Liraglutide, a GLP-1 agonist, as a new adjunct treatment in Hailey-Hailey disease: a case report

Hailey–Hailey disease (HHD) is a rare, heritable blistering disorder with a predilection for intertriginous areas, and is caused by mutations in the ATP2C1 gene. We present a case of a 60-year-old woman who has had poorly controlled HHD for 45 years, despite various treatments. Her HHD has become very well controlled since commencing liraglutide, for newly diagnosed type 2 diabetes, with loss of HHD disease control on discontinuation.

Patients' perspective, quality of life and treatment goals in Hailey-Hailey disease: Lessons learned from the German National Registry

BACKGROUND

Hailey-Hailey disease (HHD) remains a difficult-to-treat dermatosis and little is known about the patient's perception of the disease activity, the treatment success and its impact on quality-of-life (QoL).

OBJECTIVE

To obtain better understanding of HHD patients' needs regarding their medical condition, financial burden, QoL, subjective well-being and treatment thereof as well as satisfaction to evaluate common treatments' 'real-life' relevance.

METHODS

With initiation of the national registry for Darier's disease (DD; Morbus Darier, MD) and Hailey-Hailey disease (HH) MDHHgermany, patients with HHD diagnosis were included starting June 2020. To assess subjective symptoms, patients filled out questionnaires such as the DLQI (dermatological life quality index), numeric rating scale (NRS) for itch, pain and burning sensation, as well as the SWLS (satisfaction with life scale) questionnaire to quantify overall satisfaction in life. Additionally, data on therapies were collected along with the patients' satisfaction of those and their medical care. Furthermore, patients assessed financial aspects and work ability.

RESULTS

One hundred and two patients were recruited from dermatology clinics, office-based dermatologists and self-help platforms across Germany between June 2020 and February 2023, 90 were eligible and analysed (mean: 49.91 years, 73.33% females, 26.67% males). 39.77% stated according to the DLQI their life is severely/very severely affected. Satisfaction with life was mediocre. Burning sensation was most pronounced among subjective symptoms (NRS 5.85 ± 2.80). Systemic treatments were rated as ineffective according to 56.92%, 25.56% had never received one. Most prescribed systemic treatments were corticosteroids (73.8%), followed by low-dose naltrexone (LDN) (26.2%), retinoids (15.4%) and antibiotics (13.8%). Satisfaction with medical care was generally low.

CONCLUSION

Our 'real-life' data state a major disease burden and impact on the QoL for affected individuals, as well as limited disease control due to inadequate therapies. MDHHgermany can provide insights into improvement of healthcare support with this debilitating disease and improve QoL. In the long term, it aims to provide basis for further clinical trials, epidemiological studies and immunological investigations.

Topical timolol 0.5% as a novel therapeutic approach for Hailey-Hailey disease

We present the case of a 63-year-old man with refractory Hailey–Hailey disease who successfully responded to topical timolol 0.5%. This is a novel therapeutic approach that provides an alternative management option in this challenging disease.

Hailey-Hailey disease successfully treated with photodynamic therapy: Case report

Hailey-Hailey disease (HHD) is a rare genetic benign condition resulting in blisters predominantly on the skin folds. The inheritance is autosomal dominant with complete penetrance, but a variable expressivity in affected family members. It can be triggered by a vast variety of factors such as sweating, weight gain, infection, trauma, pregnancy, and ultraviolet radiation, but the major cause of the disease is a mutation in the ATP2C1 gene. The lesions are typically distributed symmetrically within intertriginous regions such as the retroarticular folds, axillae, inguinal, and perianal regions and presents as flaccid vesicles and blisters on erythematous skin, giving rise to erosions, fissures, and vegetations. There is no specific therapy for HHD. The therapeutic approach to HHD involves the control of exacerbating factors, secondary infections, and cutaneous inflammation. Because of the rarity of the disease, evidence of efficacy for topical or systemic therapies is mainly based on small observational studies, case reports, and clinical experience. We present a case of HHD successfully treated by photodynamic therapy (PDT) with a topical liposomal chlorin photosensitizer.

