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Murrell DF, Joly P, Werth VP, Ujiie H, Worm M, Mangold AR, Avetisova E, Maloney J, Laws E, Mortensen E, Dubost-Brama A, Shabbir A. Study Design of a Phase 2/3 Randomized Controlled Trial of Dupilumab in Adults with Bullous Pemphigoid: LIBERTY-BP ADEPT. Adv Ther 2024:10.1007/s12325-024-02810-3. [PMID: 38443648 DOI: 10.1007/s12325-024-02810-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/31/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Bullous pemphigoid (BP) is a rare, autoimmune, blistering skin disease associated with high disease burden, profoundly decreased quality of life and increased morbidity. Emerging evidence supports an important role for type 2 inflammation in disease pathogenesis. Current management relies on topical and/or systemic corticosteroids, non-selective immunosuppressants and antibiotics with anti-inflammatory properties, which are all limited by side effects and toxicities. Therefore, targeted, efficacious and safe therapies are needed. Dupilumab blocks the shared receptor component for interleukin (IL)-4 and IL-13, key and central drivers of type 2 inflammation. Several reports of patients successfully treated with dupilumab have been published; however, dupilumab has not been formally assessed in a double-blind, placebo-controlled trial. OBJECTIVES We report the design of LIBERTY-BP ADEPT, a multicenter, randomized, double-blind, placebo-controlled clinical trial to evaluate the efficacy and safety of dupilumab in adults with BP. METHODS LIBERTY-BP ADEPT comprises a 35-day screening, 52-week treatment and 12-week follow-up period. Approximately 98 adults aged 18-90 years with moderate-to-severe BP are being enrolled at 51 sites on 4 continents and randomized 1:1 to subcutaneous dupilumab or placebo every 2 weeks. All participants will receive concomitant oral corticosteroids (OCS). PLANNED OUTCOMES The primary endpoint is the proportion of patients achieving complete remission off steroid therapy at week 36. Key secondary endpoints include total cumulative OCS dose to week 36, percent change and proportion of patients with ≥ 4-point reduction in the weekly average of daily Peak Pruritus Numerical Rating Scale from baseline to week 36 and percent change in Bullous Pemphigoid Area Index score from baseline to week 36. CONCLUSION The trial results will provide evidence on whether the efficacy and safety of dupilumab support its use as a potential novel treatment approach for BP and will provide new insights into the role of type 2 inflammation in BP pathogenesis. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier NCT04206553.
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Affiliation(s)
- Dédée F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, NSW, Australia.
- The Church, 17 Kensington St, Kogarah, NSW, 2217, Australia.
| | - Pascal Joly
- Rouen University Hospital and INSERM 1234, Normandy University, Rouen, France
| | - Victoria P Werth
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Liu Y, Wang Y, Zhang J, Chen F, Cui S, Wang Y, Jin H, Li L. Risk factors predisposing relapse of bullous pemphigoid at initial diagnosis: A retrospective cohort study of 205 patients. Int Immunopharmacol 2023; 125:111082. [PMID: 37913571 DOI: 10.1016/j.intimp.2023.111082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Previous studies have revealed the factors associated with the relapse of bullous pemphigoid (BP). This study aims to assess the characteristics of BP patients at the time of initial diagnosis and a potential association with subsequent relapse occurrences. METHODS A retrospective cohort study was conducted on 205 BP patients from January 2009 to May 2022 at the Peking Union Medical College Hospital in Beijing, China. The median follow-up duration was 2.7 years. We conducted univariate and multivariate analyses on various clinical indicators (e.g., lesional involvements and medical history) and laboratory test results. RESULTS Among the 205 patients, 118 (57.6 %) relapsed during the follow-up period. Univariate analysis revealed several factors associated with relapse, which were greater age [Hazard Ratio (HR)1.018, 95 % confidence interval (CI) 1.004-1.032] (p = 0.010), a past medical history of thyroid diseases [HR 3.674, 95 % CI 1.472-9.167] (p = 0.005), hematological disease complications [HR 4.123, 95 % CI 1.301-13.061] (p = 0.016), negative C3 deposition in direct immunofluorescence [HR 0.574, 95 % CI 0.374-0.883] (p = 0.011) and prealbumin level less than 200 mg/L[HR 0.580, 95 % CI 0.351-0.957] (p = 0.033). Multivariate analysis demonstrated that patients with negative C3 deposition in direct immunofluorescence [HR 0.524, 95 % CI 0.296-0.927] (p = 0.026) and prealbumin levels below 200 mg/L [HR 0.541, 95 % CI 0.301-0.974] (p = 0.041) were associated with further relapses of BP. CONCLUSIONS Negative C3 deposition in direct immunofluorescence and a prealbumin level below 200 mg/L at initial diagnosis served as predictive markers for future relapses of BP. Systemic evaluation of BP patients at initial diagnosis could be essential in helping prevent recurrences and achieve more effective disease management.
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Affiliation(s)
- Yangchun Liu
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing 100730, China
| | - Yiman Wang
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing 100730, China
| | - Jialing Zhang
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing 100730, China
| | - Fangyuan Chen
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing 100730, China
| | - Shengnan Cui
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing 100730, China
| | - Yanhong Wang
- Department of Epidemiology & Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongzhong Jin
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing 100730, China.
| | - Li Li
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing 100730, China.
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Hopkins ZH, Jimenez A, Taliercio VL, Clarke JT, Hansen CB, Hull CM, Rhoads JLW, Zone JJ, Sahni VN, Kean J, Secrest AM. Skin-Related Quality of Life During Autoimmune Bullous Disease Course. JAMA Dermatol 2023; 159:1185-1194. [PMID: 37703003 PMCID: PMC10500428 DOI: 10.1001/jamadermatol.2023.3121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 07/07/2023] [Indexed: 09/14/2023]
Abstract
Importance Autoimmune bullous diseases (AIBDs) are chronic relapsing-remitting conditions with significant morbidity. Skin-related quality of life (SRQL) may vary by AIBD subtype and disease type. Disease severity and flare severity can be difficult to define; SRQL can offer a key insight. Objectives To investigate the Skindex-16 score as an SRQL measure in AIBD subtypes during flare and nonflare states and to evaluate Skindex-16 construct validity. Design, Setting, and Participants This retrospective cross-sectional study was conducted from September 1, 2016, to February 1, 2020, among 192 patients at the University of Utah Health autoimmune dermatology clinic with pemphigoid, pemphigus, dermatitis herpetiformis, and linear immunoglobulin A disease. Patients had an encounter-associated diagnosis, Skindex-16 scores, and self-reported flare status. Statistical analysis was performed from March 2022 to June 2023. Exposure Autoimmune bullous disease subtype and patient-reported flare status. Main Outcomes and Measures Skindex-16 domain scores (emotions, symptoms, and functioning; range, 0-100, where 0 indicates no effect on SRQL and 100 maximum effect) and individual item scores were described by disease and flare status. Flare scores were expected to be higher by at least the standard error of measurement (SEm). Convergent validity was assessed using Spearman correlation among Skindex-16 scores, serologic titers, and other patient-reported outcome measures. Floor or ceiling domain scores (<20% of sample scoring either lowest or highest possible domain scores, respectively) were assessed for Skindex-16. Structural validity was assessed using confirmatory factor analysis (CFA). Results The study included 192 patients with 212 visits (median age, 68 years [IQR, 58-76 years]; 123 of 212 women [58.0%]) with Skindex-16 scores (64 in flare state and 148 in nonflare state). Median Skindex-16 domain scores were higher for all disease categories among patients in the flare state compared with those in the nonflare state (pemphigoid [emotions: flare, 52.4 (IQR, 38.1-69.0); nonflare, 7 (IQR, 0-17); symptoms: flare, 37.5 (IQR, 29.2-58.0); nonflare, 13 (IQR, 0-25); functioning: flare, 26.7 (IQR, 10.0-56.7); nonflare, 0 (IQR, 0-3)]; pemphigus [emotions: flare, 54.8 (IQR, 31.0-81.0; nonflare, 0 (IQR, 0-19); symptoms: flare, 58.3 (IQR, 41.7-70.8); nonflare, 4 (IQR, 0-12.5); functioning: flare, 26.7 (IQR, 13.3-83.3); nonflare, 0 (IQR, 0-3.33)]; dermatitis herpetiformis [emotions: flare, 72.6 (IQR, 34.7-90.5); nonflare, 14.3 (IQR, 2.4-26.2); symptoms: flare, 69 (IQR, 31.3-85.4); nonflare, 12.5 (IQR, 0-29.2); functioning: flare, 38.3 (IQR, 5.0-63.2); nonflare, 0 (IQR, 0-13.3)]. This difference exceeded SEm cut points. Cronbach α was greater than 0.80 for all domains and AIBDs. Moderate or low correlations were seen with desmoglein 1 and bullous pemphigoid 180 titers. Moderate correlation existed between Skindex-16 and Patient-Reported Outcomes Measurement Information System Depression scores (emotions: ρ = 0.40; symptoms: ρ = 0.41; functioning: ρ = 0.48), and strong correlation existed between Skindex-16 and patient-reported disease severity (emotions: ρ = 0.71; symptoms: ρ = 0.73; functioning: ρ = 0.66). Floor domain scores greater than 20% were seen among patients in the nonflare state, but ceiling domain scores were rare (<10% for all domains); CFA model fit was poor. Conclusions and Relevance In this cross-sectional study, SRQL was highly associated with flare of AIBDs. Skin-related quality of life was worse during periods without flare among patients with pemphigoid and dermatitis herpetiformis compared with pemphigus, highlighting residual SRQL morbidity. Skindex-16 showed good construct validity, but the poor CFA model fit needs further research. Clinical measurement of SRQL in AIBDs can add critical disease-severity information.
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Affiliation(s)
- Zachary H. Hopkins
- Autoimmune Dermatology Clinic, University of Utah Health, Salt Lake City
- Department of Dermatology, University of Utah Health, Salt Lake City
| | - Amber Jimenez
- Autoimmune Dermatology Clinic, University of Utah Health, Salt Lake City
| | - Vanina L. Taliercio
- Division of Medical Genetics, Department of Pediatrics, University of Utah Health, Salt Lake City
| | - Jennie T. Clarke
- Autoimmune Dermatology Clinic, University of Utah Health, Salt Lake City
| | | | | | - Jamie L. W. Rhoads
- Autoimmune Dermatology Clinic, University of Utah Health, Salt Lake City
| | - John J. Zone
- Autoimmune Dermatology Clinic, University of Utah Health, Salt Lake City
| | - Vikram N. Sahni
- Autoimmune Dermatology Clinic, University of Utah Health, Salt Lake City
| | - Jacob Kean
- Department of Population Health Sciences, University of Utah, Salt Lake City
- Division of Health System Innovation and Research, University of Utah, Salt Lake City
| | - Aaron M. Secrest
- Autoimmune Dermatology Clinic, University of Utah Health, Salt Lake City
- Department of Population Health Sciences, University of Utah, Salt Lake City
- Department of Dermatology, Te Whatu Ora–Waitaha Canterbury (Health New Zealand), Christchurch, New Zealand
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Toh WH, Lee HE, Chen CB. Targeting type 2 inflammation in bullous pemphigoid: current and emerging therapeutic approaches. Front Med (Lausanne) 2023; 10:1196946. [PMID: 37614956 PMCID: PMC10442825 DOI: 10.3389/fmed.2023.1196946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023] Open
Abstract
Bullous pemphigoid (BP) is one of the most common autoimmune bullous diseases and mainly affects an elderly population with multi-morbidity. Due to the frailty of many BP patients, existing treatment options are limited. The blisters associated with BP result from IgG and IgE autoantibodies binding to the central components of hemidesmosome, BP180, and BP230, stimulating a destructive inflammatory process. The known characteristic features of BP, such as intense pruritus, urticarial prodrome, peripheral eosinophilia, elevated IgE, as well as recent expanding evidence from in vitro and in vivo studies implicate type 2 inflammation as an important driver of BP pathogenesis. Type 2 inflammation is an inflammatory pathway involving a subset of CD4+ T cells that secrete IL-4, IL-5, and IL-13, IgE-secreting B cells, and granulocytes, such as eosinophils, mast cells, and basophils. It is believed that effectors in type 2 inflammation may serve as novel and effective treatment targets for BP. This review focuses on recent understandings of BP pathogenesis with a particular emphasis on the role of type 2 inflammation. We summarize current clinical evidence of using rituximab (B-cell depletion), omalizumab (anti-IgE antibody), and dupilumab (anti-IL-4/13 antibody) in the treatment of BP. The latest advances in emerging targeted therapeutic approaches for BP treatment are also discussed.
