Bullous skin diseases: classical types of autoimmune diseases

Adrenocorticotropic hormone (ACTH) level and adrenal deficiency in patients with mucocutaneous pemphigus

OBJECTIVES

This study aimed to evaluate the level of adrenocorticotropic hormone (ACTH) and adrenal insufficiency in patients with mucocutaneous pemphigus lesions who use oral corticosteroids.

METHODS

This descriptive-analytical study was performed on 54 patients (48.44 ± 12.74 years) with mucocutaneous pemphigus in 2019. Those patients taken corticosteroids in different doses and way. At first, collected patients information including age, sex, type of pemphigus, duration of use, patient dosage, duration of corticosteroid administration, and method of administration were collected daily. Adrenal gland function was measured by evaluating ACTH levels. Data were analyzed by using Pearson correlation coefficient and t-test.

RESULTS

Our study showed that 37 cases (68.5%) had normal ACTH average hormone level (7.3-63.3 mL/pg), 11 cases (20.4%) were lower levels (<7.2 mL/pg), and 6 cases (11.1%) were higher levels (63.3 > mL/pg). Wo observed no significant relationship between ACTH and duration of corticosteroids usage (p=0.207).

CONCLUSIONS

Taking a maintenance dose of between 12.5 and 25 mg daily does not usually lead to adrenal insufficiency. The present study showed that the lower the daily dose of corticosteroids, the lower the likelihood of adrenal insufficiency.

The Evaluation of Serum Lipids Profile in Patients with Pemphigus Vulgaris: A Case-Control Study

Background

Pemphigus vulgaris (PV) is a chronic autoimmune disease. Dyslipidemia, increased risk of atherosclerosis and higher cardiovascular morbidity, and mortality have been reported in several autoimmune conditions. It has been hypothesised that there might be an association between dyslipidemia and PV. Therefore, the objective of this study was to compare the serum lipid profile of patients with PV with healthy controls.

Methods

This case-control study was carried out on 113 patients with PV and 100 healthy controls. Total cholesterol, high-density lipoprotein (HDL) and triglycerides (TG) levels were measured and low-density lipoprotein (LDL), non-HDL cholesterol (non-HDL-C) and atherogenic index of plasma (AIP) were calculated. Chi-squared test and independent Student t-test (or their alternatives) were used for group comparison.

Results

The mean age and BMI of patients and controls were 47.7 ± 14.5 and 28 ± 6.2 and, 44.5 ± 18.5 and 25.5 ± 5.1, respectively. Total cholesterol, LDL, HDL, non-HDL-C and TG were statistically different between the two groups (P values < 0.001; < 0.001; < 0.001; < 0.001 and 0.021, respectively). However, AIP was not significantly different (P-value = 0.752).

Conclusion

The serum lipid profile was significantly higher in PV patients compared to healthy controls. Therefore, PV patients may be more prone to develop atherosclerosis and this finding can be important in the overall management of these patients.

Family dermatology life quality index in patients with pemphigus vulgaris: A cross-sectional study

BACKGROUND AND AIMS

Pemphigus vulgaris is a rare autoimmune intraepidermal vesiculobullous disease involving the skin and mucosa. It impacts the quality of life of both patients and their families.

METHODS

A total of 70 patients with pemphigus vulgaris (either outpatient or hospitalized) were enrolled using the simple sampling method between 2016 and 2017 from the dermatology clinic at Faghihi Hospital, Shiraz, Iran. A validated Persian version of the Family Dermatology Life Quality Index (FLDQI) questionnaire was filled by a family caregiver. The questionnaire contained 10 items assessing the quality of life of the family. Demographic variables were recorded in a separate form.

RESULTS

The mean age of the patients was 51 ± 11.3 years and that of the family caregivers was 32 ± 8.8 years. The FLDQI score was higher (poorer quality of life) if the patient was male, older, had shorter disease duration or had fewer disease recurrences (P = 0.046, 0.01, 0.001 and >0.001, respectively). Higher scores were also obtained in the less-educated caregivers (P = 0.026) but there was no association with either gender or age (P = 0.399, 0.1).

CONCLUSION

Pemphigus vulgaris significantly affects the Family Dermatology Life Quality Index. Education and counseling of family caregivers by various support groups such as Pemphigus Family Associations could be effective in improving the quality of life of the caregivers.

LIMITATIONS

This study did not assess the effect of comprising domain analysis, severity of disease, patients' Dermatology Life Quality Index (DLQI), mucosal involvement, response to treatment, outpatient or admitted status, socioeconomic status, or the quality of life among the various family members.