Acute generalized exanthematous pustulosis associated with clindamycin in a patient with Hailey-Hailey disease

A 61-year-old African-American female with moderately controlled Hailey-Hailey disease (HHD) presents to the emergency department with a rash and fever. One day prior to her presentation, she was started on oral clindamycin for a tooth extraction procedure. Her physical examination shows diffuse erythema on the trunk and extremities with multiple nonfollicular pustules. A punch biopsy of her upper extremity revealed intraepidermal acantholysis, neutrophilic spongiosis, and subcorneal pustules. The perivascular and interstitial superficial dermal infiltrate is mixed and composed of predominantly neutrophils, with lymphocytes and rare eosinophils. These findings suggest a superimposed acute generalized exanthematous pustulosis (AGEP) in the background of HHD. AGEP is a potentially severe cutaneous condition characterized by the abrupt onset of numerous nonfollicular pustules in a background of pruritic edematous erythroderma. To date, only two case reports have described AGEP in patients with HHD. Early diagnosis of AGEP is essential to initiate prompt and aggressive systemic therapy, prompt medication cessation, close monitoring for end-organ damage, and improve overall morbidity and mortality.

Hailey-Hailey disease (benign familial pemphigus) responsive to treatment with ocrelizumab for multiple sclerosis

Benign familial pemphigus, also known as Hailey–Hailey disease (HHD), is a rare autosomal-dominant genetic skin disorder characterized by symmetrical, well-demarcated, erythematous, painful erosive and crusted plaques in the intertrigous regions. Treatment options are limited and aimed at control and limiting complications. Ocrelizumab, an anti-CD20 antibody, was given to treat our patient’s multiple sclerosis, and incidentally found to have cleared her HHD, thus offering a potential effective treatment option.

Double-Blind, Placebo-Controlled Study of Onabotulinumtoxin A for the Treatment of Hailey-Hailey Disease

BACKGROUND

Hailey-Hailey disease (HHD) can be treated with topical steroids, antibiotics, and invasive surgical procedures. Since sweating often exacerbates HHD lesions, the use of onabotulinumtoxin A could serve as an adjunctive treatment.

OBJECTIVE

The goal of this study was to evaluate the safety and efficacy of onabotulinumtoxin A for the treatment of HHD.

METHODS

A double-blind, placebo-controlled single center study was conducted. Six HHD patients who successfully completed this trial in addition to 1 patient who exited early are reported and discussed. Four of these patients received an initial injection of Btx-A and 3 received the placebo initially.

RESULTS

All patients except 1 who received an initial or reinjection of Btx-A decreased 2 levels on a 4-point clinical severity scale at weeks 8 or 12 after treatment. Patient 6 received an initial placebo injection and maintained clearance for 6 months, while patients 5 and 7 did not have any improvement in their target lesions after a placebo injection. All patients who received a reinjection of Btx-A at the week 4 follow-up decreased by at least 1 level on the HHD severity scale.

CONCLUSION

Btx-A is a safe treatment that is effective for most cases of HHD. The most severe cases of HHD may not respond to Btx-A as sole treatment. J Drugs Dermatol. 2023;22(4): doi:10.36849/JDD.6857 Citation: Saal R, Oldfield C, Bota J, et al. Double-blind, placebo-controlled study of Onabotulinumtoxin A for the treatment of Hailey-Hailey disease. J Drugs Dermatol. 2023;22(4):339-343. doi:10.36849/JDD.6857.

Hypotonic, Acidic Oxidizing Solution Containing Hypochlorous Acid (HClO) as a Potential Treatment of Hailey-Hailey Disease

Hailey–Hailey disease (HHD) is a rare, chronic and recurrent blistering disorder, characterized by erosions occurring primarily in intertriginous regions and histologically by suprabasal acantholysis. Mutation of the Golgi Ca²⁺-ATPase ATP2C1 has been identified as having a causative role in Hailey–Hailey disease. HHD-derived keratinocytes have increased oxidative-stress that is associated with impaired proliferation and differentiation. Additionally, HHD is characterized by skin lesions that do not heal and by recurrent skin infections, indicating that HHD keratinocytes might not respond well to challenges such as wounding or infection. Hypochlorous acid has been demonstrated in vitro and in vivo to possess properties that rescue both oxidative stress and altered wound repair process. Thus, we investigated the potential effects of a stabilized form of hypochlorous acid (APR-TD012) in an in vitro model of HHD. We found that treatment of ATP2C1-defective keratinocytes with APR-TD012 contributed to upregulation of Nrf2 (nuclear factor (erythroid-derived 2)-like 2). Additionally, APR TD012-treatment restored the defective proliferative capability of siATP2C1-treated keratinocytes. We also found that the APR-TD012 treatment might support wound healing process, due to its ability to modulate the expression of wound healing associated cytokines. These observations suggested that the APR-TD012 might be a potential therapeutic agent for HHD-lesions.

