Understanding patient perspectives on vaccine decision making in adults with autoimmune bullous diseases: a qualitative study

Patients with autoimmune bullous diseases are at an increased risk of infection, both from the underlying skin disease and from immunosuppressive treatments. Limited information is available on vaccine beliefs and behaviors in dermatology patients and adults with autoimmune bullous diseases in particular. To understand vaccine decision making, identify perceived risks and benefits of vaccinations, and discuss individual experiences in patients with autoimmune bullous diseases in the United States. A qualitative study was performed utilizing semi-structured interviews, and analysis was conducted on NVivo. Patterns were identified in the coded data, and representative quotations were recorded for each major theme. Interviews were conducted between February 15, 2022 and September 15, 2022. Twenty patients with a diagnosis of bullous pemphigoid, mucous membrane pemphigoid, pemphigus vulgaris, or pemphigus foliaceous were interviewed. Of the 20 participants, 14 (70%) were female, with a mean (SD, range) age of 64.8 (13.2, 34-83) years. Key themes that emerged from qualitative analysis of the interviews included patient concerns regarding their increased susceptibility to infection, potential exacerbation of skin disease following vaccination, and the effect of immunosuppressive medications on humoral response to vaccines. Lack of appointment availability, difficulty accessing vaccines, and cost were commonly identified barriers to vaccination. These findings provide valuable knowledge for dermatologists in regard to providing counseling specific to patient concerns and to improve communication surrounding vaccination in the dermatology setting.

Single-cell sequencing reveals distinct immune cell features in cutaneous lesions of pemphigus vulgaris and bullous pemphigoid

Bullous pemphigoid (BP) and pemphigus vulgaris (PV) are two common subtypes of autoimmune bullous disease (AIBD). The key role of circulating autoreactive immune cells contributing to skin damage of AIBD has been widely recognized. Nevertheless, the immune characteristics in cutaneous lesions remain unclear. Here, we performed single-cell RNA sequencing (scRNA-seq) and single-cell VDJ sequencing (scRNA-seq) to generate transcriptional profiles for cells and T/B cell clonetype in skin lesions of BP and PV. We found that the proportions of NK&T, macrophages/ dendritic cells, B cells, and mast cells increased in BP and PV lesions. Then, BP and PV cells constituted over 75% of all myeloid cell subtypes, CD4+ T cell subtypes and CD8+ T cell subtypes. Strikingly, CD8+ Trm was identified to be expanded in PV, and located in the intermediate state of the pseudotime trajectory from CD8+ Tm to CD8+ Tem. Interestingly, CD8+ Tem and CD4+ Treg highly expressed exhaustion-related genes, especially in BP lesions. Moreover, the enhanced cell communication between stromal cells and immune cells like B cells and macrophages/ dendritic cells was also identified in BP and PV lesions. Finally, clone expansion was observed in T cells of BP and PV compared with HC, while CD8+ Trm represented the highest ratio of hyperexpanded TCR clones among all T cell subtypes. Our study generally depicts a large and comprehensive single-cell landscape of cutaneous lesions and highlights immune cell features in BP and PV. This offers potential research targets for further investigation.

Outcome of COVID-19 in patients with autoimmune bullous diseases

Background Data on outcomes of Coronavirus disease 2019 (COVID-19) infection in autoimmune bullous diseases (AIBDs) patients is scarce. Materials and methods This single-centre survey-based-observational study included patients registered in the AIBD clinic of the Postgraduate Institute of Medical Education and Research, Chandigarh, India. All registered patients were contacted over telephone between June and October 2021. A survey was conducted after obtaining informed consent. Results Among 1389 registered patients, 409 completed the survey. Two hundred and twenty-two (55.3%) patients were females and 187 (45.7%) were males. The mean age was 48.52 ± 14.98 years. Active disease was reported by 34% patients. The frequency of COVID-19 infection in responders was 12.2% (50/409), with a case-fatality ratio of 18% (9/50). Rituximab infusion after the onset of pandemic significantly increased the risk of COVID-19 infection. Active AIBD and concomitant comorbidities were significantly associated with COVID-19 related death. Limitation Relative risk of COVID-19 infection and complications among AIBD patients could not be estimated due to lack of control group. The incidence of COVID-19 in AIBD could not be determined due to lack of denominator (source population) data. Other limitations include telephonic nature of the survey and lack of COVID-19 strain identification. Conclusion Use of rituximab is associated with higher probability of COVID-19 infection, while advanced age, active disease and presence of comorbidities may increase the risk of COVID-19 mortality in AIBD patients.

