Adriana Maria Porro
- Federal University of São Paulo, Paulista School of Medicine, Dermatology Department, São PauloSP, Brazil, Dermatologist. Masters Degree and PhD . Adjunct Professor and Coordinator of Bullous Dermatosis at the Dermatology Department, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP) - São Paulo (SP), Brazil
| | - Livia de Vasconcelos Nasser Caetano
- Federal University of São Paulo, Paulista School of Medicine, Dermatology Department, São PauloSP, Brazil, Dermatologist with specialization in Bullous Dermatosis at the Dermatology Department, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP) - São Paulo (SP), Brazil
| | - Laura de Sena Nogueira Maehara
- Federal University of São Paulo, Paulista School of Medicine, Dermatology Department, Dermatologist with specialization in Bullous Dermatosis and Pediatric Dermatology at the Dermatology Department, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP). PhD-candidate at UNIFESP (Translational Medicine) and the University of Groningen (Center for Blistering Diseases, Groningen University Medical Center, Netherlands)
| | - Milvia Maria dos Santos Enokihara
- Federal University of São Paulo, Paulista School of Medicine, Dermatology and Pathology Departments, São PauloSP, Brazil, Pathologist. Masters Degree and PhD. Dermatopathologist at the Dermatology and Pathology Departments, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP) - São Paulo (SP), Brazil
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Abstract
Rituximab is a monoclonal therapeutic anti-CD20 antibody that has been approved for use in lymphoma and rheumatoid arthritis. Over the past decade several reports based on case series and observational studies have recorded the benefits of rituximab in particular groups of dermatological patients. Off-label use of rituximab in many dermatological indications is not uncommon in many countries in the world. This article reviews the available data that may be of use to the practicing dermatologist. Because of its potential complications, paucity of clinical data, and cost considerations, rituximab is favoured only when standard systemic therapies fail or corticosteroids are absolutely contraindicated. Further research is required in this field.
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Affiliation(s)
- Prasan R Bhandari
- Department of Pharmacology, S.D.M. College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - Varadraj V Pai
- Department of Dermatology, S.D.M. College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
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50
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Corral IS, Freitas THPD, Aquino RTRD, Koller DAS, Magliari MER, Muller H. Severe multi-resistant pemphigus vulgaris: prolonged remission with a single cycle of rituximab. An Bras Dermatol 2014; 88:639-42. [PMID: 24068143 PMCID: PMC3760947 DOI: 10.1590/abd1806-4841.20131990] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 08/30/2012] [Indexed: 11/28/2022] Open
Abstract
Pemphigus vulgaris is an autoimmune bullous disease whose therapy is based on
systemic corticosteroids, with or without immunosuppressants. Rituximab is a chimeric
monoclonal antibody of the IgG class, directed at a specific CD20 B cell surface
antigen, used in pemphigus vulgaris empirically since 2002, with success in 90% of
the cases and long periods of remission. Male patient, 33 years old, diagnosed with
pemphigus vulgaris, confirmed by histopathology and direct immunofluorescence. He was
treated for seven months with numerous treatments, including immunosuppressive drugs,
with an unsatisfactory response, until he had complete remission with the use of
rituximab. During a 34-month follow-up period, the patient presented a slight
clinical relapse, which was successfully controlled with prednisone in a daily dose
of 120mg, soon reduced to 20mg.
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