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Affiliation(s)
- Wu Han Toh
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, United States
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, United States
- Department of Biology, Johns Hopkins University, Baltimore, MD, United States
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Taoyuan, Taiwan
| | - Hua-En Lee
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Taoyuan, Taiwan
- Department of Dermatology and Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Bing Chen
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Taoyuan, Taiwan
- Department of Dermatology and Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- Xiamen Chang Gung Allergology Consortium, Xiamen Chang Gung Hospital, Xiamen, China
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Olbrich H, Sadik CD, Schmidt E. Autoimmune blistering diseases: promising agents in clinical trials. Expert Opin Investig Drugs 2023; 32:615-623. [PMID: 37526503 DOI: 10.1080/13543784.2023.2242778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Treatment options for autoimmune bullous diseases (AIBD) are currently limited to corticosteroids and traditional immunomodulants and immunosuppressants that are associated with unfavorable adverse effect profiles. The most frequent AIBDs, i.e. bullous pemphigoid, pemphigus vulgaris, and mucous membrane pemphigoid, impose a high disease burden onto affected patients and can be detrimental due to infections, exsiccosis, and impaired food intake. Significant progress has been made in elucidating disease mechanisms and key mediators by in vivo and in vitro models, thus identifying a multifaceted range of possible drug targets. However, except for rituximab for pemphigus vulgaris, no new drugs have been approved for the treatment of AIBDs in the last decades. AREAS COVERED This review covers new drug developments and includes ongoing or completed phase 2 and 3 clinical trials. Studies were identified by querying the registries of ClinicalTrials.gov and Cochrane Library. EXPERT OPINION Promising results were shown for a variety of new agents including nomacopan, efgartigimod, omalizumab, dupilumab, as well as chimeric autoantibody receptor T cells. Clinical translation in the field of AIBDs is highly active, and we anticipate significant advances in the treatment landscape.
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Affiliation(s)
- Henning Olbrich
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | | | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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Intravenous immunoglobulin in patients with bullous pemphigoid insufficient response to corticosteroids: Nationwide post-marketing surveillance in Japan. J Dermatol Sci 2023; 109:22-29. [PMID: 36697305 DOI: 10.1016/j.jdermsci.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/19/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND In Japan, intravenous immunoglobulin (IVIG) has been approved for corticosteroid-unresponsive bullous pemphigoid (BP); however, its usage, efficacy, and safety in clinical settings remain unclear. OBJECTIVE To elucidate IVIG efficacy, we examined the improvement in disease severity based on the Bullous Pemphigoid Disease Area Index (BPDAI). METHODS In this 3-year (April 2016-March 2019), prospective, post-marketing, observational surveillance study, we enrolled 379 patients (51.3 % men; mean age, 74.5 years) with corticosteroid-unresponsive BP treated with IVIG from 143 institutions in Japan (720 treatment cycles). The percentage of patients who improved by at least one severity stage or whose symptoms completely resolved based on the BPDAI score was evaluated at 15, 30, and 60-90 days. RESULTS The improvement rates at 15, 30, and 60-90 days after initial treatment in the 328 IVIG-naïve patients were 70.7 %, 83.5 %, and 84.3 %, respectively. The BPDAI score decreased rapidly and significantly by 15 days compared with that observed during pre-treatment. Further improvement was observed at 30 and 60-90 days. The corticosteroid dose and anti-BP180 antibody titers decreased significantly post-treatment (both, p < .001). Approximately 25 % of IVIG-naïve patients underwent multiple treatment cycles. The improvement rate at 30 days after the final dose was 88 %, and the symptoms completely resolved in 44 % of patients. The incidence of adverse drug reactions per cycle was 8.34 %; the most common reaction was transient thrombocytopenia. CONCLUSION Most patients showed improvement in severity and decrease in corticosteroid dose and anti-BP180 antibody levels post-treatment, indicating that IVIG is useful for corticosteroid-unresponsive BP treatment.
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Wan V, Chen D, Shiau CJ, Jung GW. Association between COVID-19 vaccination and bullous pemphigoid - a case series and literature review. SAGE Open Med Case Rep 2022; 10:2050313X221131868. [PMID: 36274858 PMCID: PMC9580082 DOI: 10.1177/2050313x221131868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Bullous pemphigoid is an acquired autoimmune blistering dermatosis that is commonly associated with high morbidity and mortality. New-onset bullous pemphigoid following vaccinations has rarely been reported in the literature. We report two cases of new-onset bullous pemphigoid after COVID-19 vaccination followed by a brief literature review. Twenty-six cases were included in our analysis. Our cases support that new-onset bullous pemphigoid may develop following COVID-19 vaccinations. Entering a period of clinical remission before subsequent COVID-19 vaccinations in addition to close follow-up should be considered to lessen the risk of recurrences or exacerbations.
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Affiliation(s)
- Vincent Wan
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Dilys Chen
- Department of Dermatology & Skin Science, University of British Columbia, Vancouver, BC, Canada,Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada,Department of Pathology, Royal Columbian Hospital, New Westminster, BC, Canada
| | - Carolyn J Shiau
- Department of Dermatology & Skin Science, University of British Columbia, Vancouver, BC, Canada,Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada,Department of Pathology, Royal Columbian Hospital, New Westminster, BC, Canada
| | - Gordon W Jung
- Department of Dermatology & Skin Science, University of British Columbia, Vancouver, BC, Canada,Gordon W Jung, Department of Dermatology & Skin Science, University of British Columbia, 467 E Columbia Street, New Westminster, BC V3L 3X6, Canada.
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8
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Borradori L, Van Beek N, Feliciani C, Tedbirt B, Antiga E, Bergman R, Böckle BC, Caproni M, Caux F, Chandran NS, Cianchini G, Daneshpazhooh M, De D, Didona D, Di Zenzo GM, Dmochowski M, Drenovska K, Ehrchen J, Goebeler M, Groves R, Günther C, Horvath B, Hertl M, Hofmann S, Ioannides D, Itzlinger-Monshi B, Jedličková J, Kowalewski C, Kridin K, Lim YL, Marinovic B, Marzano AV, Mascaro JM, Meijer JM, Murrell D, Patsatsi K, Pincelli C, Prost C, Rappersberger K, Sárdy M, Setterfield J, Shahid M, Sprecher E, Tasanen K, Uzun S, Vassileva S, Vestergaard K, Vorobyev A, Vujic I, Wang G, Wozniak K, Yayli S, Zambruno G, Zillikens D, Schmidt E, Joly P. Updated S2 K guidelines for the management of bullous pemphigoid initiated by the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol 2022; 36:1689-1704. [PMID: 35766904 DOI: 10.1111/jdv.18220] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 05/04/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and presents with itch and localized or, most frequently, generalized bullous lesions. A subset of patients only develops excoriations, prurigo-like lesions, and eczematous and/or urticarial erythematous lesions. The disease, which is significantly associated with neurological disorders, has high morbidity and severely impacts the quality of life. OBJECTIVES AND METHODOLOGY The Autoimmune blistering diseases Task Force of the European Academy of Dermatology and Venereology sought to update the guidelines for the management of BP based on new clinical information, and new evidence on diagnostic tools and interventions. The recommendations are either evidence-based or rely on expert opinion. The degree of consent among all task force members was included. RESULTS Treatment depends on the severity of BP and patients' comorbidities. High-potency topical corticosteroids are recommended as the mainstay of treatment whenever possible. Oral prednisone at a dose of 0.5 mg/kg/day is a recommended alternative. In case of contraindications or resistance to corticosteroids, immunosuppressive therapies, such as methotrexate, azathioprine, mycophenolate mofetil or mycophenolate acid, may be recommended. The use of doxycycline and dapsone is controversial. They may be recommended, in particular, in patients with contraindications to oral corticosteroids. B-cell-depleting therapy and intravenous immunoglobulins may be considered in treatment-resistant cases. Omalizumab and dupilumab have recently shown promising results. The final version of the guideline was consented to by several patient organizations. CONCLUSIONS The guidelines for the management of BP were updated. They summarize evidence- and expert-based recommendations useful in clinical practice.
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Affiliation(s)
- L Borradori
- Department of Dermatology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - N Van Beek
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - C Feliciani
- Dermatology Unit, Department of Medicine and Surgery, University Hospital, University of Parma, Italy
| | - B Tedbirt
- Department of Dermatology, Rouen University Hospital, Referral Center for Autoimmune Bullous Diseases, Referral Center for Autoimmune Bullous Diseases, Rouen University Hospital, INSERM U1234, Normandie University, Rouen, France
| | - E Antiga
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - R Bergman
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - B C Böckle
- Department of Dermatology, Venereology & Allergology, Innsbruck Medical University, Innsbruck, Austria
| | - M Caproni
- Department of Health Sciences, Section of Dermatology, AUSL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Italy
| | - F Caux
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - N S Chandran
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - G Cianchini
- Department of Dermatology, Ospedale Classificato Cristo Re, Rome, Italy
| | - M Daneshpazhooh
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - D De
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - D Didona
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - G M Di Zenzo
- Laboratory of Molecular and Cell Biology, Istituto Dermopatico dell'Immacolata, IDI-IRCCS, Rome, Italy
| | - M Dmochowski
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
| | - K Drenovska
- Department of Dermatology, Medical University of Sofia, Sofia, Bulgaria
| | - J Ehrchen
- Department of Dermatology, University of Münster, Münster, Germany
| | - M Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - R Groves
- St. John's Institute of Dermatology, Viapath Analytics LLP, St. Thomas' Hospital, London, UK.,Division of Genetics and Molecular Medicine, King's College London, Guy's Hospital, London, UK
| | - C Günther
- Department of Dermatology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - B Horvath
- Department of Dermatology, Center for Blistering Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - M Hertl
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - S Hofmann
- Department of Dermatology, Allergy and Dermatosurgery, Helios University Hospital Wuppertal, University Witten, Herdecke, Germany
| | - D Ioannides
- 1st Department of Dermatology-Venereology, Hospital of Skin and Venereal Diseases, Aristotle University Medical School, Thessaloniki, Greece
| | - B Itzlinger-Monshi
- Department of Dermatology, Venereology and Allergy, Clinical Center Landstrasse, Academic Teaching Hospital of the Medical University of Vienna, Vienna, Austria.,Medical Faculty, The Sigmund Freud Private University, Vienna, Austria
| | - J Jedličková
- Department of Dermatovenereology, Masaryk University, University Hospital St. Anna, Brno.,Department of Dermatovenereology, University Hospital Brno, Brno, Czech Republic
| | - C Kowalewski
- Department Dermatology and Immunodermatology, Medical University of Warsaw, Warsaw, Poland
| | - K Kridin
- National Skin Centre, Singapore, Singapore
| | - Y L Lim
- Department of Dermatology and Venereology, School of Medicine, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - B Marinovic
- Dermatology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - A V Marzano
- Dermatology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - J-M Mascaro
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - J M Meijer
- Department of Dermatology, Center for Blistering Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - D Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - K Patsatsi
- 2nd Department of Dermatology, Autoimmune Bullous Diseases Unit, Aristotle University School of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - C Pincelli
- DermoLab, Institute of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - C Prost
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - K Rappersberger
- Department of Dermatology, Venereology and Allergy, Clinical Center Landstrasse, Academic Teaching Hospital of the Medical University of Vienna, Vienna, Austria.,Medical Faculty, The Sigmund Freud Private University, Vienna, Austria.,Abteilung Dermatologie, Venerologie und Allergologie, Lehrkrankenhaus der Medizinischen Universität Wien, Austria
| | - M Sárdy
- Department of Dermatology and Allergology, Ludwig Maximilian University, Munich, Germany.,Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - J Setterfield
- Department of Oral Medicine, St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - M Shahid
- Department of Dermatology, Medical University, Sofia, Bulgaria
| | - E Sprecher
- Division of Dermatology, Tel Aviv Sourasky Medical Center and Department of Human Molecular Genetics & Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - K Tasanen
- Department of Dermatology, the PEDEGO Research Unit, University of Oulu and Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - S Uzun
- Department of Dermatology and Venereology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - S Vassileva
- Department of Dermatology, Medical University, Sofia, Bulgaria
| | - K Vestergaard
- Department of Dermatology, Aarhus University Hospital, Aarhus, Denmark
| | - A Vorobyev
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - I Vujic
- Department of Dermatology, Venereology and Allergy, Clinical Center Landstrasse, Academic Teaching Hospital of the Medical University of Vienna, Vienna, Austria.,Medical Faculty, The Sigmund Freud Private University, Vienna, Austria
| | - G Wang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - K Wozniak
- National Skin Centre, Singapore, Singapore
| | - S Yayli
- Department of Dermatology, School of Medicine, Koç University, Istanbul, Turkey
| | - G Zambruno
- Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - P Joly
- Department of Dermatology, Rouen University Hospital, Referral Center for Autoimmune Bullous Diseases, Referral Center for Autoimmune Bullous Diseases, Rouen University Hospital, INSERM U1234, Normandie University, Rouen, France
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9
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Ujiie H, Rosmarin D, Schön MP, Ständer S, Boch K, Metz M, Maurer M, Thaci D, Schmidt E, Cole C, Amber KT, Didona D, Hertl M, Recke A, Graßhoff H, Hackel A, Schumann A, Riemekasten G, Bieber K, Sprow G, Dan J, Zillikens D, Sezin T, Christiano AM, Wolk K, Sabat R, Kridin K, Werth VP, Ludwig RJ. Unmet Medical Needs in Chronic, Non-communicable Inflammatory Skin Diseases. Front Med (Lausanne) 2022; 9:875492. [PMID: 35755063 PMCID: PMC9218547 DOI: 10.3389/fmed.2022.875492] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/09/2022] [Indexed: 12/15/2022] Open
Abstract
An estimated 20-25% of the population is affected by chronic, non-communicable inflammatory skin diseases. Chronic skin inflammation has many causes. Among the most frequent chronic inflammatory skin diseases are atopic dermatitis, psoriasis, urticaria, lichen planus, and hidradenitis suppurativa, driven by a complex interplay of genetics and environmental factors. Autoimmunity is another important cause of chronic skin inflammation. The autoimmune response may be mainly T cell driven, such as in alopecia areata or vitiligo, or B cell driven in chronic spontaneous urticaria, pemphigus and pemphigoid diseases. Rare causes of chronic skin inflammation are autoinflammatory diseases, or rheumatic diseases, such as cutaneous lupus erythematosus or dermatomyositis. Whilst we have seen a significant improvement in diagnosis and treatment, several challenges remain. Especially for rarer causes of chronic skin inflammation, early diagnosis is often missed because of low awareness and lack of diagnostics. Systemic immunosuppression is the treatment of choice for almost all of these diseases. Adverse events due to immunosuppression, insufficient therapeutic responses and relapses remain a challenge. For atopic dermatitis and psoriasis, a broad spectrum of innovative treatments has been developed. However, treatment responses cannot be predicted so far. Hence, development of (bio)markers allowing selection of specific medications for individual patients is needed. Given the encouraging developments during the past years, we envision that many of these challenges in the diagnosis and treatment of chronic inflammatory skin diseases will be thoroughly addressed in the future.
