Evaluation of Dupilumab in Patients With Bullous Pemphigoid

Type 2 Inflammation and Its Role in Dermatologic Diseases

Atopic dermatitis, prurigo nodularis, and chronic spontaneous urticaria are immune-mediated, inflammatory skin conditions characterized by intense itch and disease-specific skin lesions. Despite their different clinical presentations, the three diseases are unified by an aberrant type 2 immune response involving type 2 cytokines, immune cells, and sensory nerves that may underlie their shared clinical manifestations of inflammation and pruritus. The chronic nature of these conditions is associated with significant impairment in patients' quality of life and psychological disorders, such as anxiety and depression. This article reviews type 2 inflammation and its role in atopic dermatitis, prurigo nodularis, and chronic spontaneous urticaria, focusing on the pathophysiologic drivers of type 2 inflammation in each dermatologic condition. Understanding the shared immune mechanisms that underlie these seemingly distinct skin diseases and other concomitant inflammatory conditions is critical for applying therapeutic interventions targeting the type 2 immune pathway.

Autoimmune bullous diseases: pathogenesis and clinical management

Autoimmune bullous diseases (AIBDs) represent a heterogeneous group of immune-mediated disorders characterized by life-threatening blistering of the skin and mucous membranes. This Review synthesizes current understanding of AIBD pathogenesis, clinical phenotypes, diagnostic approaches, and therapeutic strategies, emphasizing recent advancements and translational opportunities. At the core of AIBDs is autoantibody-mediated disruption of structural proteins in the epidermis or basement membrane zone, particularly at desmosomal and hemidesmosomal junctions. Key subtypes, including pemphigus, paraneoplastic pemphigus, pemphigoid, and IgA-related diseases, are distinguished by their target antigens, clinical manifestations, and immunopathological profiles. Diagnostic workflows rely on direct immunofluorescence, and serological assays, yet subtype differentiation remains challenging due to overlapping features. Traditional therapies, such as systemic corticosteroids and immunosuppressants, have improved outcomes but are limited by toxicity. Recent breakthroughs highlight targeted interventions, including B-cell depletion with rituximab, cytokine modulation via dupilumab, and JAK inhibitors for inflammatory pathways. Innovative strategies like chimeric autoantibody receptor T-cell (CAART) therapy further address refractory cases by eliminating autoreactive B cells. Additionally, the Review underscores the emerging role of inflammation-driven mechanisms and the necessity of multidisciplinary care, given AIBDs' associations with malignancies, autoimmune comorbidities. Despite progress, challenges persist in early diagnosis, personalized therapy optimization, and understanding antigen-specific immune responses. Future directions include refining diagnostic biomarkers, exploring novel targets, and developing precision medicine approaches.

Clinical Outcomes and Prognostic Factors in Bullous Pemphigoid Patients: A 15-Year Review in China

BACKGROUND

There are limited data on clinical outcomes and prognosis factors for bullous pemphigoid (BP) at long-term follow-up.

OBJECTIVE

We aimed to investigate the clinical outcomes and prognostic factors in BP patients.

METHODS

This retrospective study was performed between January 1, 2009 and December 31, 2023 in Shandong Province, China. The primary outcomes were the rates and predictive factors of mortality, complete remission off-therapy (CROT), and relapse by Cox proportional hazards models or logistic regression analyses. Nomograms for BP mortality and CROT were also described.

RESULTS

Of the 1063 BP patients enrolled, 45 were excluded due to loss to follow-up. The cohort comprised 1018 BP patients to analyze. A total of 344 (33.8%) patients died, with cumulative 1-, 3-, and 5-year mortality rates of 22.8%, 31.2%, and 34.5%, respectively. Increased age at onset (HR = 1.08), body surface area (BSA) involvement 10-30%, BSA involvement > 30% (HR = 7.19; HR = 9.84, respectively), double-positive IgG and C3 on DIF (HR = 1.37), and systemic corticosteroid in combination  with immunosuppressants treatments (HR = 0.50) were associated with mortality. A total of 321 (31.5%) patients achieved CROT. Cumulative CROT rates at 1, 3, and 5 years were 10.9%, 32.9%, and 47.5%, respectively. Shorter diagnosis delay time (HR = 1.01), baseline anti-BP180 antibody < 50 IU/mL (HR = 1.48) and systemic drugs other than corticosteroid treatment (HR = 1.68) were associated with CROT. Predictive models demonstrated outstanding performance in classifying mortality at 1, 3, and 5 years (AUCs 0.83, 0.86, 0.88), but moderate classification for CROT (AUCs 0.67, 0.62, 0.63). A total of 749 (73.6%) patients experienced relapses.

