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Costan VV, Popa C, Hâncu MF, Porumb-Andrese E, Toader MP. Comprehensive review on the pathophysiology, clinical variants and management of pemphigus (Review). Exp Ther Med 2021; 22:1335. [PMID: 34630689 PMCID: PMC8495539 DOI: 10.3892/etm.2021.10770] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/09/2021] [Indexed: 12/16/2022] Open
Abstract
Pemphigus represents a group of chronic inflammatory disorders characterized by autoantibodies that target components of desmosomes, leading to the loss of intercellular adhesion between keratinocytes and causing intraepithelial blistering. The pemphigus group consists of four main clinical types with several variants: pemphigus vulgaris (with pemphigus vegetans and pemphigus herpetiformis as variants), pemphigus foliaceus, paraneoplastic pemphigus and IgA pemphigus (with two clinical variants: intraepidermal neutrophilic IgA dermatosis and subcorneal pustular dermatosis). Genetic factors are involved in the pathogenesis, with HLA-DR4 (DRB1*0402) and HLA-DRw6 (DQB1*0503) allele more common in patients with pemphigus vulgaris, HLA class II DRB1*0344 and HLA Cw*1445 correlated with paraneoplastic pemphigus, and HLA-DRB1*04:01, HLA-DRB1*04:06, HLA-DRB1*01:01, HLA-DRB1*14, associated with a higher risk of developing pemphigus foliaceus. Autoantibodies are conducted against structural desmosomal proteins in the skin and mucous membranes, mainly desmogleins, desmocollins and plakins. Cell-mediated immunity may also play a role, especially in paraneoplastic pemphigus. Patients may present erythema, blisters, erosions, and ulcers that may affect the skin, as well as mucosal surfaces of the oral cavity, eyes, nose, leading to severe complaints including pain, dysphagia, and fetor. Oral mucosal postbullous erosive lesions are frequently the first sign of disease in pemphigus vulgaris and in paraneoplastic pemphigus, without skin involvement, making the diagnosis difficult. Treatment options classically include immunosuppressive agents, such as corticosteroids and corticosteroid-sparing agents such as azathioprine, mycophenolate mofetil, cyclophosphamide, methotrexate or dapsone. Newer therapies focus on blocking cell signaling events induced by pathogenic autoantibodies and/or targeting specific autoantibodies. The disease evolution is conditioned by the treatment with maximum doses of corticosteroids and the side effects associated with long-term immunosuppressive therapy, which is why patients need a multidisciplinary approach in following the treatment. In this review, we provide a comprehensive overview of the epidemiology, pathophysiology, clinical aspect, diagnosis and management of the main intraepidermal blistering diseases from the pemphigus group.
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Affiliation(s)
- Victor-Vlad Costan
- Department of Oral and Maxillofacial Surgery, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Cristina Popa
- Department of Oral Medicine and Oral Dermatology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Mădălina Florina Hâncu
- Department of Dermatology, 'Sf. Spiridon' Clinical Emergency County Hospital, 700111 Iași, Romania
| | - Elena Porumb-Andrese
- Department of Dermatology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Mihaela Paula Toader
- Department of Oral Medicine and Oral Dermatology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iași, Romania
