Autoimmune bullous diseases: ocular manifestations and management

Ocular involvement in oral vesiculobullous diseases: A review on reported cases in the literature

Introduction

Vesiculobullous disorders are a group of autoimmune diseases manifesting as chronic ulcers in the oral cavity. Ocular involvement may accompany oral ulcers and cause various problems for patients. This review summarizes the data regarding ocular involvement in patients with oral vesiculobullous.

Methods

Web of Science, Scopus, PubMed/MEDLINE, and Embase electronic databases were searched according to related keywords. Finally, 58 articles were included, all of which were case reports or series. Characteristics such as the age and sex of patients, location and type of oral lesion, type of ophthalmic injury, the interval between oral and ocular lesion, and treatment of oral and ocular disorders were summarized in tables.

Results

Eye involvement was 1.6 times more prevalent in women, and most patients were between 30 and 60 years old (67.4 %). Pemphigus vulgaris accounted for almost half of the cases (48.4 %), though lichen planus is more prevalent in the general population. The most frequently affected oral site was the buccal mucosa (17.5 %), and oral ulcers usually presented as erythema, erosion, or inflammation (22.7 %). Conjunctivitis was the most common type of eye involvement (18.4 %), and ophthalmic lesions regularly appeared 12-60 months after the development of oral lesions (30.1 %). Blindness was reported in only one case. Corticosteroids and immunosuppressives were the most frequent oral and ocular lesion therapies.

Conclusion

Considering the serious burdens of any ocular injury, monitoring the ocular health of patients with oral vesiculobullous diseases is highly recommended in high-risk cases, especially middle-aged women with oral pemphigus vulgaris.

Ocular involvement in autoimmune bullous diseases

Autoimmune bullous diseases represent a heterogenous group of disorders caused by autoantibodies against adhesion molecules; the location of the target protein determines the level of cleft formation. The spectrum of ocular lesions in autoimmune bullous diseases can range from mild symptoms to severe involvement with sight impairment and even, in some cases, blindness. In pemphigus vulgaris, the prevalence of ocular involvement has been reported to be between 7% and 26%. The most common clinical sign of ocular pemphigus vulgaris is bilateral conjunctivitis with hyperemia. Ocular involvement also occurs in 41% to 70% of patients with paraneoplastic pemphigus. The main ocular manifestations are bilateral cicatrizing conjunctivitis with symblepharon formation, and shortening of the fornices. In mucous membrane pemphigoid, ocular involvement is seen in 61% to 70% of patients; the most frequent ocular finding is cicatricial conjunctivitis. Patients with autoimmune bullous diseases having common ocular involvement should be assessed by an ophthalmologist to avoid serious complications. Diagnostic procedures and treatment require multidisciplinary care based on the close cooperation between dermatologists and ophthalmologists.

Ocular surface disorders affect quality of life in patients with autoimmune blistering skin diseases: a cross-sectional study

Background

Autoimmune blistering skin diseases (AIBD) are a group of rare chronic autoimmune diseases which are associated with ocular surface diseases especially dry eye disease. This study is designed to investigate the relationship between ocular surface disorders and quality of life among patients with autoimmune blistering skin diseases.

Methods

Twenty-four AIBD patients (18 pemphigus and 7 pemphigoid) and twenty-five non-AIBD controls were included. Ocular surface disease index (OSDI), ocular surface evaluation, including slit-lamp examination, Schirmer I test, tear break-up time, corneal fluorescein staining, lid-parallel conjunctival folds, meibomian gland evaluation, presence of symblepharon and corneal opacity were assessed. Life quality was evaluated by multiple questionnaires, including Medical Outcomes Study 36-Item Short Form Questionnaire (SF-36), Hospital Anxiety and Depression Scale (HADS), Pittsburgh Sleep Quality Index (PSQI) and Health Assessment Questionnaire-Disability Index (HAQ-DI). Ocular surface tests and quality of life were compared between AIBD patients and non-AIBD controls. In the AIBD patients, the associations between ocular surface parameters and quality of life were also evaluated.

Results

92% of AIBD patients and 87.5% of age- and sex-matched non-AIBD controls were diagnosed with dry eye in this study. Compared with non-AIBD controls, AIBD patients reported lower SF-36 scores (P < 0.05) and severer OSDI, Schirmer I test, tear break-up time, corneal fluorescein staining, presence of symblepharon and corneal opacity measures (P < 0.05). OSDI, Schirmer I test were correlated with SF-36 composite scores or scores on the SF-36 subscales.