CONCLUSIONS

This study, the first large cohort to examine long-term outcomes in BP patients, identifies risk factors for mortality and CROT, offering key insights for clinicians to improve prognosis and reduce relapse rates.

Effectiveness of Dupilumab and Omalizumab in Bullous Pemphigoid: A Nationwide Retrospective Cohort Study

Bullous pemphigoid (BP) is the most common autoimmune blistering skin disease worldwide. In the difficult-to-treat BP or if standard therapies are contraindicated, the use of biologics may be also considered although there is no strong evidence supporting their use. This study aimed to investigate clinical and diagnostic findings as well as treatment outcomes among patients diagnosed with BP and undergoing omalizumab or dupilumab in a real-world setting. A multicenter retrospective cohort study was performed across 15 Italian tertiary referral hospital. Medical records of 2435 BP patients were screened, identifying 58 (2.3%) Caucasian patients who met the inclusion criteria. Within this study population, 39 (67.2%) were treated with dupilumab and 19 (32.8%) received omalizumab. Disease control was achieved in 90.6% of dupilumab-treated patients and complete remission on minimal therapy was observed in 71.0%. Omalizumab-treated patients achieved disease control in 77.8% of cases and 64.7% obtained complete remission on minimal therapy. Log-rank test comparing relapse rate between treatment groups was not significant (p = 0.58). Finally, parameter estimates associated with the fixed effect of time were consistently negative, indicating a generally significant (p = < 0.05) decrease in scores over time for patients treated with both biologics. This cohort of patients undergoing dupilumab or omalizumab adds to the existing evidence concerning the effectiveness of biologic agents in BP. Both biologics seem to be promising treatment adjuvants in the management of BP, with dupilumab showing a descriptive trend toward better outcomes.

JAK-STAT pathway, type I/II cytokines, and new potential therapeutic strategy for autoimmune bullous diseases: update on pemphigus vulgaris and bullous pemphigoid

Autoimmune Bullous Diseases (AIBDs), characterized by the formation of blisters due to autoantibodies targeting structural proteins, pose significant therapeutic challenges. Current treatments, often involving glucocorticoids or traditional immunosuppressants, are limited by their non-specificity and side effects. Cytokines play a pivotal role in AIBDs pathogenesis by driving inflammation and immune responses. The JAK-STAT pathway is central to the biological effects of various type I and II cytokines, making it an attractive therapeutic target. Preliminary reports suggest that JAK inhibitors may be a promising approach in PV and BP, but further clinical validation is required. In AIBDs, particularly bullous pemphigoid (BP) and pemphigus vulgaris (PV), JAK inhibitors have shown promise in modulating pathogenic cytokine signaling. However, the safety and selectivity of JAK inhibitors remain critical considerations, with the potential for adverse effects and the need for tailored treatment strategies. This review explores the role of cytokines and the JAK-STAT pathway in BP and PV, evaluating the therapeutic potential and challenges associated with JAK inhibitors in managing these complex disorders.

Eosinophil extracellular traps drive T follicular helper cell differentiation via VIRMA-dependent MAF stabilization in bullous pemphigoid

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune blistering disease characterized by the presence of pathogenic autoantibodies and a substantial influx of immune cells into skin lesions. However, the role of eosinophils in BP remains inadequately elucidated.

OBJECTIVE

We sought to determine the pathologic involvement of eosinophils and eosinophil extracellular traps (EETs) in BP.

METHODS

Human samples collected from BP patients and healthy controls were utilized to explore the potential role of eosinophils and their EETs in BP patients through serologic detection, flow cytometry, and immunofluorescence. Naive CD4+ T cells isolated from healthy donors were stimulated and subjected to further analysis via RNA sequencing. We additionally evaluated the potential of targeting EETs in BP180-immunized BP-like mice and in in vitro settings.

RESULTS

We found that elevated levels of eosinophils and EETs in BP patients correlated with disease severity. The DNA components within EETs played a crucial role in driving the differentiation of naive CD4+ T cells into follicular helper T (Tfh) cells by activating coil domains containing 25 (CCDC25). Treatment with DNase I, which disrupts the structural integrity of EETs, or neutralizing antibody against CCDC25 reduced the expansion of Tfh cells and suppressed the production of autoantibodies in BP180-immunized BP-like mouse models. Additionally, we discovered that EETs induced the N6-methyladenosine methylation of the transcription factor musculoaponeurotic fibrosarcoma (MAF) via the DNA-CCDC25-VIRMA pathway, thereby enhancing its mRNA stability and promoting Tfh cell differentiation.