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Affiliation(s)
- Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - David Rosmarin
- Department of Dermatology, Tufts Medical Center, Boston, MA, United States
| | - Michael P Schön
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany.,Lower Saxony Institute of Occupational Dermatology, University Medical Center Göttingen, Göttingen, Germany
| | - Sonja Ständer
- Center for Chronic Pruritus, Department of Dermatology, University Hospital Muenster, Muenster, Germany
| | - Katharina Boch
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Martin Metz
- Institute for Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Marcus Maurer
- Institute for Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Diamant Thaci
- Institute and Comprehensive Center for Inflammation Medicine, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Connor Cole
- Division of Dermatology, Rush University Medical Center, Chicago, IL, United States.,Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Kyle T Amber
- Division of Dermatology, Rush University Medical Center, Chicago, IL, United States.,Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Dario Didona
- Department of Dermatology and Allergology, Philipps-Universität, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps-Universität, Marburg, Germany
| | - Andreas Recke
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Hanna Graßhoff
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Alexander Hackel
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Anja Schumann
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Gant Sprow
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Joshua Dan
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Tanya Sezin
- Department of Dermatology, Columbia University Medical Center, New York, NY, United States
| | - Angela M Christiano
- Department of Dermatology, Columbia University Medical Center, New York, NY, United States
| | - Kerstin Wolk
- Psoriasis Research and Treatment Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Interdisciplinary Group Molecular Immunopathology, Dermatology/Medical Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Sabat
- Psoriasis Research and Treatment Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Interdisciplinary Group Molecular Immunopathology, Dermatology/Medical Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Victoria P Werth
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Ralf J Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
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10
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Ruggiero A, Megna M, Villani A, Comune R, Fabbrocini G, di Vico F. Strategies to Improve Outcomes of Bullous Pemphigoid: A Comprehensive Review of Clinical Presentations, Diagnosis, and Patients' Assessment. Clin Cosmet Investig Dermatol 2022; 15:661-673. [PMID: 35444441 PMCID: PMC9014958 DOI: 10.2147/ccid.s267573] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/07/2022] [Indexed: 01/27/2023]
Abstract
Bullous pemphigoid (BP) is the most frequent autoimmune bullous disease mainly affecting elderlies. Diagnosis usually results from clinical features, histological examination, and the quantification of circulating typical autoantibodies, due to its higher incidence in elderly patients, bullous pemphigoid treatment and management still represents a challenge due to the higher frequency of several comorbidities in this group of patients, which may also be linked to a reduced tolerance to BP treatments. Hence, an early diagnosis and a prompt correct treatment are mandatory to reach better clinical outcomes and improve as much as possible BP outcomes. Herein, we carried out a comprehensive literature review about the known clinical presentations, diagnosis, assessment and monitoring procedures used in daily clinical practice in patients with BP, to better define strategies to improve as much as possible BP clinical outcomes.
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Affiliation(s)
- Angelo Ruggiero
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Matteo Megna
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Alessia Villani
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Rosita Comune
- Section of Radiology and Radiotherapy, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, 80138, Italy
| | - Gabriella Fabbrocini
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Francesca di Vico
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, 80131, Italy
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11
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Wang Y, Mao X, Liu Y, Yang Y, Jin H, Li L. IL-13 Genetic Susceptibility to Bullous Pemphigoid: A Potential Target for Treatment and a Prognostic Marker. Front Immunol 2022; 13:824110. [PMID: 35140724 PMCID: PMC8818855 DOI: 10.3389/fimmu.2022.824110] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 01/05/2022] [Indexed: 01/07/2023] Open
Abstract
Background Bullous pemphigoid (BP) is a senile chronic autoimmune bullous skin disease with a high relapse rate, which significantly impairs patients’ quality of life and contributes to disease mortality. This observational case-control study explores the gene polymorphisms of cytokines and their clinical significance in Chinese patients with BP. Methods IL-1α (rs1800587), IL-1β (rs16944, rs1143627, rs1143634), IL-4 (rs2243250), IL-6 (rs1800795), IL-10 (rs1800896, rs1800871, rs1800872), IL-13 (rs1800925, rs20541), TNF-α (rs1799964, rs1800630, rs1799724, rs361525), IFN-γ (rs1799964, rs1800630, rs361525, rs1800629, rs4248160, rs1800750), and TGF-β1 (rs2317130, rs1800469, rs4803457) genes were genotyped in the healthy controls and BP patients, respectively. Expression of these cytokines in serum was measured. Medical profiles of patients, including baseline characteristics and prognosis, were statistically analyzed. Results We found that IL-1 β and IL-13 concentrations were higher in the BP patients’ sera compared to those in the controls. For IL-13, significant differences were found in the nucleotide ratio/genotype/haploid frequency/haplotype, respectively. IL-13 (rs20541, rs1800925) is related to gender, and the IL-13 genotype was significantly associated with recurrence. Conclusions BP is associated with IL-13 gene polymorphism and IL-13 concentration is elevated in blood circulation in patients with BP. Our results support that IL-13 is relevant in the pathogenesis of BP, suggesting that IL-13 could potentially represent a promising target for BP therapy and a prognostic marker.
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Affiliation(s)
- Yiman Wang
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Xuming Mao
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Yangchun Liu
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Yuyan Yang
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Hongzhong Jin
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Li Li
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
- *Correspondence: Li Li,
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12
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Battesti G, Garcia C, Viguier M, Marchal V, Castel M, Joly P, Ledard AP, Konstantinou MP, Seta V, Cordel N, Duvert-Lehembre S, Tancrède-Bohin E, Belmondo T, Ingen-Housz-Oro S, d'Incan M. Real-life impact of the immunological tests to predict relapse after treatment cessation in patients with bullous pemphigoid: a French multicenter retrospective study. J Am Acad Dermatol 2022; 86:1293-1300. [DOI: 10.1016/j.jaad.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/10/2021] [Accepted: 01/14/2022] [Indexed: 10/19/2022]
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13
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Zhou T, Peng B, Geng S. Emerging Biomarkers and Therapeutic Strategies for Refractory Bullous Pemphigoid. Front Immunol 2021; 12:718073. [PMID: 34504496 PMCID: PMC8421646 DOI: 10.3389/fimmu.2021.718073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/04/2021] [Indexed: 12/18/2022] Open
Abstract
Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disorder in the elderly. Systemic and topical use of glucocorticoids and immunosuppressants has been shown to be effective in most patients. However, refractory BP patients are challenged to clinicians with severe clinical symptoms, resistance to treatment, and high relapse rate. How to predict and assess the refractory and severity of bullous pemphigoid is the key issue in clinical practice, and the urgent need for precision medicine in refractory patients is driving the search for biomarkers and biologics. Recently, some biomarkers, such as the level of specific autoantibodies and released cytokines, have been proposed as the potential parameters to reflect the disease severity and predict the treatment response and relapse of refractory BP. Moreover, new biologics targeting pathogenic antibodies, complement, Th2 axis, eosinophils, and Th17 axis have shown potent efficacy on refractory BP. Here, we review the literature and give an overview of emerging biomarkers and therapeutic strategies for refractory bullous pemphigoid to improve the prognosis of the patient.
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Affiliation(s)
- Tong Zhou
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Bin Peng
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Songmei Geng
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
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14
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Ujiie I, Iwata H, Yoshimoto N, Izumi K, Shimizu H, Ujiie H. Clinical characteristics and outcomes of bullous pemphigoid patients with versus without oral prednisolone treatment. J Dermatol 2021; 48:502-510. [PMID: 33600037 DOI: 10.1111/1346-8138.15816] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/31/2021] [Indexed: 11/30/2022]
Abstract
Bullous pemphigoid (BP) varies in severity and stratified treatments are needed. However, there are no definitive standards for choosing appropriate treatments. To elucidate the factors involved in choosing treatments and the clinical outcomes of BP, we retrospectively reviewed the clinical records of 78 BP patients at a single center. Of the 78 patients, 49 (62.8%) were treated with oral prednisolone (PSL) and 29 (37.2%) were treated without PSL. The patients with older age, lower Bullous Pemphigoid Disease Area Index (BPDAI), and/or lower anti-BP180NC16a antibody titer at onset tended to be treated without oral PSL. Notably, only 9.1% patients without PSL experienced relapse, whereas 36.7% patients with oral PSL experienced relapse when the PSL was around 0.1 mg/kg. It suggests that the patients with mild disease severity could be well controlled without oral PSL. Receiver-operator curve analysis demonstrated that the cut-off value for the use of oral PSL was 31 for total BPDAI and was 7 for BPDAI skin urticaria/erythema, with a high (>0.9) area under the curve. Notably, none of the patients who were negative for the anti-BP180NC16a antibody at onset experienced relapse even though they were treated without PSL. In conclusion, in BP patients who were negative for anti-BP180NC16a antibody at onset, with a total BPDAI score of less than 31 or with an urticaria/erythema score of less than 7 can be treated without PSL. When the PSL is tapered to around 0.1 mg/kg, we should carefully monitor the patients to detect relapse.
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Affiliation(s)
- Inkin Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Norihiro Yoshimoto
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kentaro Izumi
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Shimizu
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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15
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Zhao W, Wang Y, Mao X, Payne AS, Feng S, Li W, Wang Y, Wang D, Jin H, Yuan J, Li L. Detection of underlying dementia in bullous pemphigoid patients using cognitive evaluation tests: a multicenter case-control study. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1397. [PMID: 33313142 PMCID: PMC7723532 DOI: 10.21037/atm-20-1319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Preliminary observation in clinical practice showed that subjective neurocognitive complaints are relatively common in bullous pemphigoid (BP) patients. Yet, little has been done to investigate the neurocognitive status in BP. Methods This is a multicenter observational case-control study comprised of 61 BP patients and 65 matched control subjects from 3 medical centers in China from 2014 to 2019. To evaluate the cognitive function between BP patients and matched controls, all the subjects finished the mini-mental state examination (MMSE) and montreal cognitive assessment (MoCA). Results The overall scores were significantly lower in BP than in controls (PMoCA<0.001). The percentage of patients screened positive for cognitive impairment in the BP group was significantly higher than in the control group (PMMSE<0.001, PMoCA<0.001). On multivariate analysis, BP was associated with increased odds of cognitive impairment by MMSE and MoCA (PMMSE=0.017, PMoCA=0.007). Conclusions BP patients had decreased cognitive abilities and were at a higher risk of cognitive impairment. The evaluation of cognitive impairment may be warranted for BP patients in clinical practice for early diagnosis and therapy of dementia.
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Affiliation(s)
- Wenling Zhao
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Dermatology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Yiman Wang
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuming Mao
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Suying Feng
- Institute of Dermatology, Department of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
| | - Wei Li
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China
| | - Yanhong Wang
- Department of Epidemiology and Bio-statistics, Institute of Basic Medical Sciences, China Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Di Wang
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongzhong Jin
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Yuan
- Department of Neurology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Li
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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16
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Treatment of Bullous Pemphigoid in People Aged 80 Years and Older: A Systematic Review of the Literature. Drugs Aging 2020; 38:125-136. [PMID: 33230804 DOI: 10.1007/s40266-020-00823-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Bullous pemphigoid commonly affects older adults and has a detrimental effect on both quality of life and longevity. Systemic corticosteroids, the mainstay of therapy, may cause significant adverse effects, especially in older patients. Therefore, safer therapeutic options are being sought. OBJECTIVE The objective of this article was to systematically review the published evidence on the efficacy and safety of different treatment modalities for bullous pemphigoid in older patients. METHODS We performed a systematic review of all publications until May 2020 in PubMed, Google Scholar, and the ongoing trials registry of the US National Institutes of Health databases evaluating the efficacy and safety of bullous pemphigoid treatments in patients aged older than 80 years. The primary outcome was complete response. The secondary outcomes were partial response, complete remission on minimal therapy or during tapering, recurrence, adverse events, and mortality. RESULTS Twenty-eight publications were included: 2 randomized controlled trials, 5 prospective cohort studies, 10 retrospective cohort studies, and 11 case series, with a total of 153 older patients. The overall complete response rate was 31%. Topical corticosteroids had the highest complete response rate (55%) with a low side-effect profile. Biologics (omalizumab and rituximab) were effective in achieving complete remission on minimal therapy (29%) without recurrence, although rituximab was associated with a relatively high mortality rate (29%). CONCLUSIONS Current data suggest that topical corticosteroids are effective and safe and should remain the first line of treatment for bullous pemphigoid in older adults. However, their application is difficult and requires a high-functioning patient, third-party assistance, or a relatively mild disease. Biological agents are effective but warrant meticulous patient selection owing to the relatively high mortality rate associated with rituximab. CLINICAL TRIAL REGISTRATION PROSPERO registration number CRD42020186686.