Persisting Ulcerating Lesions After Cyclosporine Therapy for Erosions Found in Flexural Sites

In February 2012, a patient with a 15-year history of painful, pruritic eruptions presented with a severe exacerbation that had lasted for the previous week. The patient also reported severe headaches, a fever of 38.9°C (102.1°F), a cough, and diarrhea, which had now resolved. Physical examination showed erythematous macerated patches with erosions in the left submammary region, bilateral axillae, and vaginal area (Figure 1), and greasy scale covering the scalp. Despite lessening of the lesions in the submammary region and abdomen with the administration of minocycline 100 mg twice per day and cyclosporine 100 mg three times per day, the patient continued to complain of persistent painful ulcerations in the labia majora and perianal area (Figure 2). The patient was started on acyclovir 400 mg three times per day for 10 days for positive herpes simplex viral culture and ampicillin for Proteus infection of the area.

Hailey-Hailey Disease Presenting as Lichenoid Plaques on the Thigh

A 40-year-old woman presented with multiple itchy violaceous papules and plaques on the medial aspects of both thighs. This was accompanied by a burning sensation on friction and increased itching that interfered with her daily activities, particularly in the summer. The family history was noncontributory. Cutaneous examination showed multiple flat-topped hyperkeratotic violaceous papules and plaques, appearing in linear fashion on the medial aspects of the thighs bilaterally (Figure 1). Histopathologic examination showed acanthosis, widespread suprabasal acantholysis resembling a "dilapidated brick wall," without any evidence of dyskeratosis. There was a mild dermal perivascular infiltrate (Figure 2). On the basis of the clinical and histologic findings, she was diagnosed as having localized Hailey-Hailey disease. She was treated conservatively with topical corticosteroids and antimicrobials. She was also advised to lose weight, to avoid friction, and to wear loose-fitting cotton garments. There was marked symptomatic relief, and the lesion showed mild improvement over the next 2 months.

Methotrexate-Induced Nasal Septal Perforation

A 58-year-old woman with a 31-year history of Hailey-Hailey (HH) disease that was refractory to treatment with mycophenolate mofetil, cyclosporine, dapsone, sulfasalazine, topical/oral antibiotics, and topical/oral steroids presented for alternative treatment options. Active erythematous, malodorous, eroded, and crusted plaques were present in the axillae, inframammary region, groin, and back (Figure 1). The patient had an undulant course, with acute exacerbations and partial remissions. During a 3-year period, she was prescribed oral methotrexate at a dose of 10 mg to 15 mg per week with daily oral folic acid (1 mg) supplementation, except on the day she took methotrexate. Oral clarithromycin and prednisone were also used intermittently for antibacterial and anti-inflammatory effects.

Successful botulinum toxin (onabotulinumtoxinA) treatment of Hailey-Hailey disease

Hailey-Hailey disease is a genetic disorder that affects flexural skin with scale, blisters, and maceration. Botulinum toxins have been previously used to treat Hailey-Hailey disease. Here, we present a patient who underwent one treatment of onabotulinumtoxinA and achieved excellent improvement that was sustained for three months post initial treatment.

[Acantholytic rosacea of the forehead and scalp in a patient with Hailey-Hailey disease]

BACKGROUND

Rosacea is a common dermatosis that can involve the bald area of the scalp. We report the case of a man presenting clinical symptoms of rosacea of the forehead and the scalp, but with a histological picture of familial chronic benign pemphigus.

PATIENTS AND METHODS

A 47-year-old man with a history of Hailey-Hailey disease had been presenting facial dermatosis for 5 years. The clinical features were erythema with pustules and scales located on the mid-forehead and the androgenic bald area of the frontal scalp. The histological aspect of the skin biopsy showed suprabasilar clefting and ancantholysis at all levels of the epidermis and sparse perivascular infiltrate. Direct immunofluorescence was negative. These findings were typical of Hailey-Hailey disease. Based on clinical findings, and without taking account of the skin biopsy results, treatment with doxycycline and a topical antifungal was administered for 3 months, leading to remission of symptoms.

DISCUSSION

The site of rosacea on the bald area of the scalp in males is described in the literature, and when present, is probably enhanced by exposure to UV radiation. In this patient, the histological features were interpreted as histopathologically equivalent to Köbner phenomenon.