Conclusions

AIBD patients experience reduced quality of life and more severe ocular surface disorders including dry eye, symblepharon and corneal opacity. Early treatments of dry eye and collaborations among multidisciplinary physicians are necessary in patients with AIBD.

Ocular Involvement in Pemphigus Vulgaris Without Skin Lesions: A Case Report

Pemphigus vulgaris (PV) is an autoimmune disorder affecting the skin and mucous membranes. The condition may be confused with a number of disorders, including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and erythema multiforme (EM), all of which are life-threatening. Immunohistological and histochemical analyses remain the optimal methods for differentiating these diseases. There is still insufficient evidence regarding the true incidence rate of ocular disease in PV as well as its distinct clinical types. This report sets to review the case of a 62-year-old male with atypical ocular pemphigus vulgaris and review the literature.

Ultra-high frequency ultrasound in the differential diagnosis of oral pemphigus and pemphigoid: An explorative study

OBJECTIVES

Intraoral ultra-high frequency ultrasound (UHFUS) is an emerging technique in oral medicine, due to its possibility to provide submillimeter resolution imaging of superficial mucosal structures. In this study, the potential role of UHFUS in the diagnosis of oral pemphigus vulgaris (PV) and mucous membrane pemphigoid (MMP) is assessed.

MATERIALS AND METHODS

Consecutive patients with suspected oral PV or MMP were enrolled. All patients underwent clinical examination, laboratory tests, intraoral UHFUS scan, and biopsy. Histology and direct immunofluorescence were set as benchmark for diagnosis confirmation. The sensitivity and specificity of UHFUS compared to histology were assessed. Mann-Whitney test was performed to evaluate the presence of differences in the echogenicity of PV and MMP. P-value was set at P < 0.05.

RESULTS

Twenty-five patients were included. Thirteen patients were diagnosed with PV, and twelve with MMP. The UHFUS features of PV and MMP lesions were described. Image analysis showed statistically significant differences between the echogenicity of PV and MMP lesions (P < 0.05). Good concordance between UHFUS and histology was found. UHFUS showed 75% sensitivity in the diagnosis of PV and 66.7% in the diagnosis of MMP.

CONCLUSIONS

UHFUS appears a valuable tool in the diagnosis of PV and MMP. Although histology and immunofluorescence remain the gold standard, UHFUS role in the diagnostic algorithm of PV and MMP seems promising as a chair-side tool consistently enhancing clinical evaluation of oral bullous lesions.

Ocular Manifestations and Management of Autoimmune Bullous Diseases

Autoimmune bullous diseases with ocular involvement consist of a group of systemic entities that are characterized by formation of autoantibodies against the proteins of the epithelial basement membrane zone of the conjunctiva. Mostly, the elderly are affected by these diseases. The characteristic patterns of mucocutaneous involvement and the specific tissue components targeted by these autoantibodies are differentiating features of these diseases. Ocular pemphigus vulgaris exhibits intraepithelial activity, whereas the autoimmune activity in linear immunoglobulin A disease, mucous membrane pemphigoid, and epidermolysis bullosa acquisita occurs at a subepithelial location. Given the increased risk for blindness with delays in diagnosis and management, early detection of ocular manifestations in these diseases is vital. The precise diagnosis of these autoimmune blistering diseases, which is essential for proper treatment, is based on clinical, histological, and immunological evaluation. Management usually includes anti-inflammatory and immunosuppressive medications. Inappropriate treatment results in high morbidity and even potential mortality.

Pemphigus and mucous membrane pemphigoid: An update from diagnosis to therapy

Pemphigus diseases (PDs) and mucous membrane pemphigoid (MMP) are a group of immune-mediated mucocutaneous disorders clinically characterized by the formation of blisters, erosions and ulcers. The skin and mucous membranes are predominantly affected, with the oropharyngeal mucosa as the initially involved site. Ocular involvement is also a frequent feature of these diseases. Because of the considerable overlap in their clinical presentations, the diagnosis of PDs vs. MMP can be challenging. A recognition of their specific immunological and histopathologic features is crucial in the differential diagnosis. Treatment modalities include systemically administered corticosteroids, steroid-sparing immunosuppressive agents, and biologic therapies (rituximab, intravenous immunoglobulins, and anti-tumor necrosis factor agents). Topical, oral, conjunctival, or intralesional corticosteroids as well as anti-inflammatory drugs and antibiotics are prescribed as needed.