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17
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Monshi B, Gulz L, Piringer B, Wiala A, Kivaranovic D, Schmidt M, Sesti A, Heil T, Vujic I, Posch C, Rappersberger K. Anti-BP180 autoantibody levels at diagnosis correlate with 1-year mortality rates in patients with bullous pemphigoid. J Eur Acad Dermatol Venereol 2020; 34:1583-1589. [PMID: 32170780 DOI: 10.1111/jdv.16363] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 02/25/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most frequent autoimmune blistering disease mainly affecting elderly patients. Among several published risk factors, a recent post hoc analysis linked anti-BP180 autoantibodies (AABs) to fatal outcomes in BP. To date, this finding has not been confirmed independently. OBJECTIVE To investigate the potential of anti-BP180-AAB levels as a marker of prognosis and to identify a cut-off level indicative of an increased risk for early death. Secondly, to characterize parameters associated with mortality. METHODS Retrospective, single-centre study of BP patients diagnosed between 2001 and 2012. Analyses included epidemiological and patient- and disease-specific characteristics as well as immunological parameters at diagnosis and during follow-up. Standardized mortality ratios as well as uni- and multivariate regression analyses were calculated. RESULTS One hundred patients (56 women, 44 men) with a median age of 81 years (interquartile range 74-86) were followed up for a median of 775 days (interquartile range 162-1617). One-year mortality rates were 25.0% implying a 2.4-fold increased risk of death compared with the general population. High anti-BP180 autoantibody levels at diagnosis (CI95 1.30-2.89; P = 0.001), dementia (CI95 1.13-6.72; P =0.03), length of hospitalization (CI95 1.16-2.41; P = 0.01) and age (CI95 1.23-4.19; P = 0.009) correlated significantly with 1-year mortality. BP180-AAB concentrations of ≥61 U/mL characterized a subgroup of patients with a particular higher risk for early death compared with the general population (CI95 1.81-3.81; P < 0.0001). CONCLUSION In bullous pemphigoid, serum concentrations of BP180 autoantibodies at diagnosis could help to identify patients at risk for death within the first year after diagnosis (cut-off value 61 U/mL).
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Affiliation(s)
- B Monshi
- Department of Dermatology and Venereology, The Rudolfstiftung Hospital, Vienna, Austria
| | - L Gulz
- Department of Dermatology and Venereology, The Rudolfstiftung Hospital, Vienna, Austria
| | - B Piringer
- Department of Neonatology, Johannes Kepler University Linz, Med Campus IV, Linz, Austria
| | - A Wiala
- Department of Dermatology and Venereology, The Rudolfstiftung Hospital, Vienna, Austria
| | - D Kivaranovic
- Department of Statistics and Operations Research, University of Vienna, Vienna, Austria
| | - M Schmidt
- Department of Dermatology and Venereology, The Rudolfstiftung Hospital, Vienna, Austria
| | - A Sesti
- Department of Dermatology and Venereology, Medical University of Vienna, Vienna, Austria
| | - T Heil
- Department of Dermatology and Venereology, The Rudolfstiftung Hospital, Vienna, Austria
| | - I Vujic
- Department of Dermatology and Venereology, The Rudolfstiftung Hospital, Vienna, Austria
| | - C Posch
- Department of Dermatology and Allergy, School of Medicine, Technical University of Munich, Munich, Germany.,School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - K Rappersberger
- Department of Dermatology and Venereology, The Rudolfstiftung Hospital, Vienna, Austria.,School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
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Shih YC, Wang B, Yuan H, Zheng J, Pan M. Role of BP230 autoantibodies in bullous pemphigoid. J Dermatol 2020; 47:317-326. [PMID: 32048350 DOI: 10.1111/1346-8138.15251] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 01/05/2020] [Indexed: 01/16/2023]
Abstract
Bullous pemphigoid (BP) is an autoimmune disease associated with subepidermal blistering due to autoantibodies directed against BP180 and BP230. BP180 is currently considered as the major pathogenic autoantigen. However, previous clinical findings suggested that anti-BP230 autoantibodies alone can cause skin lesions in animal models and many BP patients. The characteristics of BP230 and the pathogenic roles of anti-BP230 antibodies have been proposed. First, at the molecular level, BP230 mediates the attachment of keratin intermediate filaments to the hemidesmosomal plaque and interacts with other constituents of hemidesmosomes. Second, the presence of BP230 autoantibodies may correlate with specific clinical features of BP. The immunoglobulin (Ig)G autoantibodies from BP patients react mainly against the C-terminus of BP230, while the IgE autoantibodies are still inconclusive. Third, in vivo, autoantibodies against BP230 involved in the disease may not only induce the inflammatory response but also impair the structural stability of hemidesmosomes. This article reviews recently published work about the role of BP230 and its antibodies, including IgG and IgE, aiming to find clues of its clinical association and lay the foundation for the research on the pathogenicity of antibodies against BP230.
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Affiliation(s)
- Yen-Chi Shih
- Department of Dermatology, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bo Wang
- Department of Dermatology, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Huijie Yuan
- Department of Dermatology, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jie Zheng
- Department of Dermatology, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Meng Pan
- Department of Dermatology, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
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19
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Meijer JM, Diercks GFH, de Lang EWG, Pas HH, Jonkman MF. Assessment of Diagnostic Strategy for Early Recognition of Bullous and Nonbullous Variants of Pemphigoid. JAMA Dermatol 2019; 155:158-165. [PMID: 30624575 DOI: 10.1001/jamadermatol.2018.4390] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance A substantial number of patients with bullous pemphigoid do not develop skin blisters and may not have received the correct diagnosis. Diagnostic criteria and an optimal diagnostic strategy are needed for early recognition and trials. Objectives To assess the minimal requirements for diagnosis of bullous and nonbullous forms of pemphigoid and to evaluate the optimal diagnostic strategy. Design, Setting, and Participants This paired, multivariable, diagnostic accuracy study analyzed data from 1125 consecutive patients with suspected pemphigoid who were referred to the Groningen Center for Blistering Diseases from secondary and tertiary care hospitals throughout the Netherlands. Eligible participants were patients with paired data on at least (1) a skin biopsy specimen for the direct immunofluorescence (DIF) microscopy test; (2) indirect immunofluorescence on a human salt-split skin substrate (IIF SSS) test; and (3) 1 or more routine immunoserologic tests administered between January 1, 2002, and May 1, 2015. Samples were taken from patients at the time of first diagnosis, before introduction of immunosuppressive therapy, and within an inclusion window of a maximum of 4 weeks. Data analysis was conducted from October 1, 2015, to December 1, 2017. Main Outcomes and Measures Pairwise DIF, IIF SSS, IIF on monkey esophagus, BP180 and BP230 enzyme-linked immunosorbent assays, and immunoblot for BP180 and BP230 tests were performed. The results were reported in accordance with 2015 version of the Standards for Reporting Diagnostic Accuracy. Results Of the 1125 patients analyzed, 653 (58.0%) were women and 472 (42.0%) were men, with a mean (SD) age of 63.2 (19.9) years. In total, 343 participants received a pemphigoid diagnosis, with 782 controls. Of the 343 patients, 74 (21.6%, or 1 in 5) presented with nonbullous pemphigoid. The DIF microscopy was the most sensitive diagnostic test (88.3% [n = 303]; 95% CI, 84.5%-91.3%), whereas IIF SSS was less sensitive (77.0% [n = 263]; 95% CI, 72.2%-81.1%) but was highly specific (99.9%; 95% CI, 99.3%-100%) and complemented most cases with negative DIF findings. Results of the BP180 NC16A enzyme-linked immunosorbent assay did not add diagnostic value for initial diagnosis in multivariable logistic regression analysis of combined tests. These findings lead to the proposed minimal criteria for diagnosing pemphigoid: (1) pruritus and/or predominant cutaneous blisters, (2) linear IgG and/or C3c deposits (in an n-serrated pattern) by DIF on a skin biopsy specimen, and (3) positive epidermal side staining of IgG by IIF SSS on a serum sample; this proposal extends bullous pemphigoid with the unrecognized nonbullous form. Conclusions and Relevance Both DIF and IIF SSS tests should be performed for diagnosis of the bullous and nonbullous variants of pemphigoid, and the BP180 NC16A enzyme-linked immunosorbent assay is recommended as an add-on test for disease activity monitoring.
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Affiliation(s)
- Joost M Meijer
- Center for Blistering Diseases, Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Gilles F H Diercks
- Center for Blistering Diseases, Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Emma W G de Lang
- Center for Blistering Diseases, Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hendri H Pas
- Center for Blistering Diseases, Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marcel F Jonkman
- Center for Blistering Diseases, Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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20
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Nesmond S, Muller C, Le Naour R, Viguier M, Bernard P, Antonicelli F, Le Jan S. Characteristic Pattern of IL-17RA, IL-17RB, and IL-17RC in Monocytes/Macrophages and Mast Cells From Patients With Bullous Pemphigoid. Front Immunol 2019; 10:2107. [PMID: 31572359 PMCID: PMC6749098 DOI: 10.3389/fimmu.2019.02107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/21/2019] [Indexed: 01/08/2023] Open
Abstract
Inflammation is largely implicated in bullous pemphigoid (BP), the most frequent skin auto-immune blistering disease. IL-17, essentially IL-17A/F, has been involved in blister formation through regulation of protease production, and its specific serum profile within BP was related to disease outcome. However, relationships between IL-17 family ligands and receptors are quite complex with six different IL-17 isoforms, and five different receptors. We here aimed at clarifying the contribution of the IL-17 axis in BP by characterizing not only the expression of IL-17 receptor (IL-17R) members within immune cells isolated from BP patients (PMNs, n = 9; T-lymphocytes, n = 10; and monocytes, n = 10) but also the expression of IL-17 isoforms in sera (n = 83), and blister fluid (n = 31) of BP patients. We showed that at diagnosis, IL-17RA and IL-17RC expression were significantly increased in monocytes isolated from BP patients as compared to those from control subjects (p = 0.006 and p = 0.016, respectively). Notably, both IL-17RA and IL-17RC mRNA expression remained elevated in BP monocytes at time of relapse. We further demonstrated a significant increase of all IL-17 isoforms tested in BP blister fluid compared with BP serum (IL-17A, p < 0.0001; IL-17A/F, p < 0.0001; IL-17B, p = 0.0023; IL-17C, p = 0.0022; IL-17E, p < 0.0001). Among all, IL-17B was the only cytokine for which a significant decreased concentration within blister fluid was observed in BP patients with severe disease compared to patients with moderate disease (p = 0.012). We further evidenced a significant negative correlation between IL-17B levels and blister/erosion BPDAI subscore (r = −0.52, p = 0.003). We finally identified mast cells as a potential target of IL-17B in lesional skin of BP patients. In conclusion, we showed here that IL-17RA and IL-17RC expression in monocyte was associated with disease activity and evidenced in situ a negative correlation between BP disease activity and IL-17B, whose effects could be mediated by IL-17RB expressed by mast cell in BP lesional skin.
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Affiliation(s)
- Stéphane Nesmond
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France
| | - Céline Muller
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France
| | - Richard Le Naour
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France.,Department of Biological Sciences, UFR Pharmacy, University of Reims Champagne-Ardenne, Reims, France
| | - Manuelle Viguier
- Department of Dermatology, University Hospital, University of Reims-Champagne-Ardenne, Reims, France
| | - Philippe Bernard
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France.,Department of Dermatology, University Hospital, University of Reims-Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims-Champagne-Ardenne, Reims, France
| | - Sébastien Le Jan
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France
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21
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Le Jan S, Muller C, Plee J, Durlach A, Bernard P, Antonicelli F. IL-23/IL-17 Axis Activates IL-1β-Associated Inflammasome in Macrophages and Generates an Auto-Inflammatory Response in a Subgroup of Patients With Bullous Pemphigoid. Front Immunol 2019; 10:1972. [PMID: 31507596 PMCID: PMC6718471 DOI: 10.3389/fimmu.2019.01972] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/05/2019] [Indexed: 12/28/2022] Open
Abstract
Bullous Pemphigoid (BP) is a skin autoimmune blistering disease characterized by immune-mediated degradation of the dermo-epidermal junction and release of a large number of inflammatory cytokines. Interleukin-1β (IL-1β) is a pleiotropic pro-inflammatory cytokine associated with inflammasome activation and known to be pivotal in several auto-immune and auto-inflammatory diseases. We sought to clarify the presence of inflammasome-dependent IL-1β and to investigate its role in BP. Skin biopsy specimens (n = 13), serum (n = 60), blister fluid (n = 26), and primary inflammatory cells from patients with BP were used to investigate inflammasome activation and function. We here highlighted a differential occurrence of a functional in situ inflammasome in patients with BP, biologically distinguished by IL-1β and NLRP3 expression. Clinically, elevated IL-1β levels were associated with the presence of erythema and urticarial plaques reflecting the inflammatory phase preceding blister formation. We further identified IL-17 and IL-23 as important molecules favoring IL-1β expression in monocyte-derived macrophages from BP patients. Finally, we demonstrated the ability of IL-1β to stimulate the release of the matrix metalloproteinase-9 in those macrophages, reinforcing the role of IL-1β in the auto-amplification loop of the inflammatory response associated to BP. However, whether this inflammasome is an epiphenomenon associated with BP disease or constitutes an amplification inflammatory step in certain patients still need to be determined. In the context of a precision medicine approach, our findings allowed us to delineate a subgroup of patients with BP that showed similarities with auto-inflammatory diseases. Subsequently, this opens up alternative therapeutic strategies targeting IL-1β pathway in the aim to control the early, pre-blistering inflammatory phase. Ultimately, this could also help in reducing the detrimental effects associated with high doses of corticosteroids treatment.
