Pemphigus vulgaris: a multidisciplinary approach to management

Addressing Challenges in Diagnosis, Differential Diagnosis, and Treatment of Pemphigus: A Case Series

Pemphigus is a rare autoimmune disease characterized by skin blisters and erosions, with or without mucosal involvement. The clinical presentation of pemphigus can resemble other bullous diseases, leading to challenges in diagnosis. This report aims to address the challenges in diagnosing and treating oral pemphigus. Three patients, ranging in age from 26 to 55 years, complained of a sore throat and mouth canker sores. Extra-oral examination revealed dry lips in case 1, while serosanguinolenta crust on the lip that bled easily was found in case 2. Intra-oral examinations in all cases showed multiple painful, sloughing-covered, erosive lesions on the entire oral mucosa. The histopathological examination of case 1 revealed pemphigus foliaceous, whereas cases 2 and 3 showed pemphigus vulgaris. Secondary syphilis-like pemphigus was given as a differential diagnosis in case 2 due to the histopathological changes not being specific. The patients were instructed to maintain oral hygiene and treated with corticosteroid, analgesic, antifungal, and anti-inflammation mouthwash, as well as vitamins and minerals. All cases showed improvement in oral lesions within 14 days to a month. In conclusion, pemphigus may mimic other bullous diseases, making diagnosis challenging. A comprehensive clinical and laboratory assessment is necessary to provide accurate diagnosis and treatment.

Gefitinib induced Pemphigus Vulgaris with PRIDE complex

Introduction: Pemphigus Vulgaris is a rare, noncommunicable, non-hereditary fatal autoimmune dermatological manifestation in which a painful blister initiates from the oral cavity. PRIDE complex stands for Papulopustules or paronychia, regulatory abnormality of hair and nails, itching, and dryness due to inhibition of EGFR. Both of these mucocutaneous manifestations are rare and are often caused by drugs. Case report: Our case reports 53-year-old patient presented with multiple crusted plaques, multiple hyperpigmented macules to patches, Solitary fluid-filled lesions on several parts of the body, and numerous erosions positive over buccal mucosa on initial follow up which was diagnosed as Pemphigus Vulgaris with PRIDE complex induced by Gefitinib. Management and outcome: The patient was treated with almost all possible treatment options, i.e., both steroids plus adjuvant therapy for pemphigus and antihistaminic, antibiotics, moisturizer, and lotions for PRIDE complex. The patient was initially admitted for infusion of the first dose of rituximab and later for management of flare-up condition and infusion of the second dose of rituximab infusion. Discussion: The complexity of the management of Pemphigus Vulgaris and PRIDE complex demands adequate monitoring of the patient's anti-cancerous therapy by clinical pharmacists, which can impact the clinical outcomes by providing pharmaceutical care and minimize the economic burden.

Diagnosis and Treatment Challenges of an Atypical Case of Pemphigus vulgaris During the COVID-19 Pandemic

Pemphigus defines a group of rare autoimmune blistering diseases that affect the skin and mucous membranes, with pemphigus vulgaris being the most common form that has increased morbidity and mortality in the absence of an early diagnosis and treatment.

We report the case of a 24-year-old male with an atypical form of pemphigus vulgaris with cutaneous onset and subsequent involvement of the oral cavity. The management of the patient initially consisted of long-term systemic corticosteroid therapy. Following a mild form of SARS-CoV-2 infection and a flare-up of the disease in this context, which was not controlled with high doses of systemic corticosteroids, targeted therapy with rituximab was initiated but immediately stopped due to the manifestations of urticaria and angioedema. Considering the magnitude of these reactions, dapsone systemic therapy i.e., a steroid-sparing agent with minimal risk of infections, was started and managed to control the underlying disease.

The management of this case of pemphigus vulgaris was challenging for both the patient and his physician, as the patient developed COVID-19 which caused disease complications and implied additional costs. This case highlights the importance of an accurate diagnosis given the atypical onset of the disease and the financial limitations with the impossibility of performing all confirmatory diagnostic tests.

An Updated Review of Pemphigus Diseases

Clinicians may encounter a variety of skin conditions that present with vesiculobullous lesions in their everyday practice. Pemphigus vulgaris, pemphigus foliaceus, IgA pemphigus, and paraneoplastic pemphigus represent the spectrum of autoimmune bullous dermatoses of the pemphigus family. The pemphigus family of diseases is characterized by significant morbidity and mortality. Considering the risks associated with a delayed diagnosis or misdiagnosis and the potential for overlap in clinical features and treatment, evaluation for suspected pemphigus disease often requires thorough clinical assessment and laboratory testing. Diagnosis is focused on individual biopsies for histopathology and direct immunofluorescence. Additional laboratory methods used for diagnosis include indirect immunofluorescence and enzyme-linked immunosorbent assay. Recent advancements, including anti-CD20 therapy, have improved the efficacy and reduced the morbidity of pemphigus treatment. This contribution presents updates on the pathophysiology, clinical features, diagnostic work-up, and medical management of pemphigus. Improved strategies for diagnosis and clinical assessment are reviewed, and newer treatment options are discussed.