A review of scoring systems for ocular involvement in chronic cutaneous bullous diseases

BACKGROUND

Epidermolysis bullosa (EB) and autoimmune blistering diseases (AIBD) describe a group of rare chronic dermatoses characterized by cutaneous fragility and blistering. Although uncommon, significant ocular surface disease (OSD) may occur in both and require ophthalmological assessment. Disease scoring systems have a critical role in providing objective and accurate assessment of disease severity. The objectives of this report were, firstly, to document the prevalence and severity of ocular involvement in EB/AIBD. Secondly, to review and evaluate existing ocular and systemic scoring systems for EB/AIBD. Finally, to identify areas where further development of ocular specific tools in EB/AIBD could be pursued.

METHODS

A literature search was performed in October 2017 utilising Medline, Embase, and Scopus databases. The results were restricted by date of publication, between 01.01.1950 and 31.10.2017. The reference lists of these articles were then reviewed for additional relevant publications. Articles of all languages were included if an English translation was available. Articles were excluded if they were duplicates, had no reference to ocular involvement in EB/AIBD or described ocular involvement in other diseases.

RESULTS

Descriptions of ocular involvement in EB/AIBD were identified in 88 peer-reviewed journal articles. Findings reported include but are not limited to: cicatrising conjunctivitis, meibomian gland dysfunction, dry eye disease, trichiasis, symblepharon, fornix fibrosis, keratopathy, ectropion/entropion, ankyloblepharon, corneal ulceration, visual impairment and blindness. Although scoring systems exist for assessment of OSD in mucous membrane pemphigoid, no such tools exist for the other AIBD subtypes or for EB. Several systemic scoring systems exist in the dermatological literature that are efficacious in grading overall EB/AIBD severity, but have limited inclusion of ocular features. To the best of our knowledge, there is no recognised or validated scoring systems which comprehensively stages or grades the spectrum of ocular manifestations in EB/AIBD.

CONCLUSIONS

There are a range of ocular complications documented in EB and AIBD. Development of a comprehensive ocular scoring system for EB/AIBD which incorporates the delineation between 'activity' and 'damage' would facilitate more objective patient assessment, improved longitudinal monitoring, comparison of intervention outcomes, and provide commonality for discussion of these patients due to the multidisciplinary nature of their care.

Ocular involvement in pemphigus vulgaris - a retrospective study of a large Spanish cohort

BACKGROUND AND OBJECTIVES

Ocular/periocular involvement in pemphigus vulgaris (OPV) has rarely been reported. The objective of the present study was to investigate the pattern of OPV and define the prognostic value of its manifestation.

PATIENTS AND METHODS

From 1985 to 2014, a total of 167 patients with pemphigus vulgaris (PV) were treated at four tertiary Spanish hospitals. In this retrospective study, we included all patients with OPV. Clinical data and information on associated symptoms were obtained from patients' medical records.

RESULTS

Only 24 (14.3 %) of all PV patients had ocular lesions. In most cases, -ocular involvement was preceded by PV lesions at various other sites (mean duration: 33.7 months). Ocular PV lesions occurred during flares of mucocutaneous pemphigus, and was never the only mucosal manifestation. The most common clinical signs were conjunctival hyperemia (87.5 %), erosions on the eyelids (41.6 %) as well as of the palpebral/bulbar conjunctiva (33.3 %) and at the medial epicanthus (20.8 %). The most relevant associated symptoms included local pain/stinging (71.4 %), irritation (47.6 %), photophobia (38.1 %), and epiphora (23.9 %). Ocular PV improved with systemic and adjuvant topical therapies. Only two patients experienced sequelae.

CONCLUSIONS

In patients with PV, ocular involvement is an exception. Ocular PV is associated with greater disease activity, and usually follows a benign course. Sites affected are the conjunctiva, the eyelids, or both.

Paraneoplastic Pemphigus and Autoimmune Blistering Diseases Associated with Neoplasm: Characteristics, Diagnosis, Associated Neoplasms, Proposed Pathogenesis, Treatment

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.