Familial benign chronic pemphigus (Hailey-Hailey Disease): use of topical immunomodulators as a modern treatment option

Benign chronic familial pemphigus (Hailey-Hailey disease) is a rare autosomal dominant blistering skin disorder characterized by suprabasal cell separation (acantholysis) of the epidermis. The Hailey brothers first described it in 1939. Hailey-Hailey disease usually appears in the third or fourth decade, although it can occur at any age. Heat, sweating and friction often exacerbates the disease, and most patients have worse symptoms during summer. It is characterized clinically by a recurrent eruption of vesicles and bullae at the sites of friction and intertriginous areas. We report a 51-year-old male presenting with grey-brown hyperkeratosis with partial papillomatosis and lichenification in the axillary and inguinal areas and infiltrated erythematous lesions in the infraorbitary region, on the side of the face. Biopsies obtained from inguinal and axillar areas revealed parakeratotic crusts overlying an acantholytic epidermis. A biopsy from one of the lesions from the infraorbital area showed a Jessner-Kanof lymphocytic infiltration. The patient was treated with antimicrobials and four days later, topical Pimecrolimus was started, leading to an improvement of the clinical picture. The efficacy of Pimecrolimus in our case suggests that cellular immunity could play a role in the pathogenesis of Hailey-Hailey disease.

Successful treatment of Hailey-Hailey disease with acitretin

Hailey-Hailey disease is an autosomal dominant skin condition characterized by waxing and waning painful and pruritic vesicles and plaques affecting the intertriginous areas. Its pathogenesis involves inherited abnormalities in a cutaneous calcium pump. Most patients are managed conservatively with topical corticosteroids as well as topical and oral anti-infective agents. Scarce reports in the literature describe the use of oral retinoid therapy to manage refractory cases. We present a case of Hailey-Hailey disease in a 64-year-old man who was refractory to conservative management but improved dramatically over 6 months of oral therapy with 25 mg of acitretin daily. The mechanism by which such therapy improves disease manifestations is unknown. A potential mechanism is based on the influence of retinoids on epidermal differentiation and may involve cutaneous calcium homeostasis. Hailey-Hailey disease is discussed and the use of oral retinoid treatment for Hailey-Hailey disease is reviewed.

Case reports of etanercept in inflammatory dermatoses

Skin disfigurations and pruritus can pose severe threats to quality of life, and treatment options for patients with recalcitrant diseases are limited. Tumor necrosis factor alpha, a proinflammatory cytokine, appears to play a central role in mediating the symptoms of many skin disorders. We report cases in which etanercept (Enbrel; Immunex Corp, Thousand Oaks, Calif), a tumor necrosis factor alpha antagonist that is approved for the treatment of moderate to severe psoriasis, was administered to ameliorate the symptoms of acute and chronic dermatologic conditions, including Hailey-Hailey disease, severe psoriasis, dermatomyositis, and subacute cutaneous lupus erythematosus. Treatment with etanercept substantially improved the clinical symptoms and quality of life in these patients, and may offer a therapeutic option for some patients with severe skin disorders.

Disseminated Hailey-Hailey disease treated with topical tacrolimus and oral erythromycin: Case report and review of the literature

Hailey-Hailey disease is a rare autosomal dominant skin disorder that typically affects the intertriginous areas. The responsible defect has been identified in the gene named ATP2C1 on chromosome 3q21-24. We present a 50-year-old man with a 16-year history of blistering eruptions and positive familial history where this disease had appeared through four generations. The diagnosis was confirmed by histopathologic studies and negative immunofluorescence findings. A combination of topical tacrolimus therapy and oral erythromycin seemed to play a considerable part in this case, in which all of the lesions healed within 2 weeks.

Bacterial infection-induced generalized Hailey-Hailey disease successfully treated by etretinate

Hailey-Hailey disease (HHD; familial benign chronic pemphigus) is a hereditary blistering disorder characterized by episodic maceration and erosions mainly in intertriginous areas, and generalized eruptions are rarely seen. We report here a 51-year-old woman with generalized HHD who was successfully treated with oral etretinate. The present case suggests that oral etretinate is effective against the generalized eruptions even in cases in which bacterial infection has triggered the generalization of HHD.

[Tacrolimus--a new therapeutic option for Hailey-Hailey-disease?]

Hailey-Hailey disease is a chronic inflammatory skin disorder. Only symptomatic measures are available for long-term treatment. Topical tacrolimus has been shown to be effective in a number of inflammatory skin diseases, such as atopic eczema and can be used over long periods of time because of its safety profile. We tested tacrolimus ointment in a patient who had problems with Hailey-Hailey disease for many years. After only five days of treatment with topical tacrolimus, improvement was apparent. After four weeks of treatment, the pain and erosions were significantly ameliorated. The efficacy of topical tacrolimus in Hailey-Hailey disease may provide new insights into the pathogenesis of the disorder.