Pemphigus Vulgaris Localized to the Scalp with Complete Response to Topical Steroids

Pemphigus vulgaris (PV) is an anti-cadherin autoimmune disease, characterized by the production of anti-desmoglein 3 (and to a lesser extent anti-desmoglein 1) antibodies, producing acanthosis, typically suprabasal, which clinically translates into flaccid blisters and erosions, generally starting on mucous membranes, with subsequent appearance of skin lesions. Only about 25 cases of PV of exclusively cutaneous location have been described in the literature. Treatment with potent topical steroids is usually sufficient to control the symptoms. We present the case of a 68-year-old female patient with localized PV in the scalp, presenting as alopecic and scabby plaque, with excellent response and hair regrowth with topical corticotherapy.

Rituximab exhibits a better safety profile when used as a first line of treatment for pemphigus vulgaris: A retrospective study

BACKGROUND

Pemphigus is an autoimmune disease that is challenging to treat and has few available therapeutic options. Recently, several studies have demonstrated that rituximab may be an efficacious first-line treatment in newest guidelines.

AIM

To compare the side effect profiles of rituximab administered after a course of immunosuppressant agents versus as a first-line therapy and evaluate the impact of patient characteristics and disease severity indices on occurrence of adverse effects.

METHODS

A retrospective cross-sectional study was conducted on 999 patients with pemphigus vulgaris who received rituximab either as a first-line treatment or after conventional adjuvant therapies. The occurrence of partial or complete remission as well as the incidence of drug-related adverse effects were evaluated and compared between the two groups.

RESULTS

Smoking, pulmonary comorbidity, and mucocutaneous phenotype were associated with an increased risk of developing infectious complications by 12.49, 5.79, and 2.37 fold, respectively. These associations were more prominent among those who received rituximab after immunosuppressant agents.

CONCLUSIONS

Early use of rituximab benefits pemphigus patients, especially those with a mucocutaneous phenotype, pulmonary comorbidity, or history of smoking, and reduces their risk of infectious adverse events.

[Anti-p200 pemphigoid: clinical, diagnostic and therapeutic aspects]

Anti-p200 pemphigoid is a rare autoimmune blistering dermatosis. The clinical course is heterogeneous. Typically, immunoglobulin G (IgG) antibodies are found on the floor of salt-split skin, which differentiates p200 pemphigoid from bullous pemphigoid. It is necessary to perform immunoblotting and enzyme-linked immunosorbent assays (ELISA) to confirm the diagnosis. Small amounts of dapsone are often sufficient for disease control. The clinical and diagnostic characteristics of anti-p200 pemphigoid and the principles of treatment are presented exemplified by two case reports.

Childhood Pemphigus Vulgaris: Report of Two Cases with Emphasis on Diagnostic Approach

Childhood pemphigus vulgaris (CPV) is a rare entity with clinical features and management primarily similar to those of adults; diagnosis may be difficult due to clinical similarity to other disorders such as herpetic gingivostomatitis which is more prevalent in this age group. We report two cases of CPV with emphasis on diagnostic approach. While treating such patients, it is imperative to diagnose CPV in the early stages to prevent serious morbidity and to adjust drug dosage to minimize side effects.

Bacteremia in autoimmune bullous disease patients undergoing double-filtration plasmapheresis

Background: Plasmapheresis is one of the treatment options for autoimmune bullous disease (AIBD). Objective: To evaluate the incidence of adverse events occurring during a course of plasmapheresis. Methods: This study enrolled 42 courses of double-filtration plasmapheresis (DFPP) from 28 patients with AIBD treated in Kurume University Hospital between 2007 and 2016. We examined the frequency of adverse events during the course of DFPP and associated features. Results: The most frequent adverse event was bacteremia (13 of 42 courses, 31.0%), followed by subcutaneous hemorrhage (1 course, 2.4%), and an abscess at the catheterization sites (1 course, 2.4%). No adverse event-related death was recorded. In the analysis of bacteremia occurrence, the erosion at the catheterization sites, the use of central venous catheter (CVC), and the number of DFPP cycles per course were significantly more or greater in the bacteremia group than in the non-bacteremia group (p = .0474, .0005, and .0035, respectively). Conclusions: Although DFPP is a good treatment option for AIBD, attention needs to be paid for the development of possible risks during a DFPP course. We believe that our results can be applied to other plasmaphereses in AIBD management.