Management of patients with ocular manifestations in vesiculobullous disorders affecting the mouth

Pemphigoid and pemphigus diseases as well as Stevens-Johnson syndrome present as vesiculobullous disorders of the skin and may additionally involve both the oral cavity and the ocular surface. Ocular involvement ranges from mild irritation and dry eye disease to chronic conjunctivitis, symblepharon, eyelid malposition, ocular surface scarring and severe visual loss. In addition to diagnostic assessments, ophthalmologists must treat the dry eye and meibomian gland dysfunction components of these diseases using a stepladder approach, including eyelid hygiene and lubricants. Topical anti-inflammatory therapy is used to treat acute inflammatory exacerbations of the ocular surface, but it cannot prevent scarring alone. Intralesional antimetabolite therapy can cause regression of conjunctival pathology in selected cases. Hence, patients with vesiculobullous disorders should be managed by a multidisciplinary team representing ophthalmology, dermatology, otolaryngology, oral medicine and pathology, internal medicine and intensive care. Systemic treatments including corticosteroids, azathioprine, cyclophosphamide, cyclosporine and mycophenolate mofetil help control inflammation. Intravenous immunoglobulins, plasmapheresis and targeted antibody therapy can be used in selected, severe and treatment-resistant cases. Local surgical management may include debridement of pseudomembranes, lysis of symblepharon, amniotic and mucous membrane grafting as well as reconstructive procedures. Prospective, multicentre, international studies are recommended to further support evidence-based practice.

Recurrent corneal melting in the paraneoplastic pemphigus associated with Castleman's disease

Background

The ocular presentation of Castleman’s disease (CD)-associated paraneoplastic pemphigus (PNP) has rarely been reported. In this report, we describe a young patient with CD-associated PNP who had recurrent corneal ulceration in addition to cicatrizing conjunctivitis.

Case presentation

We describe a case of 23-year-old male with mucocutaneous erosion and conjunctival injection and erosion who was found to have PNP. Pelvic hyaline-vascular CD was detected and completely excised. The mucocutaneous lesions improved postoperatively. Two years after pelvic surgery, the patient gradually developed conjunctival symblepharon in both eyes and pterygium in the right eye. The patient then underwent a successful exclusion of the symblepharon, an excision of the pterygium and an amniotic membrane transplantation in the right eye. However, after 6 months, he experienced an aseptic corneal ulcer and recurrent pterygiumin the right eye. After treatment with systemic and local immunosuppressive medications, the corneal ulcer gradually healed and remained stable.

Conclusion

Corneal ulceration and melting, in addition to conjunctivitis, as a complication of CD-associated PNP, can be successfully managed with systemic and local immunosuppressants.

Autoimmune bullous diseases with skin and eye involvement: Cicatricial pemphigoid, pemphigus vulgaris, and pemphigus paraneoplastica

Autoimmune blistering diseases are a heterogeneous group of disorders that mostly affect the skin and mucous membranes. Occasionally, other organ systems may be involved, depending on the unique pathophysiology of each disease. Cicatricial pemphigoid, pemphigus vulgaris, and paraneoplastic pemphigus are distinct entities, but all have the potential to have cutaneous and ocular involvement. Awareness and early recognition of ocular involvement in these diseases is important given the increased risk for vision loss and blindness with delay in management. Several skin diseases may be associated with involvement of the external eye. The most common autoimmune diseases are cicatricial pemphigoid, pemphigus vulgaris, and paraneoplastic pemphigus.

Pseudopemphigoid as caused by topical drugs and pemphigus disease

Pseudopemphigoid can cause a chronic cicatricial conjunctivitis that is clinically identical to the manifestations seen in mucous membrane pemphigoid, a disorder with a common clinical phenotype and multiple autoimmune links. For the purpose of this review, we will describe pseudopemphigoid as caused by topical drugs, the most common etiology with ocular manifestations, and as caused by the pemphigus disease, a more rare etiology. Specifically, we will discuss the ophthalmological features of drug-induced cicatricial conjunctivitis, pemphigus vulgaris, and paraneoplastic pemphigus. Other etiologies of pseudopemphigoid exist that will not be described in this review including autoimmune or inflammatory conditions such as lichen planus, sarcoidosis, granulomatosis with polyangiitis (Wegener’s granulomatosis), erythema multiforme (minor, major, and Stevens-Johnson syndrome), bullous pemphigoid, skin-dominated linear IgA bullous dermatosis, and skin-dominated epidermolysis bullosa acquisita. Prompt diagnosis of the underlying etiology in pseudopemphigoid is paramount to the patient’s outcome as certain diseases are associated with a more severe clinical course, increased ocular involvement, and differential response to treatment. A complete history and ocular examination may find early cicatricial changes in the conjunctiva that are important to note and evaluate to avoid progression to more severe disease manifestations. When such cicatricial changes are noted, proper diagnostic techniques are needed to help elucidate a diagnosis. Lastly, collaboration between ophthalmologists and subspecialists such as dermatologists, pathologists, immunologists, and others involved in the care of the patient is needed to ensure optimal management of disease.