Topical tacrolimus in Hailey-Hailey disease

Hailey-Hailey disease, or familial benign chronic pemphigus, is a rare relapsing-remitting autosomal-dominant epidermal blistering disease. It preferentially affects females and is characterized by recurrent vesicles and erosions in the intertriginous areas. There are several topical corticosteroid therapeutic options, which are often limited in their use by their secondary effects and localization of the lesions. We report a case of a 60-year-old woman with Hailey-Hailey disease involving axillary, groin, cervical, antecubital, inframammary and abdominal folds. She was treated with 0.1% tacrolimus ointment, applied twice daily, with clinical improvement in 2 weeks and total remission in 4 weeks. She remains asymptomatic after a 10-month follow-up period.

Treatment of Hailey-Hailey disease with tacrolimus ointment and clobetasol propionate foam

Hailey-Hailey disease, or familial benign chronic pemphigus, is a chronic disease without a known cure. Current therapeutic strategies attempt to suppress Hailey-Hailey outbreaks and allow the patient to live comfortably with this condition. We have found that applying topical tacrolimus 0.1% ointment (Protopic) twice a day to affected areas is an excellent way to control Hailey-Hailey disease. In addition to effectively controlling Hailey-Hailey outbreaks, tacrolimus is a relatively safe and noninvasive mode of treatment, without significant side effects. We recommend intermittent therapy with clobetasol propionate 0.05% foam (Olux Foam) for patients who break through suppressive therapy with tacrolimus a few times per year. In patients with frequent outbreaks of Hailey-Hailey disease despite suppressive therapy with tacrolimus, we recommend alternating the tacrolimus with clobetasol propionate 0.05% foam every 6 weeks.

Photodynamic therapy with 5-aminolevulinic acid for recalcitrant familial benign pemphigus (Hailey-Hailey disease)

Familial benign pemphigus is a chronic, recurrent, autosomal dominant blistering disease that may significantly affect quality of life. Surgical methods are often needed to control flares in difficult cases. We describe the use of photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) followed by irradiation with incoherent light (ALA-PDT) in 2 patients with chronic, recalcitrant familial benign pemphigus.

Acute generalized Hailey-Hailey disease

A patient with extensive histologically proven Hailey-Hailey disease is described whose initial clinical presentation was suggestive of erythema multiforme or toxic epidermal necrolysis. This potentially misleading morphology of acute proven Hailey-Hailey disease has not been described previously and may be a consequence of bacterial infection exacerbating acantholysis.

1alpha,24-dihydroxyvitamin D3 (tacalcitol) is effective against Hailey-Hailey disease both in vivo and in vitro

We report a case of Hailey-Hailey disease (HHD) in which 1alpha, 24-dihydroxyvitamin D3 (tacalcitol) was effective both clinically (in vivo) and in explant cultures (in vitro) of a skin lesion. The patient was a 65-year-old man with HHD lesions in the axillary and inguinal areas bilaterally. We applied ointment containing 1alpha, 24-dihydroxyvitamin D3 (tacalcitol), an analogue of active vitamin D3, to the lesions and assessed its clinical effectiveness. The HHD lesions in both groins disappeared after treatment with the 1alpha, 24-dihydroxyvitamin D3 ointment, and the remission has continued to the present. A punch biopsy specimen of the lesion that had remitted showed no acantholysis. In addition, dissociation of migrating keratinocytes was observed when biopsy specimens of the HHD skin lesion were cultured in medium without 1alpha,24-dihydroxyvitamin D3, but inhibition of keratinocyte dissociation was observed in medium containing it. These results suggest the effectiveness of 1alpha, 24-dihydroxyvitamin D3 against HHD both in vivo and in vitro.

Familial pemphigus vulgaris in mother and daughter

BACKGROUND

Pemphigus vulgaris is an autoimmune disease in which genetics appears to be of basic importance. Although association with certain human leukocyte antigen (HLA) alleles has been found in some ethnic groups and individuals, no true disease susceptibility genes have been established, and familial cases are very unusual.

METHODS

We report a Polish family with pemphigus vulgaris in the mother and daughter. The diagnosis was confirmed by cytologic, histologic, and immunofluorescence studies.

RESULTS

The course was severe and the disease long-lasting in the mother, probably due to treatment with small doses of corticosteroids without immunosuppressive drugs. In the daughter, treated with larger doses of corticosteroids and azathioprine, the lesions regressed within 4 months, after which maintenance therapy was instituted with 10 mg of prednisone daily. The HLA studies performed in the daughter and her three children after the mother had died showed identical haplotypes in both the patient and the healthy children. The patient has given birth to a healthy child while still having a high titer of intercellular (IC) antibodies.

CONCLUSIONS

The familial occurrence of pemphigus in first-degree relatives is suggestive of inherited susceptibility to the disease, transmitted as a dominant trait. The identical haplotypes in the healthy children of the patient favor the role of other, unknown factors required for the development of the disease in predisposed individuals.