CONCLUSION

Our study revealed a previously unrecognized mechanism by which EETs trigger abnormal Tfh cell differentiation through CCDC25, followed by Vir-like m6A methyltransferase-associated protein (VIRMA)-mediated N6-methyladenosine modification of MAF. These insights provide promising avenues for the development of targeted therapeutic interventions in the field of BP and potentially other autoimmune diseases.

Efficacy and safety of dupilumab in patients with moderate-to-severe bullous pemphigoid: a systematic review and meta-analysis

OBJECTIVE

Evaluate the safety and efficacy of dupilumab in treating moderate-to-severe bullous pemphigoid.

METHODS

The authors performed a systematic review and meta-analysis of comparative studies of Dupilumab combined with corticosteroids and conventional corticosteroid therapy alone in patients with moderate-to-severe bullous pemphigoid. PubMed, Embase and Cochrane databases were searched for studies published up to December 2023. Data were extracted from published reports and quality assessment was performed according to Cochrane recommendations.

RESULTS

A total of four studies involving 127 patients were included, of which 53 received Dupilumab combined with corticosteroids, while the other 74 were administered corticosteroids alone. Regarding efficacy, Dupilumab the time before new blister formation stopped (MD = -5.13 days; 95% CI -7.12 to -3.15; p < 0.0001) and demonstrated a greater reduction in Bullous Pemphigoid Disease Area Index (MD = -3.90; 95% CI -5.52 to -2.27; p < 0.0001) and Numeric Rating Scale for Pruritus (SMD = -1.37; 95% CI -2.02 to -0.72; p < 0.0001) compared with patients who received conventional therapy. However safety endpoints, adverse events (RR = 0.78; 95% CI 0.58 to 1.05; p = 0.10) and relapses (RR = 0.50; 95% CI 0.19 to 1.36; p = 0.17) showed no significance. The main limitations were retrospective studies with small samples and limited results in clinical practice and a moderate overall risk of bias.

CONCLUSION

Compared with conventional therapy, Dupilumab decreased the time before new blister formation stopped in 5.13 days, as well as Disease Area Index and Pruritus, without interfering with adverse events and relapse.

Pemphigoid disease model systems for clinical translation

Pemphigoid diseases constitute a group of organ-specific autoimmune diseases characterized and caused by autoantibodies targeting autoantigens expressed in the skin and mucous membranes. Current therapeutic options are still based on unspecific immunosuppression that is associated with severe adverse events. Biologics, targeting the IL4-pathway or IgE are expected to change the treatment landscape of pemphigoid diseases. However, clinical studies demonstrated that targeting these pathways alone is most likely not sufficient to meet patient and healthcare partitioners expectations. Hence, model systems are needed to identify and validate novel therapeutic targets in pemphigoid diseases. These include pre-clinical animal models, in vitro and ex vivo model systems, hypothesis-driven drug repurposing, as well as exploitation of real-world-data. In this review, we will highlight the medical need for pemphigoid diseases, and in-depth discuss the advantages and disadvantages of the available pemphigoid disease model systems. Ultimately, we discuss how rapid translation can be achieved for the benefit of the patients.

Dupilumab, corticosteroids and their combination for the treatment of bullous pemphigoid

BACKGROUND

Conventional systemic corticosteroid therapy for bullous pemphigoid (BP) has been challenged due to severe adverse events. Dupilumab has emerged as an alternative therapeutical option of BP patients.

OBJECTIVES

To evaluate the efficacy of dupilumab monotherapy and the combination with medium/low-dose corticosteroids for BP treatment.

METHODS

Thirteen, twenty-four and thirty-two BP patients treated with Dupilumab monotherapy (Dupi group), dupilumab combined with corticosteroids (Dupi + CS group), and corticosteroid monotherapy (CS group), respectively, were retrospectively analyzed for various clinical and laboratory parameters.

RESULTS

In the Dupi group, the total Bullous Pemphigoid Disease Area Index (BPDAI) Total, Erosion/Blister, Urticaria/Erythema and Itching NRS scores were all reduced significantly after 2-4 weeks of treatment, but the BPDAI Mucosal Score was not changed significantly at the end of the overextended time of treatment. All the above clinical parameters and many laboratory parameters (including the serum anti-BP180 autoantibodies [IgG] level, blood eosinophil count, and percentage) were significantly reduced in both Dupi + CS and CS groups after treatment, but no statistical differences were found in the reduction rates of these parameters between the two groups. However, the Dupi + CS group had less baseline dose and cumulative dosage of prednisone at the time of disease control, and fewer adverse effects were reported than the CS group.

STUDY LIMITATIONS

The retrospective design and small clinical sample size of the Dupi group.