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Affiliation(s)
- Sébastien Le Jan
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France
| | - Céline Muller
- Department of Dermatology, University Hospital, University of Reims-Champagne-Ardenne, Reims, France
| | - Julie Plee
- Department of Dermatology, University Hospital, University of Reims-Champagne-Ardenne, Reims, France
| | - Anne Durlach
- Laboratory Pol Bouin, Hospital Maison Blanche, University Hospital, University of Reims-Champagne-Ardenne, Reims, France
| | - Philippe Bernard
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, EA7509 IRMAIC, University of Reims-Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims-Champagne-Ardenne, Reims, France
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22
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Saschenbrecker S, Karl I, Komorowski L, Probst C, Dähnrich C, Fechner K, Stöcker W, Schlumberger W. Serological Diagnosis of Autoimmune Bullous Skin Diseases. Front Immunol 2019; 10:1974. [PMID: 31552014 PMCID: PMC6736620 DOI: 10.3389/fimmu.2019.01974] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/05/2019] [Indexed: 12/12/2022] Open
Abstract
Autoimmune bullous dermatoses (AIBD) encompass a variety of organ-specific autoimmune diseases that manifest with cutaneous and/or mucosal blisters and erosions. They are characterized by autoantibodies targeting structural proteins of the skin, which are responsible for the intercellular contact between epidermal keratinocytes and for adhesion of the basal keratinocytes to the dermis. The autoantibodies disrupt the adhesive functions, leading to splitting and blister formation. In pemphigus diseases, blisters form intraepidermally, whereas in all other disease types they occur subepidermally. Early identification of autoimmune bullous dermatoses is crucial for both treatment and prognosis, particularly as regards tumor-associated disease entities. The diagnosis is based on clinical symptoms, histopathology, direct immunofluorescence to detect antibody/complement deposits, and the determination of circulating autoantibodies. The identification of various target antigens has paved the way for the recent development of numerous specific autoantibody tests. In particular, optimized designer antigens and multiplex test formats for indirect immunofluorescence and ELISA have enhanced and refined the laboratory analysis, enabling highly efficient serodiagnosis and follow-up. This review elaborates on the current standards in the serological diagnostics for autoimmune bullous dermatoses.
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Affiliation(s)
| | - Ingolf Karl
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Christian Probst
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Cornelia Dähnrich
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Kai Fechner
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Winfried Stöcker
- Institute for Experimental Immunology, Euroimmun AG, Lübeck, Germany
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23
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Polansky M, Eisenstadt R, DeGrazia T, Zhao X, Liu Y, Feldman R. Rituximab therapy in patients with bullous pemphigoid: A retrospective study of 20 patients. J Am Acad Dermatol 2019; 81:179-186. [DOI: 10.1016/j.jaad.2019.03.049] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/18/2019] [Accepted: 03/20/2019] [Indexed: 10/27/2022]
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Duretz C, Antonicelli F, Muller C, Antonicelli N, Plee J, Viguier M, Bernard P. Association of Transient Palmoplantar Keratoderma With Clinical and Immunologic Characteristics of Bullous Pemphigoid. JAMA Dermatol 2019; 155:216-220. [PMID: 30484821 DOI: 10.1001/jamadermatol.2018.4084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Importance Development of transient palmoplantar keratoderma (PPK) with bullous pemphigoid (BP) has only been described in 2 isolated case reports. The clinical significance and the pathophysiologic mechanisms of this association are unknown. Objective To examine the clinical characteristics and immunological profile of patients with BP who develop transient PPK and analyze therapeutic options and outcomes. Design, Setting, and Participants In this case series, patients with BP who developed acquired, transient PPK, and were treated at a single institution from January 1, 2015, through December 31, 2017, were studied. Main Outcomes and Measures Clinical and immunological activity of BP, treatment administrated before and after PPK appearance, and patient outcomes. Results Six patients with BP and transient PPK were identified and included in the study. There were 5 women and 1 man with a mean age of 72 years. At baseline, all patients had a generalized, multibullous BP and high serum anti-BP180 antibodies (mean, 130 U/mL; range, 73-150), whereas anti-BP230 antibodies were elevated in only 1 case. The PPK appeared a mean 6.2 (range, 2-12) months after BP diagnosis, following a prolonged period of disease activity with recurrent flares. When the PPK occurred, BP was uncontrolled on therapy (mean Bullous Pemphigoid Disease Activity Index [BPDAI] score, 57; range, 34-105; mean anti-BP180 antibodies titer, 122 U/mL; range, 81-150). On administration of additional systemic immunosuppressive therapies, the PPK healed progressively in a mean 4.3 months (range, 2-9), along with BP clinical remission in 4 of 6 patients. No relationship was found between PPK occurrence and anti-BP180/230 antibodies profiles. In contrast, blister fluids collected at the time of PPK displayed a much higher level of interleukin 1β (IL-1β) compared with those collected in the absence of PKK. Expression of IL-17A, IL-17F, and IL-22 was also enhanced in the blister fluid of patients with BP who had PPK. Conclusions and Relevance To our knowledge, this is the first report of 6 cases of BP with transient PPK with extensive immunological investigation. The PPK appeared after a prolonged period of clinical BP activity punctuated with recurrent relapses, was transient, and healed after BP control with additional immunosuppressive therapy. Enhanced expression of a particular cytokine panel in the blister fluid at time of PPK could support keratinocyte proliferation as described in patients with psoriasis. Transient PPK could represent a clinical marker of severe, treatment-resistant BP.
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Affiliation(s)
- Claire Duretz
- Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, Faculty of Medicine, EA 7509, University of Reims Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims Champagne-Ardenne, Reims, France
| | - Céline Muller
- Laboratory of Dermatology, Faculty of Medicine, EA 7509, University of Reims Champagne-Ardenne, Reims, France
| | - Nina Antonicelli
- Laboratory of Dermatology, Faculty of Medicine, EA 7509, University of Reims Champagne-Ardenne, Reims, France
| | - Julie Plee
- Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Manuelle Viguier
- Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Dermatology, Faculty of Medicine, EA 7509, University of Reims Champagne-Ardenne, Reims, France
| | - Philippe Bernard
- Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Dermatology, Faculty of Medicine, EA 7509, University of Reims Champagne-Ardenne, Reims, France
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25
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Giusti D, Le Jan S, Gatouillat G, Bernard P, Pham BN, Antonicelli F. Biomarkers related to bullous pemphigoid activity and outcome. Exp Dermatol 2018; 26:1240-1247. [PMID: 29105148 DOI: 10.1111/exd.13459] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2017] [Indexed: 12/11/2022]
Abstract
Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease of the skin. Investigation of the BP-associated pathophysiological processes during the last decades showed that the generation of autoantibodies directed against the hemidesmosome proteins BP180 and BP230, a hallmark of the BP-associated autoimmune response, leads to the recruitment of inflammatory immune cells at the dermal-epidermal junction, and subsequently to the release of a large amount of inflammatory molecules involved in blister formation. Analysis in transversal and longitudinal studies of autoantibodies and inflammatory molecules production both at the time of diagnosis and under treatment was mainly performed within the serum but also in the blister fluid. Some autoimmune or inflammatory molecules expression was related to the presence of clinical signs, while others were mere bystanders. In this review, we focused on the autoimmune and inflammatory molecules that have been identified as potential biomarkers of BP development and outcome.
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Affiliation(s)
- Delphine Giusti
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Sébastien Le Jan
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France
| | - Gregory Gatouillat
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Philippe Bernard
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Bach Nga Pham
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, Faculty of Medicine of Reims, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims Champagne-Ardenne, Reims, France
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26
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Chakievska L, Holtsche MM, Künstner A, Goletz S, Petersen BS, Thaci D, Ibrahim SM, Ludwig RJ, Franke A, Sadik CD, Zillikens D, Hölscher C, Busch H, Schmidt E. IL-17A is functionally relevant and a potential therapeutic target in bullous pemphigoid. J Autoimmun 2018; 96:104-112. [PMID: 30219389 DOI: 10.1016/j.jaut.2018.09.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/04/2018] [Accepted: 09/07/2018] [Indexed: 01/19/2023]
Abstract
IL-17A has been identified as key regulatory molecule in several autoimmune and chronic inflammatory diseases followed by the successful use of anti-IL-17 therapy, e.g. in ankylosing spondylitis and psoriasis. Bullous pemphigoid (BP) is the most frequent autoimmune blistering disease with a high need for more specific, effective and safe treatment options. The aim of this study was to clarify the pathophysiological importance of IL-17A in BP. We found elevated numbers of IL-17A+ CD4+ lymphocytes in the peripheral blood of BP patients and identified CD3+ cells as major source of IL-17A in early BP skin lesions. IL17A and related genes were upregulated in BP skin and exome sequencing of 51 BP patients revealed mutations in twelve IL-17-related genes in 18 patients. We have subsequently found several lines of evidence suggesting a significant role of IL-17A in the BP pathogenesis: (i) IL-17A activated human neutrophils in vitro, (ii) inhibition of dermal-epidermal separation in cryosections of human skin incubated with anti-BP180 IgG and subsequently with anti-IL-17A IgG-treated leukocytes, (iii) close correlation of serum IL-17A levels and diseases activity in a mouse model of BP, (iv) IL17A-deficient mice were protected against autoantibody-induced BP, and (v) pharmacological inhibition of lL-17A reduced the induction of BP in mice. Our data give evidence for a pivotal role of IL-17A in the pathophysiology of BP and advocate IL-17A inhibition as potential novel treatment for this disease.
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Affiliation(s)
- Lenche Chakievska
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Maike M Holtsche
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Axel Künstner
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Stephanie Goletz
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | | | - Diamant Thaci
- Institute for Inflammation Medicine, University of Lübeck, Lübeck, Germany
| | - Saleh M Ibrahim
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Ralf J Ludwig
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Andre Franke
- Institute of Clinical Molecular Biology, University of Kiel, Kiel, Germany
| | | | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Christoph Hölscher
- Division of Infection Immunology, Research Center Borstel, Borstel, Germany
| | - Hauke Busch
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany; Department of Dermatology, University of Lübeck, Lübeck, Germany.
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Amber KT, Murrell DF, Schmidt E, Joly P, Borradori L. Autoimmune Subepidermal Bullous Diseases of the Skin and Mucosae: Clinical Features, Diagnosis, and Management. Clin Rev Allergy Immunol 2018; 54:26-51. [PMID: 28779299 DOI: 10.1007/s12016-017-8633-4] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Autoimmune subepidermal blistering diseases of the skin and mucosae constitute a large group of sometimes devastating diseases, encompassing bullous pemphigoid, gestational pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, and anti-p200 pemphigoid. Their clinical presentation is polymorphic. These autoimmune blistering diseases are associated with autoantibodies that target distinct components of the basement membrane zone of stratified epithelia. These autoantigens represent structural proteins important for maintenance of dermo-epidermal integrity. Bullous pemphigoid (BP) is the most common subepidermal autoimmune blistering disease of the skin and mucosae. Although the disease typically presents with a generalized blistering eruption associated with itch, atypical variants with either localized bullous lesions or "non-bullous" presentations are observed in approximately 20% of patients. A peculiar form of BP typically associated with pregnancy is pemphigoid gestationis. In anti-p200 pemphigoid, patients present with tense blisters on erythematosus or normal skin resembling BP, with a predilection for acral surfaces. These patients have antibodies targeting the 200-kDa basement membrane protein. Epidermolysis bullosa is a rare autoimmune blistering disease associated with autoantibodies against type VII collagen that can have several phenotypes including a classical form mimicking dystrophic epidermolysis bullosa, an inflammatory presentation mimicking BP, or mucous membrane pemphigoid-like lesions. Mucous membrane pemphigoid (MMP) is the term agreed upon by international consensus for an autoimmune blistering disorder, which affects one or more mucous membrane and may involve the skin. The condition involves a number of different autoantigens in the basement membrane zone. It may result in severe complications from scarring, such as blindness and strictures. Diagnosis of these diseases relies on direct immunofluorescence microscopy studies and immunoserological assays. Management of affected patients is often challenging. We will here review the clinical and immunopathological features as well as the pathophysiology of this group of organ-specific autoimmune diseases. Finally, we will discuss the diagnostic approach and the principles of management in clinical practice.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of California Irvine Health, 118 Med Surg 1, Irvine, CA, 92697, USA.
| | - Dedee F Murrell
- Department of Dermatology, St. George Hospital, Gray Street, Kogarah, Sydney, NSW, Australia
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Pascal Joly
- Department of Dermatology, INSERM U901, University of Rouen, Rouen, France
| | - Luca Borradori
- Department of Dermatology, University of Bern, Bern, Switzerland
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28
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Koga H, Teye K, Ishii N, Ohata C, Nakama T. High Index Values of Enzyme-Linked Immunosorbent Assay for BP180 at Baseline Predict Relapse in Patients With Bullous Pemphigoid. Front Med (Lausanne) 2018; 5:139. [PMID: 29868591 PMCID: PMC5954083 DOI: 10.3389/fmed.2018.00139] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 04/24/2018] [Indexed: 12/02/2022] Open
Abstract
Bullous pemphigoid (BP) presenting with erythema plaques and tense blisters is the most frequent autoimmune bullous disease. Immunologically, BP is characterized by the presence of circulating anti-epidermal basement membrane zone (BMZ) antibodies. The autoantigens in BMZs targeted by patient's antibodies are mainly BP180 (type XVII collagen) and BP230. Previous reports have indicated that IgG to the immunodominant region of BP180 in BP, 16th non-collagenous domain (NC16A), and anti-BP180NC16A IgE are related to disease activity. In the cytokine profile, serum levels of IL-6, TNF-α, IL-15, and CCL18 were associated with the severity or activity of the disease. Blood eosinophilia is seen frequently, especially in severe cases. These biomarkers are helpful to evaluate efficacy of treatment and disease severity. Due to the high frequency of disease relapse, prediction of relapse at initiation of treatment (baseline) must be beneficial for clinicians. Therefore, we evaluated biomarkers anti-BP180 IgG (BP180 ELISA), anti-BP230 IgG (BP230 ELISA), peripheral eosinophils, and serum IgE at baseline between BP patients with (n = 16) and without (n = 31) relapse. We found significantly higher index values of BP180 ELISA in the relapse group, whereas no significant difference was found in BP230 ELISA, peripheral eosinophils, and serum IgE. This study indicated that a high index value of BP180 ELISA (cutoff value, 53.09 U/mL; sensitivity, 81.3%; specificity, 48.4%) at baseline may predict relapse in patients with BP. This may help clinicians treating BP patients in decision-making regarding duration and intensity of treatment.