Cicatricial changes in ocular pemphigus

PURPOSE

To describe the clinical characteristics of ocular involvement in patients with pemphigus at an ophthalmological referral center.

METHODS

A retrospective review was conducted on patients with the immunopathological diagnosis of pemphigus examined between 1 January 2000 and 1 April 2010. Uncorrected distance visual acuity (UDVA), best corrected distance visual acuity (BCVA), ocular symptoms, and ocular surface inflammatory and scarring changes were assessed.

RESULTS

A total of 15 patients were identified, with a mean age of 68.27 ± 14.35 years, and 80% (n=12) were female. Extraocular involvement was reported in one patient. All of the eyes showed cicatricial changes in the conjunctiva. In all, 6 eyes (20%) were classified as stage I; 12 eyes (40%) as stage II; 10 eyes (33%) as stage III; and 2 eyes (7%) as stage IV. A statistically significant association was found between BCVA and the severity of ocular involvement. The mean BCVA logMAR was 1.66 (20/914), with a range from logMAR 0 (20/20) to logMAR 4 (NLP). Other ocular diseases were found in 8 (53.3%), systemic diseases in 10 (66.7%), and the use of pemphigus-inducing drugs in 10 patients (66.7%).

CONCLUSIONS

The present report represents the largest series of ocular involvement in pemphigus confirmed by immunopathology. The clinical manifestations varied from conjunctival hyperemia to corneal scarring and perforation. There was a strong association between scarring changes and low BCVA. Ocular and systemic diseases as well as the use of pemphigus-inducing drugs may predispose to ocular cicatricial changes observed in this series.

Methotrexate as a treatment in ocular cicatricial moderate pemphigoid

CLINICAL CASE

A 73 year-old woman presented with a history of non-specific symptoms and photophobia in both eyes of 1 year progression. The examination revealed a bilateral symblepharon and fornix shortening. Immunohistochemical analysis confirmed the presence of linear deposits of IgG, IgM and C3 along the conjunctival basement membrane. With the diagnosis of Ocular Cicatricial Pemphigoid, systemic treatment with subcutaneous methotrexate was prescribed.

DISCUSSION

We consider such treatment a very effective initial immunosuppressive alternative in patients with moderate conjunctival inflammation and in cases of rapid progression.

Paraneoplastic pemphigus: a paraneoplastic autoimmune multiorgan syndrome or autoimmune multiorganopathy?

Paraneoplastic pemphigus (PNP), a clinically and immunopathologically distinct mucocutaneous blistering dermatosis, is a severe form of autoimmune multiorgan syndrome generally associated with poor therapeutic outcome and high mortality. This IgG-mediated disease is initiated by an obvious or occult lymphoproliferative disorder in most cases. Clinically severe mucositis, and polymorphic blistering skin eruptions, and histologically acantholysis, keratinocyte necrosis and interface dermatitis are its hallmark features. A 58-year-old female presented with recurrent, severe, recalcitrant stomatitis and widespread erosions/blistering lesions of one-year duration. Treatment with repeated courses of systemic corticosteroids at a peripheral center would provide temporary relief. She also had fever, productive cough, odynophagia and poor oral intake, herpes zoster ophthalmicus, pain in the abdomen, and watery diarrhea. An array of investigations revealed chronic lymphocytic leukemia (CLL), mediastinal and para-aortic lymphadenopathy, bronchiolitis obliterans, and vertebral osteoporosis/fractures. With the diagnosis of CLL-associated PNP she was managed with dexamethasone-cyclophosphamide pulse (DCP) therapy for 3 cycles initially, followed by COP regimen (cyclophosphamide, vincristine, and prednisolone) for 5 cycles. Remission is being maintained with chlorambucil and prednisolone pulse therapy once in 3 weeks with complete resolution of skin lesions and adequate control of CLL.