CONCLUSIONS

For BP patients, dupilumab monotherapy based on the treatment of atopic dermatitis can significantly improve skin lesions and pruritus symptoms but may be ineffective for oral mucosal lesions. The combination of dupilumab and medium/low-dose corticosteroids can achieve the same effect of corticosteroid therapy with superior safety.

Bullous pemphigoid

Bullous pemphigoid is a chronic, subepidermal autoimmune blistering disease characterized by tense blisters on erythematous or normal skin that predominantly affects the older population. The disease arises from autoantibodies targeting hemidesmosomal proteins BP180 and BP230, which are crucial for dermal-epidermal adhesion. The incidence of bullous pemphigoid is increasing, attributed to an ageing population and improved diagnostic recognition. Genetic predisposition, environmental triggers and associations with other autoimmune disorders underline its multifactorial nature. Diagnosis involves clinical presentation, histopathology, direct immunofluorescence and serological tests. Treatment aims to reduce symptoms and prevent new blister formation, using corticosteroids, immunosuppressive agents and biologics such as rituximab and omalizumab. Despite therapeutic advancements, challenges persist in long-term management, especially in older patients with comorbidities. Ongoing research into molecular mechanisms and novel therapeutic targets and clinical trials are crucial for the development of safer and more effective treatments.

Real-world evaluation of the effectiveness and safety of dupilumab in bullous pemphigoid: an ambispective multicentre case series

BACKGROUND

Bullous pemphigoid (BP) affects elderly individuals with multiple comorbidities, making conventional treatments unsuitable.

OBJECTIVES

Evaluate the effectiveness and safety of dupilumab in the treatment of BP.

METHODS

A multicentre ambispective cohort study was conducted across 34 hospitals. Patients with BP treated with dupilumab were included. Most of the patients (97.1%) received an initial 600-mg dose followed by 300 mg every 2 weeks. The primary outcome was the proportion of patients achieving complete remission (CR) within 4 weeks, defined as an Investigator's Global Assessment score of 0 or 1. CR at weeks 16, 24 and 52, adverse events (AEs), reductions in Peak Pruritus Numerical Rating Scale (PP-NRS) and systemic glucocorticoid use were also assessed.

RESULTS

The study included 103 patients with a median age of 77.3 years; 58.3% were male. CR was achieved by 53.4% within 4 weeks and 95.7% by week 52. The PP-NRS score reduced by 70.0% by week 4 and was completely controlled by week 24. Thirteen patients presented with AEs, most of which were mild. Systemic glucocorticoid use reduced by 82.1% by week 52. Shorter disease duration and exclusive cutaneous involvement predicted better response at 16 weeks. No differences in response rates to dupilumab were observed between drug-associated BP and idiopathic cases. No significant difference in response rates was observed between patients treated with dupilumab in monotherapy and those receiving dupilumab with concomitant treatments.

CONCLUSIONS

Dupilumab is effective, rapid and safe in managing BP, reducing the need for corticosteroids and other treatments. Early initiation and exclusive skin involvement predict better outcomes.

Bullous pemphigoid: A practical approach to diagnosis and management in the modern era

Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disorder, primarily presenting with tense bullae and severe pruritus. Diagnosing and treating BP can be challenging due to its variable clinical presentations. We will briefly discuss these phenotypes, highlight diagnostic basics, and briefly summarize recent laboratory advancements that have improved diagnostic sensitivity and accuracy. The treatment landscape for BP has evolved significantly. Newer therapies, including biologics such as rituximab, omalizumab, dupilumab, and Janus kinase inhibitors target the immunopathogenesis of BP and can reduce the adverse effects associated with cumulative corticosteroid exposure and conventional immunosuppressants. This article provides a comprehensive overview of BP's clinical features, diagnostic approaches, and emerging therapeutic options, emphasizing personalized medicine, and improved patient outcomes.

Bullous pemphigoid burden of disease, management and unmet therapeutic needs

Bullous pemphigoid (BP) is an autoimmune blistering disease that can have a profound negative impact on quality of life. BP most often affects the elderly, a population with a high medical burden and special safety concerns. In this review, we outline the BP disease course, diagnosis, epidemiology and comorbidities, and describe tools commonly used to assess BP disease activity and severity and the impact of BP on health-related quality of life. We also outline biologic treatments currently under investigation for the treatment of BP and highlight the importance of considering safety when treating elderly patients.