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Affiliation(s)
- Hiroshi Koga
- Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan
| | - Kwesi Teye
- Kurume University Institute of Cutaneous Cell Biology, Fukuoka, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan
| | - Chika Ohata
- Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan
| | - Takekuni Nakama
- Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan
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Giusti D, Gatouillat G, Le Jan S, Plée J, Bernard P, Antonicelli F, Pham BN. Anti-Type VII Collagen Antibodies Are Identified in a Subpopulation of Bullous Pemphigoid Patients With Relapse. Front Immunol 2018; 9:570. [PMID: 29619029 PMCID: PMC5871753 DOI: 10.3389/fimmu.2018.00570] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/06/2018] [Indexed: 11/19/2022] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune bullous skin disease characterized by anti-BP180 and anti-BP230 autoantibodies (AAbs). Mucous membrane involvement is an uncommon clinical feature of BP which may evoke epidermolysis bullosa acquisita, another skin autoimmune disease characterized by anti-type VII collagen AAbs. We therefore evaluated the presence of anti-type VII collagen AAbs in the serum of BP patients with and without mucosal lesions at time of diagnosis and under therapy. Anti-BP180, anti-BP230, and anti-type VII collagen AAbs were measured by ELISA in the serum of unselected patients fulfilling clinical and histo/immunopathological BP criteria at baseline (n = 71) and at time of relapse (n = 24). At baseline, anti-type VII collagen AAbs were detected in 2 out of 24 patients with BP presenting with mucosal involvement, but not in patients without mucosal lesions (n = 47). At the time of relapse, 10 out of 24 BP patients either displayed a significant induction or increase of concentrations of anti-type VII collagen AAbs (P < 0.01), independently of mucosal involvement. Those 10 relapsing BP patients were also characterized by a sustained high concentration of anti-BP180 AAb, whereas the serum anti-BP230 AAb concentrations did not vary in BP patients with relapse according to the presence of anti-type VII collagen AAbs. Thus, our study showed that anti-type VII collagen along with anti-BP180 AAbs detection stratified BP patients at time of relapse, illustrating a still dysregulated immune response that could reflect a potential epitope spreading mechanism in those BP patients.
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Affiliation(s)
- Delphine Giusti
- Laboratory of Dermatology, Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Grégory Gatouillat
- Laboratory of Dermatology, Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Sébastien Le Jan
- Laboratory of Dermatology, Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France
| | - Julie Plée
- Laboratory of Dermatology, Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France.,Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Philippe Bernard
- Laboratory of Dermatology, Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France.,Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, Faculty of Odontology, University of Reims Champagne-Ardenne, Reims, France
| | - Bach-Nga Pham
- Laboratory of Dermatology, Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
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30
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Eckardt J, Eberle FC, Ghoreschi K. Diagnostic value of autoantibody titres in patients with bullous pemphigoid. Eur J Dermatol 2018; 28:3-12. [PMID: 29336324 DOI: 10.1684/ejd.2017.3166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common autoimmune blistering disease of the skin requiring skin and serum tests for a precise diagnosis. OBJECTIVES We analysed the sensitivity and specificity of BP-relevant parameters and the value of autoantibody titres during follow-up of BP patients. MATERIALS & METHODS In a retrospective single-centre study, we included 200 consecutive patients with BP and 400 non-BP patients, and evaluated the test results of patients' serum and skin. In addition, we followed patients' autoantibody titres and clinical characteristics. RESULTS BP180-ELISA revealed the highest sensitivity (85.0%; specificity: 93.9%), while BP230-ELISA demonstrated the lowest sensitivity (55.5%; specificity: 92.9%). Direct and indirect immunofluorescence showed comparable results for sensitivity (77.2%/72.7%) and specificity (94.9%/93.7%). The sensitivity for skin histology was 76.3% (specificity: 81.3%). Longitudinal analysis showed significant changes in autoantibody titres. CONCLUSIONS BP diagnostics should include serum tests for BP autoantibodies and skin immunofluorescence. Skin histology is supportive for diagnosis. Autoantibody titres are markers for disease activity.
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Affiliation(s)
- Julia Eckardt
- Department of Dermatology, University Medical Centre, Eberhard Karls University Tübingen, Germany
| | - Franziska C Eberle
- Department of Dermatology, University Medical Centre, Eberhard Karls University Tübingen, Germany
| | - Kamran Ghoreschi
- Department of Dermatology, University Medical Centre, Eberhard Karls University Tübingen, Germany
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31
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Liu Y, Li L, Xia Y. BP180 Is Critical in the Autoimmunity of Bullous Pemphigoid. Front Immunol 2017; 8:1752. [PMID: 29276517 PMCID: PMC5727044 DOI: 10.3389/fimmu.2017.01752] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/24/2017] [Indexed: 12/20/2022] Open
Abstract
Bullous pemphigoid (BP) is by far the most common autoimmune blistering dermatosis that mainly occurs in the elderly. The BP180 is a transmembrane glycoprotein, which is highly immunodominant in BP. The structure and location of BP180 indicate that it is a significant autoantigen and plays a key role in blister formation. Autoantibodies from BP patients react with BP180, which leads to its degradation and this has been regarded as the central event in BP pathogenesis. The consequent blister formation involves the activation of complement-dependent or -independent signals, as well as inflammatory pathways induced by BP180/anti-BP180 autoantibody interaction. As a multi-epitope molecule, BP180 can cause dermal-epidermal separation via combining each epitope with specific immunoglobulin, which also facilitates blister formation. In addition, some inflammatory factors can directly deplete BP180, thereby leading to fragility of the dermal-epidermal junction and blister formation. This review summarizes recent investigations on the role of BP180 in BP pathogenesis to determine the potential targets for the treatment of patients with BP.
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Affiliation(s)
- Yale Liu
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Liang Li
- National-Local Joint Engineering Research Center of Biodiagnostics and Biotherapy, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Yumin Xia
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, China
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32
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Brulefert A, Le Jan S, Plée J, Durlach A, Bernard P, Antonicelli F, Trussardi-Régnier A. Variation of the epidermal expression of glucocorticoid receptor-beta as potential predictive marker of bullous pemphigoid outcome. Exp Dermatol 2017; 26:1261-1266. [PMID: 28887823 DOI: 10.1111/exd.13444] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2017] [Indexed: 11/29/2022]
Abstract
Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease in Western countries. Although topical and/or systemic glucocorticoids treatment efficacy is widely recognized, up to 30% of patients with BP may undergo a relapse during the first year of treatment. We investigated the protein expression of the total glucocorticoid receptor and GRβ isoform in the skin biopsy specimens from patients with BP and wondered whether such investigation at baseline provided a tool to predict disease outcome. Total GR and GRβ protein expressions were detected by immunohistochemistry at baseline on 12 patients who later relapse and 11 patients who remained on remission in comparison with 14 control patients. The expression of GRβ in the epidermis of patients with BP who later relapse was significantly higher than that in the epidermis of patients with BP controlled upon corticosteroid treatment, which was also higher than control patients. Thus, our results suggest that increased protein expression of GRβ in skin epithelial cells is predictive of reduced steroid treatment efficacy, and therefore of increased risk of disease relapse in patients with BP.
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Affiliation(s)
- Adrien Brulefert
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France
| | - Sébastien Le Jan
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France
| | - Julie Plée
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Anne Durlach
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Laboratory Pol Bouin, Hospital Maison Blanche, University Hospital, Reims Cedex, France
| | - Philippe Bernard
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims Champagne-Ardenne, Reims, France
| | - Aurélie Trussardi-Régnier
- Laboratory of Dermatology, Faculty of Medicine of Reims, EA 7319, IFR CAP Santé, University of Reims Champagne-Ardenne, Reims, France
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33
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Kubin ME, Hellberg L, Palatsi R. Glucocorticoids: The mode of action in bullous pemphigoid. Exp Dermatol 2017; 26:1253-1260. [PMID: 28771827 DOI: 10.1111/exd.13408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2017] [Indexed: 12/16/2022]
Abstract
Bullous pemphigoid (BP) is the most common of pemphigoid diseases caused by autoantibodies against the structures of dermoepidermal junction followed by complement activation, innate immune cell infiltration, neutrophil proteinase secretion and subepidermal blister formation. The first-line treatment of BP is topical and systemic glucocorticoids (GC). Regulation of the immune system and inflammatory cells is the main target of GC actions. GCs act through genomic and non-genomic mechanisms. The human glucocorticoid receptor (GR) mediates most of the biologic effects of GC: cytosolic GR binds GCs and is capable to bind to glucocorticoid response elements in DNA and either transactivate or transrepress genes depending on the tissue and cell type. In addition, GR exerts rapid, non-genomic effects possibly mediated by membrane-localized receptors or by translocation to mitochondria. GCs can also interact directly with several enzymes and cytokines. As a target treatment for BP, the production of autoantibodies should be discontinued. GCs, in spite of their wide immunosuppressive actions, are weak to stop immunoglobulin G (IgG) autoantibody formation. However, both systemic and topical GCs are able to reduce the clinical symptoms of BP. GCs are used to inhibit the secondary inflammation and symptoms, such as blistering and pruritus, and it is shown that GC treatment will gradually decrease also the autoantibody formation. Our review article analyses the mode of action of GC treatment in BP, as far it is possible due to paucity of modern immunological studies.