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Watanabe H, Watanabe Y, Tashiro Y, Mushiroda T, Ozeki T, Hashizume H, Sueki H, Yamamoto T, Utsunomiya-Tate N, Gouda H, Kusakabe Y. A docking model of dapsone bound to HLA-B*13:01 explains the risk of dapsone hypersensitivity syndrome. J Dermatol Sci 2017; 88:320-329. [PMID: 28870516 DOI: 10.1016/j.jdermsci.2017.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/04/2017] [Accepted: 08/08/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Dapsone (4,4'-diaminodiphenylsulfone) has been widely used for the treatment of infections such as leprosy. Dapsone hypersensitivity syndrome (DHS) is a major side effect, developing in 0.5-3.6% of patients treated with dapsone, and its mortality rate is ∼10%. Recently, human leukocyte antigen (HLA)-B*13:01 was identified as a marker of susceptibility to DHS. OBJECTIVES To investigate why HLA-B*13:01 is responsible for DHS from a structural point of view. METHODS First, we used homology modeling to derive the three-dimensional structures of HLA-B*13:01 (associated with DHS) and HLA-B*13:02 (not so associated despite strong sequence identity [99%] with HLA-B*13:01). Next, we used molecular docking, molecular dynamic simulations, and the molecular mechanics Poisson-Boltzman surface area method, to investigate the interactions of dapsone with HLA-B*13:01 and 13:02. RESULTS We found a crucial structural difference between HLA-B*13:01 and 13:02 in the F-pocket of the antigen-binding site. As Trp95 in the α-domain of HLA-B*13:02 is replaced with the less bulky Ile95 in HLA-B*13:01, we found an additional well-defined sub-pocket within the antigen-binding site of HLA-B*13:01. All three representative docking poses of dapsone against the antigen-binding site of HLA-B*13:01 used this unique sub-pocket, indicating its suitability for binding dapsone. However, HLA-B*13:02 does not seem to possess a binding pocket suitable for binding dapsone. Finally, a binding free energy calculation combined with a molecular dynamics simulation and the molecular mechanics Poisson-Boltzman surface area method indicated that the binding affinity of dapsone for HLA-B*13:01 would be much greater than that for HLA-B*13:02. CONCLUSIONS Our computational results suggest that dapsone would fit within the structure of the antigen-recognition site of HLA-B*13:01. This may change the self-peptides that bind to HLA-B*13:01, explaining why HLA-B*13:01 is a marker of DHS susceptibility.
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Affiliation(s)
- Hideaki Watanabe
- Department of Dermatology, Showa University School of Medicine, Tokyo, Japan.
| | - Yurie Watanabe
- Department of Analytical and Physical Chemistry, Showa University School of Pharmacy, Tokyo, Japan
| | - Yasuya Tashiro
- Department of Dermatology, Showa University School of Medicine, Tokyo, Japan
| | | | - Takeshi Ozeki
- RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Hideo Hashizume
- Department of Dermatology, Shimada Municipal Hospital, Shizuoka, Japan
| | - Hirohiko Sueki
- Department of Dermatology, Showa University School of Medicine, Tokyo, Japan
| | - Toshinori Yamamoto
- Showa University Medical Foundation, Showa University School of Pharmacy, Tokyo, Japan
| | - Naoko Utsunomiya-Tate
- Laboratory of Chemistry, Faculty of Pharma Sciences, Teikyo University, Tokyo, Japan
| | - Hiroaki Gouda
- Department of Analytical and Physical Chemistry, Showa University School of Pharmacy, Tokyo, Japan.
| | - Yoshio Kusakabe
- Department of Analytical and Physical Chemistry, Showa University School of Pharmacy, Tokyo, Japan; Laboratory of Chemistry, Faculty of Pharma Sciences, Teikyo University, Tokyo, Japan
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Al'banova VI, Nefedova MA. AUTOIMMUNE BULLOUS DERMATOSES. DIFFERENTIAL DIAGNOSIS. VESTNIK DERMATOLOGII I VENEROLOGII 2017. [DOI: 10.25208/0042-4609-2017-93-3-10-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The review presents modern ideas concerning autoimmune bullous dermatoses (pemphigoid group): Duhring disease, bullous pemphigoid, cicatrizing pemphigus, pemphigoid gestationis, linear IgA bullous dermatosis and acquired bullous epidermolysis. Pathogenesis, clinical manifestations and modern methods of disease diagnostics are reported. Particular attention is paid to the diagnosis of acquired bullous epidermolysis, in which the leading role belongs to the reaction of immunofluorescence. The pathogenetic similarity between bullous pemphigoid, linear IgA dermatosis, cicatrizing pemphigoid and pemphigoid gestationis is shown, which allows us to regard them as a variety of a single pathological process.