Geriatric dermatoses: a clinical review of skin diseases in an aging population

Geriatric dermatoses are a challenging job for the physician in terms of diagnosis, management, and followup. Since skin of the elderly population is going through a lot of changes from both an intrinsic and extrinsic point of view, it is imperative for the physician to have a better understanding of the pathophysiology of geriatric skin disorders and their specific management, which differs slightly from an adult population. This review focuses on a brief introduction to the pathophysiological aspects of skin disorders in elderly, the description of some common geriatric skin disorders and their management and the new emerging role of psychodermatological aspects of geriatric dermatoses is also discussed. At the end, ten multiple choice questions are also added to further enhance the knowledge base of the readers.

Ocular involvement and blindness secondary to linear IgA dermatosis

A 43-year-old man with linear immunoglobulin A (IgA) dermatosis associated with gluten intolerance presented with progressive vision loss, pain and photosensitivity in both eyes. His visual acuity was light perception (LP) in both eyes. A physical examination revealed bullous, papular lesions with erythematous borders in periocular tissues, limbs, and thorax. Slit-lamp examination showed conjunctival hyperemia, fibrosis, corneal opacification, and vascularization with epithelial defects. Immunofluorescent skin and corneal surface biopsy studies showed linear IgA deposits. The patient was treated with keratolimbal allogenic transplantation and cryopreserved amniotic membrane in the right eye. Regardless of the treatment he persisted with torpid evolution developing retinal and choroidal detachments. After these events he was started on intravenous immune globulin (IVIG) and showed very slight improvement in ocular surface. These types of blistering diseases are rare in the eye. Even when adequate local treatment is given, systemic treatment is mandatory and ocular prognosis can be unsatisfactory.

Clinical implications of aging skin: cutaneous disorders in the elderly

Aging skin undergoes progressive degenerative change. Structural and physiologic changes that occur as a natural consequence of intrinsic aging combined with the effects of a lifetime of ongoing cumulative extrinsic damage and environment insult (e.g. overexposure to solar radiation) can produce a marked susceptibility to dermatologic disorders in the elderly. As skin ages, the vasculature progressively atrophies. The supporting dermis also deteriorates, with collagen and elastin fibers becoming sparse and increasingly disordered. These changes leave the elderly increasingly susceptible to both vascular disorders such as stasis dermatitis and skin injuries such as pressure ulcers and skin tears, with a steadily decreasing ability to effect skin repair. A parallel erosion of normal immune function produces higher levels of autoimmune skin disorders such as bullous pemphigoid, benign mucous membrane pemphigoid, paraneoplastic pemphigoid, and pemphigus vulgaris. Lichen sclerosus, an autoimmune disorder often occurring in the genital area in older women, is not common but is an important development because of the potential for substantial discomfort as well as serious complications. The prevalence of polypharmacy in this population increases the risk for autoimmune drug reactions, and diagnosis should be undertaken with an awareness that polypharmacy in this population creates a greatly increased susceptibility to drug eruptions that can mimic other cutaneous disorders. Immunologic senescence in the elderly also sets the stage for potential reactivation of the Varicella zoster virus, in which initial dermatologic involvement expands into the major sensory ganglia. Known as shingles, this disorder can be excruciatingly painful with the potential to cause blindness if the optic nerve becomes involved. Dermatoses such as xerosis, pruritus, and eczema are also widespread in the elderly, create substantial suffering in those afflicted, and often prove recalcitrant to treatment. Individual susceptibility to specific types of contact dermatitis changes over the lifetime, and seborrheic dermatitis is substantially more prevalent in the elderly. It is not uncommon for older patients to have multiple impairments, with the potential for cognitive dysfunction as well as impaired vision, hearing, or mobility. In addition, they may not have adequate housing or nutrition, or the financial resources necessary for adequate compliance. Physicians must take into consideration the patient's physical ability to comply with the recommended therapy as well as socioeconomic factors that may impact on compliance. Simple topical regimens are preferable wherever possible in order to maximize compliance and, therefore, efficacy. Extra effort may be necessary to ensure that instructions are accurately followed and that ongoing compliance with the regimen prescribed is actually achieved. Management of dermatologic disorders in the elderly is often less than optimal, due to the fact that the special needs and limitations of this population are not adequately considered. Treatments should consider the intrinsic differences between younger and older patients that may impact on diagnosis and therapy choice. The aged patient is often afflicted with numerous co-morbidities that can influence the choice of therapy. Skin integrity in the elderly is compromised, and safety concerns are increased with the long-term use of any medication prescribed. In addition, the prevalence of polypharmacy in the aged population substantially increases the risk of cutaneous drug reactions, which can profoundly complicate accurate diagnosis of dermatologic disorders. The aged population also needs to be more closely monitored because of increased fragility of the skin and the physical limitations that may hinder compliance with prescribed regimens.