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Affiliation(s)
- Minna E Kubin
- PEDEGO Research Unit, Oulu Center for Cell-Matrix Research, Department of Dermatology and Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Lars Hellberg
- Institute for Medical Microbiology and Hygiene, University of Lübeck, Lübeck, Germany
| | - Riitta Palatsi
- PEDEGO Research Unit, Oulu Center for Cell-Matrix Research, Department of Dermatology and Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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34
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Chalmers JR, Wojnarowska F, Kirtschig G, Mason J, Childs M, Whitham D, Harman K, Chapman A, Walton S, Schmidt E, Godec TR, Nunn AJ, Williams HC. A randomised controlled trial to compare the safety, effectiveness and cost-effectiveness of doxycycline (200 mg/day) with that of oral prednisolone (0.5 mg/kg/day) for initial treatment of bullous pemphigoid: the Bullous Pemphigoid Steroids and Tetracyclines (BLISTER) trial. Health Technol Assess 2017; 21:1-90. [PMID: 28406394 DOI: 10.3310/hta21100] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune blistering skin disorder with increased morbidity and mortality in the elderly. OBJECTIVES To evaluate the effectiveness, safety and cost-effectiveness of a strategy of initiating BP treatment with oral doxycycline or oral prednisolone. We hypothesised that starting treatment with doxycycline gives acceptable short-term blister control while conferring long-term safety advantages over starting treatment with oral prednisolone. DESIGN Pragmatic multicentre two-armed parallel-group randomised controlled trial with an economic evaluation. SETTING A total of 54 dermatology secondary care centres in the UK and seven in Germany. PARTICIPANTS Adults with BP [three or more blisters at two sites and positive direct and/or indirect immunofluorescence (immunoglobulin G and/or complement component 3 immunofluorescence at the dermal-epidermal junction)] and able to give informed consent. INTERVENTIONS Participants were allocated using online randomisation to initial doxycycline treatment (200 mg/day) or prednisolone (0.5 mg/kg/day). Up to 30 g/week of potent topical corticosteroids was permitted for weeks 1-3. After 6 weeks, clinicians could switch treatments or alter the prednisolone dose as per normal practice. MAIN OUTCOME MEASURES Primary outcomes: (1) the proportion of participants with three or fewer blisters at 6 weeks (investigator blinded) and (2) the proportion with severe, life-threatening and fatal treatment-related events at 52 weeks. A regression model was used in the analysis adjusting for baseline disease severity, age and Karnofsky score, with missing data imputed. Secondary outcomes included the effectiveness of blister control after 6 weeks, relapses, related adverse events and quality of life. The economic evaluation involved bivariate regression of costs and quality-adjusted life-years (QALYs) from a NHS perspective. RESULTS In total, 132 patients were randomised to doxycycline and 121 to prednisolone. The mean patient age was 77.7 years and baseline severity was as follows: mild 31.6% (three to nine blisters), moderate 39.1% (10-30 blisters) and severe 29.3% (> 30 blisters). For those starting on doxycycline, 83 out of 112 (74.1%) had three or fewer blisters at 6 weeks, whereas for those starting on prednisolone 92 out of 101 (91.1%) had three or fewer blisters at 6 weeks, an adjusted difference of 18.6% in favour of prednisolone [90% confidence interval (CI) 11.1% to 26.1%], using a modified intention-to-treat (mITT) analysis. Per-protocol analysis showed similar results: 74.4% compared with 92.3%, an adjusted difference of 18.7% (90% CI 9.8% to 27.6%). The rate of related severe, life-threatening and fatal events at 52 weeks was 18.2% for those started on doxycycline and 36.6% for those started on prednisolone (mITT analysis), an adjusted difference of 19.0% (95% CI 7.9% to 30.1%; p = 0.001) in favour of doxycycline. Secondary outcomes showed consistent findings. There was no significant difference in costs or QALYs per patient at 1 year between doxycycline-initiated therapy and prednisolone-initiated therapy (incremental cost of doxycycline-initiated therapy £959, 95% CI -£24 to £1941; incremental QALYs of doxycycline-initiated therapy -0.024, 95% CI -0.088 to 0.041). Using a willingness-to-pay criterion of < £20,000 per QALY gained, the net monetary benefit associated with doxycycline-initiated therapy was negative but imprecise (-£1432, 95% CI -£3094 to £230). CONCLUSIONS A strategy of starting BP patients on doxycycline is non-inferior to standard treatment with oral prednisolone for short-term blister control and considerably safer in the long term. The limitations of the trial were the wide non-inferiority margin, the moderate dropout rate and that serious adverse event collection was unblinded. Future work might include inducing remission with topical or oral corticosteroids and then randomising to doxycycline or prednisolone for maintenance. TRIAL REGISTRATION Current Controlled Trials ISRCTN13704604. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | - Gudula Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - James Mason
- Durham University, School of Medicine, Pharmacy and Health, Stockton-on-Tees, UK
| | - Margaret Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | - Diane Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | - Karen Harman
- University Hospitals Leicester, Dermatology Department, Leicester Royal Infirmary, Leicester, UK
| | | | | | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Thomas R Godec
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Kremer N, Zeeli T, Sprecher E, Geller S. Failure of initial disease control in bullous pemphigoid: a retrospective study of hospitalized patients in a single tertiary center. Int J Dermatol 2017; 56:1010-1016. [PMID: 28856675 DOI: 10.1111/ijd.13736] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/20/2017] [Accepted: 07/22/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most prevalent autoimmune blistering skin disease in Western countries and in Israel. Initial disease control is achieved in 60-90% of BP patients within 1-4 weeks of corticosteroid therapy. In the remainder of patients, recalcitrant disease is controlled with additional immunosuppressive treatment. OBJECTIVES We aimed to evaluate the rate of BP patients who needed adjuvant therapy to achieve initial disease control and to identify potential predictors for recalcitrant disease. METHODS We conducted a retrospective study of newly diagnosed BP patients who were hospitalized at the Tel Aviv Sourasky Medical Center between the years 2008-2014. We performed statistical analyses to assess the association between clinical factors and failure of initial disease control. RESULTS Among 114 hospitalized patients with newly diagnosed BP, 1.8% presented with oral mucosa involvement. Seven patients (6.1%) required systemic agents in addition to corticosteroids to achieve disease control. Hypertension (P = 0.048), involvement of the head region (P = 0.042), and metformin treatment (P = 0.02) were significantly more prevalent among patients with recalcitrant disease. CONCLUSIONS The low frequency of recalcitrant BP (6.1%) and the rarity of involvement of the oral mucosa (1.8%) in this study suggest that Israeli BP patients present a milder phenotype compared to similar patients from other geographic areas. Hypertension, head involvement, and metformin therapy were found to be significantly associated with the need for adjuvant therapy to achieve initial control, suggesting that these parameters may serve as predictors of treatment response in BP.
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Affiliation(s)
- Noa Kremer
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Zeeli
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eli Sprecher
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shamir Geller
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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36
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Chun SH, Kim BY, Kim CM, Park JB, Ryu HJ. A Case of Wolf's Isotopic Response Presenting as Bullous Pemphigoid. Ann Dermatol 2017; 29:499-500. [PMID: 28761305 PMCID: PMC5500722 DOI: 10.5021/ad.2017.29.4.499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/25/2016] [Accepted: 08/04/2016] [Indexed: 11/08/2022] Open
Affiliation(s)
- Seung Hyun Chun
- Department of Dermatology, Korea University Ansan Hospital, College of Medicine, Korea University, Ansan, Korea
| | - Bo Young Kim
- Department of Dermatology, Korea University Ansan Hospital, College of Medicine, Korea University, Ansan, Korea
| | - Chang Min Kim
- Department of Dermatology, Korea University Ansan Hospital, College of Medicine, Korea University, Ansan, Korea
| | - Jae Beom Park
- Department of Dermatology, Korea University Ansan Hospital, College of Medicine, Korea University, Ansan, Korea
| | - Hwa Jung Ryu
- Department of Dermatology, Korea University Ansan Hospital, College of Medicine, Korea University, Ansan, Korea
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Abstract
Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease in Western countries, and typically affects the elderly. BP is immunologically characterized by tissue-bound and circulating autoantibodies directed against either the BP antigen 180 (BP180, or BPAG2) or the BP antigen 230 (BP230, or BPAG1e), or even both, which are components of hemidesmosomes involved in the dermal-epidermal cohesion. Risk factors for BP include old age, neurologic diseases (dementia, Parkinson's disease, cerebrovascular disease), and some particular drugs, including loop diuretics, spironolactone and neuroleptics. The spectrum of clinical presentations is extremely broad. Clinically, BP is an intensely pruritic erythematous eruption with widespread blister formation. In the early stages, or in atypical, non-bullous variants of the disease, only excoriated, eczematous or urticarial lesions (either localized or generalized) are present. The diagnosis of BP relies on immunopathologic findings, especially based on both direct and indirect immunofluorescence microscopy observations, as well as on anti-BP180/BP230 enzyme-linked immunosorbent assays (ELISAs). BP is usually a chronic disease, with spontaneous exacerbations and remissions, which may be accompanied by significant morbidity. In the past decade, potent topical corticosteroids have emerged as an effective and safe first-line treatment for BP, but their long-term feasibility is still controversial. Newer therapeutic agents targeting molecules involved in the inflammatory cascade associated with BP represent future alternatives to classical immunosuppressant drugs for maintenance therapy.
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Eosinophil Cationic Protein (ECP), a predictive marker of bullous pemphigoid severity and outcome. Sci Rep 2017; 7:4833. [PMID: 28684769 PMCID: PMC5500584 DOI: 10.1038/s41598-017-04687-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/18/2017] [Indexed: 12/29/2022] Open
Abstract
Bullous Pemphigoid (BP) is an inflammatory rare autoimmune bullous dermatosis, which outcome cannot be predicted through clinical investigations. Eosinophils are the main immune infiltrated cells in BP. However, the release of Major Basic Protein (MBP), Eosinophil Derived Neurotoxin (EDN), and Eosinophil Cationic Protein (ECP) upon eosinophil activation has still not been evaluated with respect to BP development. MBP, EDN and ECP were measured by ELISA in serum (n = 61) and blister fluid (n = 20) of patients with BP at baseline, and in serum after 2 months of treatment (n = 41). Eosinophil activation in BP patients was illustrated at baseline by significantly higher MBP, EDN and ECP serum concentrations as compared with control subjects (n = 20), but without distinction according to disease severity or outcome. EDN and ECP values were even higher in the blister fluids (P < 0.01 and P < 0.05, respectively), whereas MBP values were lower (P < 0.001). ECP serum concentration decreased after 60 days of treatment in BP patients with ongoing remission but not in patients who later relapsed (P < 0.05). A reduction of at least 12.8 ng/mL in ECP concentrations provided a positive predictive value for remission of 81%, showing that ECP serum variation could be a useful biomarker stratifying BP patients at risk of relapse.
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Liu YD, Wang YH, Ye YC, Zhao WL, Li L. Prognostic factors for mortality in patients with bullous pemphigoid: a meta-analysis. Arch Dermatol Res 2017; 309:335-347. [PMID: 28317060 PMCID: PMC5486568 DOI: 10.1007/s00403-017-1736-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/03/2017] [Accepted: 03/08/2017] [Indexed: 12/13/2022]
Abstract
Bullous pemphigoid (BP) is a chronic debilitating autoimmune blistering disease that frequently occurs in the elderly population. Previous studies have suggested a high morbidity and mortality associated with BP. However, relatively few studies have investigated prognostic factors of BP mortality, and they showed considerably various results. This meta-analysis aimed to quantitatively assess the association between several potential prognostic factors and risk of mortality in bullous pemphigoid. A comprehensive search was performed using Pubmed, Embase, and Cochrane Library. Cohort studies that assessed prognostic factors of BP mortality were included. Random-effects model was utilized to calculate the pooled hazard ratio (HR). Publication bias was evaluated qualitatively by constructing a funnel plot and quantitatively by conducting Egger's test. 14 studies were included comprising 2499 patients. Combined HRs suggested that advanced age (HR 1.63, 95% CI 1.34-1.97), presence of circulating antibodies (HR 1.77, 95% CI 1.20-2.62), concomitant dementia (HR 2.01, 95% CI 1.22-3.33), and concomitant stroke (HR 1.86, 95% CI 1.29-2.67) have an unfavorable impact on patient survival. Gender, disease extent, mucosal involvement, and indirect immunofluorescence result were not shown to be linked to mortality by our analysis. This study indicated that BP patients with older age, circulating antibodies, dementia, and stroke are at greater risk of mortality. Clinicians should be aware of this association and utilize this information in patient education and treatment process.
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Affiliation(s)
- Yi-Di Liu
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, 100730, China
| | - Yan-Hong Wang
- Department of Epidemiology and Bio-statistics, Institute of Basic Medical Sciences, China Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yi-Cong Ye
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, 100730, China
| | - Wen-Ling Zhao
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, 100730, China
| | - Li Li
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, 100730, China.
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Ali A, Hu L, Zhao F, Qiu W, Wang P, Ma X, Zhang Y, Chen L, Qian A. BPAG1, a distinctive role in skin and neurological diseases. Semin Cell Dev Biol 2017. [PMID: 28627382 DOI: 10.1016/j.semcdb.2017.06.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Spectraplakins are multifunctional cytoskeletal linker proteins that act as important communicators, connecting cytoskeletal components with each other and to cellular junctions. Bullous pemphigoid antigen 1 (BPAG1)/dystonin is a member of spectraplakin family and expressed in various tissues. Alternative splicing of BPAG1 gene produces various isoforms with unique structure and domains. BPAG1 plays crucial roles in numerous biological processes, such as cytoskeleton organization, cell polarization, cell adhesion, and cell migration as well as signaling transduction. Genetic mutation of BPAG1 isoforms is the miscreant of epidermolysis bullosa and multifarious, destructive neurological diseases. In this review, we summarize the recent advances of BPAG1's role in various biological processes and in skin and neurological diseases.
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Affiliation(s)
- Arshad Ali
- Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, Shaanxi 710072, PR China; Shenzhen Research Institution of Northwestern Polytechnical University, Shenzhen, 518057, PR China; Northwestern Polytechnical University-Hong Kong Baptist University Joint Research Centre for Translational Medicine on Musculoskeletal Health in Space, Xi'an, 710072, PR China
| | - Lifang Hu
- Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, Shaanxi 710072, PR China; Shenzhen Research Institution of Northwestern Polytechnical University, Shenzhen, 518057, PR China; Northwestern Polytechnical University-Hong Kong Baptist University Joint Research Centre for Translational Medicine on Musculoskeletal Health in Space, Xi'an, 710072, PR China
| | - Fan Zhao
- Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, Shaanxi 710072, PR China; Shenzhen Research Institution of Northwestern Polytechnical University, Shenzhen, 518057, PR China; Northwestern Polytechnical University-Hong Kong Baptist University Joint Research Centre for Translational Medicine on Musculoskeletal Health in Space, Xi'an, 710072, PR China
| | - Wuxia Qiu
- Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, Shaanxi 710072, PR China; Shenzhen Research Institution of Northwestern Polytechnical University, Shenzhen, 518057, PR China; Northwestern Polytechnical University-Hong Kong Baptist University Joint Research Centre for Translational Medicine on Musculoskeletal Health in Space, Xi'an, 710072, PR China
| | - Pai Wang
- Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, Shaanxi 710072, PR China; Shenzhen Research Institution of Northwestern Polytechnical University, Shenzhen, 518057, PR China; Northwestern Polytechnical University-Hong Kong Baptist University Joint Research Centre for Translational Medicine on Musculoskeletal Health in Space, Xi'an, 710072, PR China
| | - Xiaoli Ma
- Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, Shaanxi 710072, PR China; Shenzhen Research Institution of Northwestern Polytechnical University, Shenzhen, 518057, PR China; Northwestern Polytechnical University-Hong Kong Baptist University Joint Research Centre for Translational Medicine on Musculoskeletal Health in Space, Xi'an, 710072, PR China
| | - Yan Zhang
- Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, Shaanxi 710072, PR China; Shenzhen Research Institution of Northwestern Polytechnical University, Shenzhen, 518057, PR China; Northwestern Polytechnical University-Hong Kong Baptist University Joint Research Centre for Translational Medicine on Musculoskeletal Health in Space, Xi'an, 710072, PR China
| | - Lei Chen
- Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, Shaanxi 710072, PR China; Shenzhen Research Institution of Northwestern Polytechnical University, Shenzhen, 518057, PR China; Northwestern Polytechnical University-Hong Kong Baptist University Joint Research Centre for Translational Medicine on Musculoskeletal Health in Space, Xi'an, 710072, PR China
| | - Airong Qian
- Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, Shaanxi 710072, PR China; Shenzhen Research Institution of Northwestern Polytechnical University, Shenzhen, 518057, PR China; Northwestern Polytechnical University-Hong Kong Baptist University Joint Research Centre for Translational Medicine on Musculoskeletal Health in Space, Xi'an, 710072, PR China.