Cytoskeletal Regulation of Inflammation and Its Impact on Skin Blistering Disease Epidermolysis Bullosa Acquisita

Actin remodelling proteins regulate cytoskeletal cell responses and are important in both innate and adaptive immunity. These responses play a major role in providing a fine balance in a cascade of biological events that results in either protective acute inflammation or chronic inflammation that leads to a host of diseases including autoimmune inflammation mediated epidermolysis bullosa acquisita (EBA). This review describes the role of the actin cytoskeleton and in particular the actin remodelling protein called Flightless I (Flii) in regulating cellular inflammatory responses and its subsequent effect on the autoimmune skin blistering disease EBA. It also outlines the potential of an antibody based therapy for decreasing Flii expression in vivo to ameliorate the symptoms associated with EBA.

Oral pemphigus vulgaris: A case report with direct immunofluorescence study

Pemphigus vulgaris (PV) is a chronic, autoimmune, intraepidermal blistering disease of the skin and mucous membranes. The initial clinical manifestation is frequently the development of intraoral lesions, and later, the lesions involve the other mucous membranes and skin. The etiology of this disease still remains obscure although the presence of autoantibodies is consistent with an autoimmune disease. These antibodies are targeted against the adhesion proteins of keratinocytes, leading to acantholysis (disruption of spinous layer, leading to intraepidermal clefting) and blister formation. Because only oral lesions are present initially, the chances of misdiagnosing the disease as another condition are increased, leading to inappropriate therapy. In this article, we report a case of PV with only oral manifestations in a 36-year-old male.

Epidermal multinucleated giant cells are not always a histopathologic clue to a herpes virus infection: multinucleated epithelial giant cells in the epidermis of lesional skin biopsies from patients with acantholytic dermatoses can histologically mimic a herpes virus infection

BACKGROUND

Multinucleated giant cells in the epidermis can either be epithelial or histiocytic. Epithelial multinucleated giant cells are most often associated with herpes virus infections.

PURPOSE

To review the histologic differential diagnosis of conditions with epithelial and histiocytic multinucleated giant cells-since multinucleated giant cells in the epidermis are not always pathognomonic of a cutaneous herpes virus infection-and to summarize dermatoses in which herpes virus infection has been observed to coexist.

METHODS

Two individuals with acantholytic dermatoses whose initial lesional skin biopsies showed multinucleated epithelial giant cells suggestive of a herpes virus infection are reported. Using the PubMed database, an extensive literature search was performed on multinucleated giant cell (and epidermis, epithelial, and histiocytic) and herpes virus infection. Relevant papers were reviewed to discover the skin conditions with either multinucleated giant cells in the epidermis or coincident cutaneous herpes virus infection.

RESULTS

Initial skin biopsies from patients with either pemphigus vulgaris or transient acantholytic dermatosis mimicked herpes virus infection; however, laboratory studies and repeat biopsies established the correct diagnosis of their acantholytic dermatosis. Hence, epidermal multinucleated giant cells are not always a histopathologic clue to a herpes virus infection. Indeed, epithelial multinucleated giant cells in the epidermis can be observed not only in the presence of infection (herpes virus), but also acantholytic dermatoses and tumors (trichoepithelioma and pleomorphic basal cell carcinoma). Histiocytic multinucleated giant cells in the epidermis can be observed in patients with either giant cell lichenoid dermatitis or lichen nitidus of the palms.

CONCLUSIONS

Epithelial and histiocytic multinucleated giant cell can occur in the epidermis. Keratinocyte-derived multinucleated giant cells are most commonly associated with herpes virus infection; yet, they can also be observed in patients with skin tumors or acantholytic dermatoses. Cutaneous herpes simplex virus infection can coexist in association with other conditions such as acantholytic dermatoses, benign skin tumors, bullous disorders, hematologic malignancies, inflammatory dermatoses, and physical therapies. However, when a herpes virus infection is suspected based upon the discovery of epithelial multinucleated giant cells in the epidermis, but either the clinic presentation or lack of response to viral therapy or absence of confirmatory laboratory studies does not support the diagnosis of a viral infection, the possibility of a primary acantholytic dermatosis should be considered and additional lesional skin biopsies performed. Also, because hematoxylin and eosin staining is not the golden standard for confirmation of autoimmune bullous dermatoses, skin biopsies for direct immunofluorescence should be performed when a primary bullous dermatosis is suspected since the histopathology observed on hematoxylin and eosin stained sections can be misleading.