[Mucous membrane pemphigoid with ocular involvement. Part II: therapy]

Treatment of mucous membrane pemphigoid (MMP) aims at reduction of conjunctival inflammation by means of systemic immunosuppression. In addition, cicatricial progression and management of the resulting ocular surface disease requires topical conservative or surgical measures. The former includes systemic immunosuppression with steroids and other immunosuppressive agents: dapsone in mild to moderate disease and cyclophosphamide in severe cases have been established in two randomized trials. Other agents such as methotrexate, azathioprine, mycophenolate mofetil or monoclonal antibodies including daclizumab or rituximab were found to be effective in uncontrolled small studies. Surgery is primarily focused on eyelid problems such as entropium and trichiasis. Ocular surface disease and secondary complications, e.g. cataract formation and glaucoma, may need surgical treatment. Any surgery is associated with the risk of a relapse of inflammation and should be postponed until inflammation is controlled by systemic therapy. Management of MMP patients requires close collaboration of a specialized ophthalmologist with specialists from dermatology and internal medicine.

Ocular manifestations of blistering diseases

Ocular manifestations are a comorbidity of a group of chronic autoimmune blistering diseases that includes mucous membrane pemphigoid, linear immunoglobulin A disease, epidermolysis bullosa acquisita, and ocular pemphigus vulgaris. Various diagnostic measures differentiate between the diseases and allow for appropriate treatment including a specific selection of immunomodulatory medications. New treatment modalities offer alternatives that may minimize disease severity and residual tissue damage and may reduce treatment-related complications.

Response of ocular pemphigus vulgaris to therapy. Case report and review of literature

BACKGROUND

Pemphigus vulgaris is an autoimmune bullous disease characterized by blistering and erosions within skin and mucous membranes. Lesions appear most commonly on mucosal surfaces of the oral cavity. Ocular involvement in patients with PV has rarely been reported.

MAIN OBSERVATION

A 47-year-old male patient with a 2 month history of oral erosions and dysphagia developed severe conjunctivitis with periodical presence of purulent discharge, photophobia and burning sensations. The diagnosis of pemphigus vulgaris was confirmed by histopathology, direct immunofluorescence and detection of anti-desmogelin 3 antibodies in patients' serum. Treatment was introduced with prednisone at a dose of 80 mg per day (1 mg/kg) and cyclophosphamide at a dose of 100 mg daily (1.25 mg/kg). After 7 days of therapy a significant reduction of eye symptoms was observed and after 4 weeks of treatment full clinical remission was achieved.

CONCLUSIONS

The grounds for rare involvement of conjunctiva in pemphigus vulgaris is unclear. We hypothesize that inactivation of conjunctival desmoglein 3 may be compensated by other desmosomal proteins. Severe conjunctivitis may be the dominating clinical manifestation in pemphigus vulgaris. This implies a need of establishing distinct severity criteria and therapeutic standards for ocular pemphigus. In our patient rapid clinical response was achieved after introducing combined treatment with prednisone and oral cyclophosphamide.

Ocular cicatricial pemphigoid

PURPOSE OF REVIEW

To review the content and importance of articles on ocular cicatricial pemphigoid (OCP), or mucous membrane pemphigoid (MMP) with relevance to ocular involvement, published from 2005 to 2006.

RECENT FINDINGS

There is wide antigenic heterogeneity in MMP and OCP and attempts are being made to link this with clinical variations with varying degrees of success. A larger study demonstrates a link between multiple autoantibody reactivity and disease severity. Details of epitope specificity are emerging. A highly sensitive ELISA for laminin 5 has been developed which may provide prognostic information.Clinically, younger OCP patients show more severe ocular disease and are less well controlled by medication. A systematic review shows good evidence only for steroids and cyclophosphamide in OCP. Continued small trials suggest some role for the expensive intravenous immunoglobulin therapy in OCP where conventional treatment fails. Ocular reconstruction surgery has made some progression, and is enhanced by adjunctive medical therapy; osteo-odonto-keratoprosthesis offers some hope of prolonged retention of limited vision in end-stage disease.

SUMMARY

OCP remains a difficult disease to manage well and the progress being made in understanding disease mechanisms is whence true disease-modifying, safe therapy is likely to emerge in the future.