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41
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Frequency of Neurological Disorders in Bullous Pemphigoid Patients: A Cross-Sectional Study. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2017. [PMID: 28630891 PMCID: PMC5463116 DOI: 10.1155/2017/6053267] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Bullous pemphigoid (BP) is an autoimmune subepidermal blistering skin disorder which occurs mostly in the elderly. Several studies have reported an association between BP and neurological disorders (ND). Objective The purpose of this study was to evaluate the association between BP and neurological disorders in Iranian patients. Methods In this cross-sectional study, 87 patients with BP were enrolled. They were compared to 184 controls. Statistical analysis was done by SPSS statistical software version 19. Results Out of 87 patients with BP, 17 (19.5%) had at least one neurological disease. Cerebrovascular accident (CVA) was the most common neurological disease that was seen in 7 patients (8.0%) in the case group and 4 (2.1%) in the control group. The incidence of CVA was significantly different between BP patients and the control group (P = 0.022). Dementia was observed in 6 patients in the case group (16.8%) and 2 (1.0%) in the control group. The incidence of dementia was significantly different between BP patients and the control group (P = 0.008). In this study, the incidences of Parkinson's disease (P = 0.830), epilepsy (P = 0.067), and multiple sclerosis (P = 0.326) were not statistically significant between the two groups. Conclusion The incidence of CVA and dementia in patients with BP compared to the control group was significantly higher.
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Bağcı IS, Horváth ON, Ruzicka T, Sárdy M. Bullous pemphigoid. Autoimmun Rev 2017; 16:445-455. [DOI: 10.1016/j.autrev.2017.03.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 11/27/2022]
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Hentati-Kallel M, Le Jan S, Bernard P, Antonicelli F, Trussardi-Régnier A. Histone deacetylases meet microRNA-associated MMP-9 expression regulation in glucocorticoid-sensitive and -resistant cell lines. Int J Oncol 2016; 50:717-726. [DOI: 10.3892/ijo.2016.3830] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 11/21/2016] [Indexed: 11/05/2022] Open
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Schneiderbauer R, Martinache S, Engstner M, Enk AH, Hadaschik EN. Correlation of autoantibodies against BP180/BP230 in response to topical corticosteroids in patients with bullous pemphigoid. Dermatol Ther 2016; 29:419-423. [PMID: 27550573 DOI: 10.1111/dth.12403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Topical steroids are effective in treating bullous pemphigoid (BP). Autoantibodies against BP180 are related to disease activity, but correlation of these autoantibodies with response to topical steroid therapy has not yet been clearly evaluated. We investigate the usefulness of close and early monitoring of autoantibodies against BP180 and BP230 for assessment of response to therapy and early detection of therapeutic failure in BP patients treated topically. In eight BP patients under treatment with topical or systemic steroid therapy we retrospectively evaluated clinical course and autoantibodies against BP180 and BP230 as well as indirect immunofluorescence titres (IIF). Data were included at diagnosis, during hospitalization and follow-ups. Autoantibodies against BP180 parallel disease activity in all topically and as well as systemically treated patients. Autoantibodies against BP230 correlated in five out of eight patients. Autoantibodies directed against BP180 and, to a lesser degree, against BP230 correlate with the clinical course of topically treated BP patients. Monitoring autoantibodies against BP180 is a useful tool to evaluate the efficacy of topical therapy in BP.
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Affiliation(s)
| | | | - Monika Engstner
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Eva N Hadaschik
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
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Riani M, Le Jan S, Plée J, Durlach A, Le Naour R, Haegeman G, Bernard P, Antonicelli F. Bullous pemphigoid outcome is associated with CXCL10-induced matrix metalloproteinase 9 secretion from monocytes and neutrophils but not lymphocytes. J Allergy Clin Immunol 2016; 139:863-872.e3. [PMID: 27637385 DOI: 10.1016/j.jaci.2016.08.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 06/24/2016] [Accepted: 08/08/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The outcome of bullous pemphigoid (BP), the most frequent autoimmune skin-blistering disease, involves matrix metalloproteinase 9 (MMP-9), IL-17, and IL-23 release from infiltrated inflammatory cells. The chemokine CXCL10 has been associated with several autoimmune diseases, but its participation in BP pathophysiology still needs to be clarified. OBJECTIVE We sought to assess whether BP outcome was associated with different CXCL10 levels and to evaluate the contribution of CXCL10 to the described cytokine/protease inflammatory loop associated with disease outcome. METHODS Skin biopsy specimens (n = 16), serum (n = 114), blister fluid (n = 23), and primary inflammatory cells from patients with BP were used to investigate CXCL10 expression and function. RESULTS At baseline, both resident cells, such as keratinocytes and fibroblasts, and infiltrating immune cells expressed CXCL10 at lesional sites in skin of patients with BP. CXCL10 levels were higher in blister fluid (P < .0001) and serum (P < .005) from patients with BP than in serum from age- and sex-matched control subjects (n = 34). Furthermore, CXCL10 serum levels increased at day 60 only in patients who relapsed within the first year of treatment (n = 33, P < .005). Interestingly, CXCL10 expression could be upregulated by itself and IL-17 in inflammatory cells. Notably, neutrophils and monocytes from patients with BP, but not lymphocytes, responded to CXCL10 by increasing MMP-9 secretion through the activation of extracellular signal-regulated kinase 1/2, p38, phosphoinositide-3 kinase signaling pathways. Finally, CXCL10-increased MMP-9 secretion was inhibited by methylprednisolone and also by compound A, a novel nonsteroidal glucocorticoid receptor ligand. CONCLUSION We showed that increased levels of inflammatory biomarkers in patients with BP, such as CXCL10, favor neutrophil- and monocyte-associated MMP-9 release and disease relapse and opened new therapeutic horizons in patients with this autoimmune disease.
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Affiliation(s)
- Meriem Riani
- Laboratory of Dermatology, EA7319 Derm-I-C, University of Reims-Champagne-Ardenne, Reims, France
| | - Sébastien Le Jan
- Laboratory of Dermatology, EA7319 Derm-I-C, University of Reims-Champagne-Ardenne, Reims, France
| | - Julie Plée
- Laboratory of Dermatology, EA7319 Derm-I-C, University of Reims-Champagne-Ardenne, Reims, France; Department of Dermatology, University Hospital, University of Reims-Champagne-Ardenne, Reims, France
| | - Anne Durlach
- Laboratory Pol Bouin, Hospital Maison Blanche, University Hospital, Reims, France
| | - Richard Le Naour
- Laboratory IMAB, EA4683, University of Reims-Champagne-Ardenne, Reims, France
| | | | - Philippe Bernard
- Laboratory of Dermatology, EA7319 Derm-I-C, University of Reims-Champagne-Ardenne, Reims, France; Department of Dermatology, University Hospital, University of Reims-Champagne-Ardenne, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, EA7319 Derm-I-C, University of Reims-Champagne-Ardenne, Reims, France; Department of Dermatology, University Hospital, University of Reims-Champagne-Ardenne, Reims, France.
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46
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Lee J, Kim T, Park S, Han K, Kim SC. Prognostic clinical factors associated with remission and relapse in bullous pemphigoid. J Eur Acad Dermatol Venereol 2016; 31:81-84. [DOI: 10.1111/jdv.13839] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/18/2016] [Indexed: 01/01/2023]
Affiliation(s)
- J.H. Lee
- Department of Dermatology; Gangnam Severance Hospital; Cutaneous Biology Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - T.H. Kim
- Department of Dermatology; Gangnam Severance Hospital; Cutaneous Biology Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - S.H. Park
- Department of Dermatology; Gangnam Severance Hospital; Cutaneous Biology Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - K. Han
- Department of Dermatology; Gangnam Severance Hospital; Cutaneous Biology Research Institute; Yonsei University College of Medicine; Seoul Korea
- Biostatistics Collaboration Unit; Gangnam Medical Research Center; Yonsei university College of Medicine; Seoul Korea
| | - S.-C. Kim
- Department of Dermatology; Gangnam Severance Hospital; Cutaneous Biology Research Institute; Yonsei University College of Medicine; Seoul Korea
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47
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Zhao CY, Murrell DF. Approach and Management of Autoimmune Blistering Diseases. CURRENT DERMATOLOGY REPORTS 2016. [DOI: 10.1007/s13671-016-0140-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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48
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Chevalier V, Barbe C, Reguiai Z, Plée J, Grange F, Bernard P. [Impact of neurological diseases on the prognosis of bullous pemphigoid: A retrospective study of 178 patients]. Ann Dermatol Venereol 2016; 143:179-86. [PMID: 26831943 DOI: 10.1016/j.annder.2015.12.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 10/23/2015] [Accepted: 12/17/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) mainly affects elderly patients. It is often associated with neurological disorders, which constitute a major risk factor of the disease. The aim of our study was to determine whether neurological disorders, particularly dementia, influence outcome and mortality in BP patients. PATIENTS AND METHODS We conducted a retrospective study of all patients with BP seen in our dermatology department consecutively between 1997 and 2011. Clinical, immunological and therapeutic data, number of relapses and survival status were compared according to the presence at diagnosis of neurological disorders, particularly dementia. RESULTS Among the 178 patients included, an associated neurological disease was present in 84 (47.2%) and dementia in 43 (24.2%) at the time of diagnosis of BP. Patients with associated dementia were older and had a lower Karnofsky index. Sixty-four patients (37.8%) had had at least one clinical relapse of BP, chiefly within the first 18 months after starting therapy. Coexistent neurological disease was not associated with BP relapse (P=0.55) contrary to an extensive BP phenotype at diagnosis (P=0.008). Coexistent neurological disease and/or dementia were associated with higher mortality (P=0.03 and P<0.001, respectively), but did not modify the type or the total duration of BP treatment. CONCLUSION A coexistent neurological disease or dementia at the time of diagnosis of BP significantly increase the risk of mortality and shortens the duration of clinical follow-up of patients with BP, thus limiting the analysis of their influence on the outcome of BP itself.
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Affiliation(s)
- V Chevalier
- Service de dermatologie, hôpital Robert-Debré, avenue du Général-Koenig, 51092 Reims cedex, France
| | - C Barbe
- Département de recherche clinique, hôpital Robert-Debré, avenue du Général-Koenig, 51092 Reims cedex, France
| | - Z Reguiai
- Service de dermatologie, hôpital Robert-Debré, avenue du Général-Koenig, 51092 Reims cedex, France
| | - J Plée
- Service de dermatologie, hôpital Robert-Debré, avenue du Général-Koenig, 51092 Reims cedex, France
| | - F Grange
- Service de dermatologie, hôpital Robert-Debré, avenue du Général-Koenig, 51092 Reims cedex, France
| | - P Bernard
- Service de dermatologie, hôpital Robert-Debré, avenue du Général-Koenig, 51092 Reims cedex, France.
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Integrating longitudinal serum IL-17 and IL-23 follow-up, along with autoantibodies variation, contributes to predict bullous pemphigoid outcome. Sci Rep 2015; 5:18001. [PMID: 26656739 PMCID: PMC4677293 DOI: 10.1038/srep18001] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 11/09/2015] [Indexed: 12/17/2022] Open
Abstract
Bullous pemphigoid (BP) is an inflammatory autoimmune bullous disease involving cytokines and proteases in the process of blister formation. Recently, IL-17 and IL-23 were evidenced in lesional skin and serum of BP patients at time of diagnosis, but their involvement in disease outcome has still not been investigated yet. We then analysed IL-17 and IL-23 serum levels during the first months of follow-up upon treatment. Compared with age- and sex- matched controls, high levels of IL-23 were observed at baseline in BP patients serum (P < 0.01), while IL-17 levels was not. However, some BP patients expressed high IL-17 serum level, independently of disease severity. In these patients, those with ongoing remission reduced IL-17 concentration upon treatment (P < 0.001), whereas IL-17 level remained elevated in patients who relapsed. Meanwhile, IL-23 serum levels increased during the first month of treatment in BP patients who later relapsed (P < 0.01) and MMP-9 serum level was not controlled. Accordingly, we found that both IL-17 and IL-23 increased MMP-9 secretion from leukocytes in-vitro. Then, we showed that elevated IL-17/IL-23 serum concentrations helped to discriminate BP patients who later relapsed. Such uncontrolled inflammatory response raises the question whether these molecules could become biological target for BP patients resistant to steroid treatment.
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50
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Künzli K, Favre B, Chofflon M, Borradori L. One gene but different proteins and diseases: the complexity of dystonin and bullous pemphigoid antigen 1. Exp Dermatol 2015; 25:10-6. [DOI: 10.1111/exd.12877] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2015] [Indexed: 12/16/2022]
Affiliation(s)
- Kseniia Künzli
- Department of Dermatology; Inselspital; Bern University Hospital; Bern Switzerland
| | - Bertrand Favre
- Department of Dermatology; Inselspital; Bern University Hospital; Bern Switzerland
| | - Michel Chofflon
- Department of Clinical Neurosciences; Geneva University Hospitals; Geneva Switzerland
| | - Luca Borradori
- Department of Dermatology; Inselspital; Bern University Hospital; Bern Switzerland
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