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Kartan S, Shi VY, Clark AK, Chan LS. Paraneoplastic Pemphigus and Autoimmune Blistering Diseases Associated with Neoplasm: Characteristics, Diagnosis, Associated Neoplasms, Proposed Pathogenesis, Treatment. Am J Clin Dermatol 2017; 18:105-126. [PMID: 27878477 DOI: 10.1007/s40257-016-0235-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Autoimmune paraneoplastic and neoplasm-associated skin syndromes are characterized by autoimmune-mediated cutaneous lesions in the presence of a neoplasm. The identification of these syndromes provides information about the underlying tumor, systemic symptoms, and debilitating complications. The recognition of these syndromes is particularly helpful in cases of skin lesions presenting as the first sign of the malignancy, and the underlying malignancy can be treated in a timely manner. Autoimmune paraneoplastic and neoplasm-associated bullous skin syndromes are characterized by blister formation due to an autoimmune response to components of the epidermis or basement membrane in the context of a neoplasm. The clinical manifestations, histopathology and immunopathology findings, target antigens, associated neoplasm, current diagnostic criteria, current understanding of pathogenesis, and treatment options for a selection of four diseases are reviewed. Paraneoplastic pemphigus manifests with clinically distinct painful mucosal erosions and polymorphic cutaneous lesions, and is often associated with lymphoproliferative neoplasm. In contrast, bullous pemphigoid associated with neoplasm presents with large tense subepidermal bullae of the skin, and mild mucosal involvement, but without unique clinical features. Mucous membrane pemphigoid associated with neoplasm is a disorder of chronic subepithelial blisters that evolve into erosions and ulcerations that heal with scarring, and involves stratified squamous mucosal surfaces. Linear IgA dermatosis associated with neoplasm is characterized by annularly grouped pruritic papules, vesicles, and bullae along the extensor surfaces of elbows, knees, and buttocks. Physicians should be aware that these autoimmune paraneoplastic and neoplasm-associated syndromes can manifest distinct or similar clinical features as compared with the non-neoplastic counterparts.
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Comparative Study of Direct Immunofluorescence in Discoid Lupus Erythematosus and Bullous Pemphigoid. Am J Dermatopathol 2016; 38:121-3. [DOI: 10.1097/dad.0000000000000387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bascones-Martínez A, García-García V, Meurman JH, Requena-Caballero L. Immune-mediated diseases: what can be found in the oral cavity? Int J Dermatol 2014; 54:258-70. [PMID: 25514833 DOI: 10.1111/ijd.12681] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Immune-mediated diseases frequently affect oral mucosa, which may often be the first site of clinical manifestation. In this review, we describe the most important oral lesions related to inflammatory disorders and present their management and novel therapies. The review is based on an open PubMed literature search from 1980 to 2012 with relevant keywords. Pemphigus vulgaris, oral lichen planus, cicatricial pemphigoid, erythema multiforme, Stevens-Johnson syndrome, systemic lupus erythematosus, Sjögren's syndrome, and linear IgA dermatosis are the immune-mediated diseases with oral manifestations discussed. Etiology is unknown in most of these diseases, but recently some of them have been found to share common genes. Modern treatment of these diseases is based on drugs that interfere along the pathogenic mechanisms instead of the still commonly used palliative measures. However, the immunomodulatory drugs may also cause oral side effects, complicating the clinical picture. Therefore, consulting dental or oral medicine specialists can be necessary in some cases with various immune-mediated diseases.
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Affiliation(s)
- Antonio Bascones-Martínez
- Department of Stomatology III, Faculty of Odontology, Complutense University of Madrid, Madrid, Spain
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Dyshidrosiform Linear Immunoglobulin A Dermatosis. ACTAS DERMO-SIFILIOGRAFICAS 2014. [DOI: 10.1016/j.adengl.2013.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Borja-Consigliere HA, Ormaechea-Pérez N, Lobo-Morán C, Tuneu-Valls A. Dyshidrosiform linear immunoglobulin a dermatosis. ACTAS DERMO-SIFILIOGRAFICAS 2013; 105:429-30. [PMID: 24002009 DOI: 10.1016/j.ad.2013.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 04/12/2013] [Accepted: 05/05/2013] [Indexed: 10/26/2022] Open
Affiliation(s)
| | - N Ormaechea-Pérez
- Sección de Dermatología, Hospital Universitario Donostia, San Sebastián, España
| | - C Lobo-Morán
- Servicio de Anatomía Patológica, Hospital Universitario Donostia, San Sebastián, España
| | - A Tuneu-Valls
- Sección de Dermatología, Hospital Universitario Donostia, San Sebastián, España
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