Regulatory T-cell deficiency leads to pathogenic bullous pemphigoid antigen 230 autoantibody and autoimmune bullous disease

BACKGROUND

Autoimmune bullous diseases/dermatoses (AIBDs) are severe autoantibody-mediated skin diseases. The pathogenic relevance of autoreactive CD4⁺ T cells for the induction of autoantibody production remains to be fully evaluated. Scurfy mice lack functional regulatory T (Treg) cells, experience spontaneous activation of autoreactive CD4⁺ T cells, and display severe erosive skin lesions suggestive of AIBDs.

OBJECTIVE

We sought to determine whether AIBDs develop in Treg cell-deficient scurfy mice.

METHODS

Histology, indirect immunofluorescence (IF) microscopy, direct IF, and ELISA were used to prove the presence of AIBDs in scurfy mice. Monoclonal autoantibodies from sera of scurfy mice were screened by using indirect IF on murine skin, and immunoprecipitation and mass spectrometry were used for target antigen identification, followed by confirmation in modified human embryonic kidney cells and murine keratinocytes. Pathogenicity was determined by injecting the autoantibody into neonatal mice and transferring scurfy CD4⁺ T cells into nu/nu mice.

RESULTS

Autoantibodies against different known autoantigens of AIBDs spontaneously develop in scurfy mice. Histology reveals subepidermal blisters, and direct IF of skin of scurfy mice shows a predominant linear staining pattern. The mAb 20B12 shows a linear staining pattern in indirect IF, recognizes the murine hemidesmosomal protein bullous pemphigoid antigen 230 (BP230) as the target antigen, and cross-reacts with human BP230. Purified mAb 20B12 induces subepidermal blisters in neonatal mice. Transfer of scurfy CD4⁺ T cells is sufficient to induce antibodies with reactivity to AIBD autoantigens and subepidermal blisters in the skin of recipient T cell-deficient nu/nu mice.

CONCLUSION

We show that the absence of Treg cells leads to AIBDs by pathogenic autoantibodies targeting BP230.

Reliability and validity of the Chinese version of the autoimmune bullous disease quality of life (ABQOL) questionnaire

BACKGROUND

The autoimmune bullous diseases quality of life (ABQOL) questionnaire was recently developed by an Australian group and has been validated in Australian and North American patient cohorts. It is a 17-item, multidimensional, self-administered English questionnaire. The study aimed to validate the Chinese version of the ABQOL questionnaire and evaluate the reliability in Chinese patients.

METHODS

The Chinese version of the ABQOL questionnaire was produced by forward-backward translation and cross-cultural adaptation of the original English version. The ABQOL questionnaire was then distributed to a total of 101 patients with autoimmune bullous diseases (AIBDs) together with the Dermatology Life Quality Index (DLQI) and the 36-item Short Form Health Survey (SF-36). Validity was analyzed across a range of indices and reliability was assessed using internal consistency and test-retest methods.

RESULTS

The Chinese version of the ABQOL questionnaire has a high internal consistency (Cronbach's alpha coefficient, 0.88) and test-retest reliability (the intraclass correlation coefficient, 0.87). Face and content validity were satisfactory. Convergent validity testing showed that the correlation coefficients for the ABQOL and DLQI was 0.77 and for the ABQOL and SF-36 was -0.62. In terms of discriminant validity, there was no significant difference between the proportions of insensitive items in ABQOL and DLQI (p = 0.236). There was no significant difference between the proportions of insensitive items in ABQOL and SF-36 (p = 0.823).

CONCLUSIONS

The Chinese version of the ABQOL questionnaire has adequate validity and reliability. It may constitute a useful instrument to measure disease burden in Chinese patients with AIBDs.

Autoimmune Bullous Disease in Childhood

Background:

Autoimmune bullous disorders (AIBDs) are a heterogeneous group of diseases which are rarely seen in children. Studies concerning the immunobullous diseases in pediatric patients are scarce.

Aims and Objectives:

In this study, we aimed to investigate the clinical features and treatment outcomes of AIBDs in children.

Materials and Methods:

The electronic records of the patients in our AIBDs outpatient clinic were retrospectively reviewed. All cases diagnosed before the age of 16 years were included in the analysis of clinical features, treatment outcomes, and follow-up data.

Results:

Of the 196 patients with immunobullous diseases, 9 (4.6%) were diagnosed before the age of 16 years. Mean age of the patients at the time of diagnosis was 7.72 ± 5.66 years. Among nine patients, linear immunoglobulin A disease (LAD), pemphigus vulgaris (PV), and bullous pemphigoid (BP) were seen in 5, 2, and 2 children, respectively. All patients were treated with at least two systemic agents (including methylprednisolone, dapsone, methotrexate, salazopyrine, intravenous Ig [IVIg], and rituximab) leading to clinical remission in all of them after a mean period of 31.77 ± 27.99 months.

Conclusion:

In line with earlier studies, LAD was the most common immunobullous disease and in general, associated with a favorable response to dapsone. This study was noteworthy in that the patients with PV and BP demonstrated a relatively more recalcitrant course, requiring rituximab and IVIg for remission, respectively. Overall, patients had a good prognosis.

Bullous Pemphigoid with Lymphocytic Colitis: A Case Report and Short Literature Review

The association of autoimmune bullous diseases (i.e., bullous pemphigoid, linear IgA disease, mucous membrane pemphigoid and IgA pemphigus) and inflammatory bowel disease, namely ulcerative colitis and Crohn’s disease has formerly been reported. However, to our knowledge, we report herein the first case of lymphocytic colitis with concomitant bullous pemphigoid.

Is there a causal relationship between HSV-1 and pemphigus vulgaris?

Background

Pemphigus vulgaris is a chronic autoimmune bullous disease, the initiation of autoimmunity has been linked to viral infections. In 1974, Krain first reported the association between herpes simplex virus and pemphigus vulgaris, since then, there have been few such studies, prompting us to examine this link.

Findings

We randomly selected 15 cases of PV, the diagnosis was confirmed using hematoxylin and eosin (H&E)-stained slides—2-micron sections were deparaffinized and rehydrated to be processed by immunohistochemistry, antigen retrieval was performed with 0.1 % sodium citrate, pH 6.2, endogenous peroxidase was inactivated with 0.9 % H₂O₂, and washes were performed with distilled water. Finally the slides were allowed to stand for 5 min in phosphate-buffered saline (PBS). The tissues were incubated for 45 min with polyclonal anti-HSV-I, (1:150, Dako Corporation, Carpinteria, CA). The MACH 1 system was applied for 15 min to visualize the reaction using 3,3′-diaminobenzidine-H₂O₂ (both from Biocare Medical) as substrate under a microscope. The tissues were counterstained with Lillie-Mayer’s hematoxylin (Biocare Medical). We failed to observe positivity for HSV-1 in any of the 15 PV cases that were processed.

Conclusions

It is not possible to determine whether HSV-PV is a causal relationship; most studies are case reports. Thus, we propose research studies with greater methodological weight to determine the involvement of HSV in the pathogenesis of PV and demonstrate that the relationship between HSV-1 and PV is a trigger at the beginning of the disease and has an etiologic function in its pathogenesis or that it is merely a coinfection due to the immunosuppression of patients with PV.

Myeloid-related proteins-8 and -14 are expressed but dispensable in the pathogenesis of experimental epidermolysis bullosa acquisita and bullous pemphigoid

BACKGROUND

Myeloid-related protein-8 (MRP-8) and its heterodimeric partner, MRP-14 belong to the group of danger-associated molecular patterns (DAMPs) and are associated with numerous chronic human disorders. However, their functional role in autoimmunity remains largely unclear.

OBJECTIVE

Here, we examined the involvement of MRP-8/-14 in two difficult-to-treat autoimmune blistering diseases, epidermolysis bullosa acquisita (EBA) and bullous pemphigoid (BP).

METHODS

MRP-8/-14 concentrations in the sera of EBA and BP patients were quantified by ELISA. Experimental EBA and BP in mice were induced by transfer of antibodies directed against type VII or XVII collagen, respectively. Expression of MRP-8/-14 was analyzed in skin samples of these experimental mouse models. The functional role of MRP-8/-14 proteins was evaluated by the induction of experimental EBA and BP in MRP-14-deficient mice.

RESULTS

We found serum levels of MRP-8/-14 to be elevated in both, EBA and BP patients. Furthermore, in the lesional skin of mice with experimental diseases expression of MRP-8/-14 was increased as compared to healthy controls. However, MRP-14-deficient mice were fully susceptible to experimental disease with a phenotype comparable to that of wild type controls.

CONCLUSION

Although MRP-8/-14 expression is highly increased in experimental as well as human disease, these proteins do not contribute to the pathogenesis in the effector phase of EBA and BP.

Scoring systems in pemphigus

Pemphigus is a dreaded disease encountered not infrequently in dermatology settings. While scoring systems in various dermatological conditions exist, objective parameters for assessing disease activity and therapeutic responses in pemphigus are not uniform and foolproof. This article presents various scoring systems in pemphigus.