Polarization of circulating follicular helper T cells correlates with bullous pemphigoid severity

BACKGROUND

Follicular helper T (Tfh) cells form a distinct population of T-helper cells with different polarizations (type 1, type 2 and type 17) that regulates humoral responses and may participate in the pathophysiology of B-cell-mediated autoimmune diseases such as bullous pemphigoid (BP), a dermatosis mediated by autoantibodies specific for hemi-desmosomal proteins.

OBJECTIVES

To evaluate the impact on circulating Tfh cells of super potent topical corticosteroid (TCS) treatment, which is more effective and safer than high doses of oral corticosteroids, and is the recommended first-line treatment of BP.

METHODS

Using flow cytometry, we compared the frequency, polarization and activation of Tfh cells in the blood of patients with BP with age- and sex-matched control participants without BP at baseline and longitudinally, after the initiation of TCS treatment.

RESULTS

We found that, at baseline, circulating Tfh cells were more frequent in patients with BP than in participants without BP and exhibited an activated phenotype. We further showed a decrease in type 1 and an increase in type 17 Tfh cells in the blood of patients with BP, which resulted in a higher type 2 + type 17 to type 1 Tfh cell ratio. This ratio correlated positively with disease severity, as measured by the Bullous Pemphigoid Disease Area Index. Remarkably, with TCS treatment, although the frequency of Tfh cells in patients with BP returned to a level similar to that of control participants, the activated phenotype persisted. Interestingly, serum interleukin-21 levels and the Tfh cell subset ratio, similarly to disease activity and serum anti-BP180 and anti-BP230 autoantibodies, decreased with TCS treatment.

CONCLUSIONS

Overall, our findings suggest the involvement Tfh cell polarization in the pathophysiology of BP and open the door to modulation of Tfh cell activity for treatment purposes.

Immune Checkpoint Inhibitor-Associated Cutaneous Adverse Events: Mechanisms of Occurrence

Immunotherapy, particularly that based on blocking checkpoint proteins in many tumors, including melanoma, Merkel cell carcinoma, non-small cell lung cancer (NSCLC), triple-negative breast (TNB cancer), renal cancer, and gastrointestinal and endometrial neoplasms, is a therapeutic alternative to chemotherapy. Immune checkpoint inhibitor (ICI)-based therapies have the potential to target different pathways leading to the destruction of cancer cells. Although ICIs are an effective treatment strategy for patients with highly immune-infiltrated cancers, the development of different adverse effects including cutaneous adverse effects during and after the treatment with ICIs is common. ICI-associated cutaneous adverse effects include mostly inflammatory and bullous dermatoses, as well as severe cutaneous side reactions such as rash or inflammatory dermatitis encompassing erythema multiforme; lichenoid, eczematous, psoriasiform, and morbilliform lesions; and palmoplantar erythrodysesthesia. The development of immunotherapy-related adverse effects is a consequence of ICIs' unique molecular action that is mainly mediated by the activation of cytotoxic CD4+/CD8+ T cells. ICI-associated cutaneous disorders are the most prevalent effects induced in response to anti-programmed cell death 1 (PD-1), anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), and anti-programmed cell death ligand 1 (PD-L1) agents. Herein, we will elucidate the mechanisms regulating the occurrence of cutaneous adverse effects following treatment with ICIs.

Immune modules to guide diagnosis and personalized treatment of inflammatory skin diseases

Previous advances have identified immune pathways associated with inflammatory skin diseases, leading to the development of targeted therapies. However, there is a lack of molecular approaches that delineate these pathways at the individual patient level for personalized diagnostic and therapeutic guidance. Here, we conduct a cross-comparison of expression profiles from multiple inflammatory skin diseases to identify gene modules defining relevant immune pathways. Seven modules are identified, representing key immune pathways: Th17, Th2, Th1, Type I IFNs, neutrophilic, macrophagic, and eosinophilic. These modules allow the development of a molecular map with high diagnostic efficacy for inflammatory skin diseases and clinico-pathologically undetermined cases. Aligning dominant modules with treatment targets offers a rational framework for treatment selection, improving response rates in both treatment-naïve patients and non-responders to targeted therapies. Overall, our approach offers precision medicine for inflammatory skin diseases, utilizing transcriptional modules to support diagnosis and guide personalized treatment selection.

Pathophysiology of Bullous Pemphigoid: Role of Type 2 Inflammation and Emerging Treatment Strategies (Narrative Review)

Bullous pemphigoid (BP) is an autoimmune blistering disease that most often affects elderly individuals and has a significant negative impact on quality of life. The disease is characterized primarily by autoantibodies to hemidesmosomal proteins BP180 and/or BP230, and an inflammatory reaction with notable features of type 2 inflammation, including elevated serum IgE, increased numbers of eosinophils in lesions and peripheral blood, and elevated expression of type 2 cytokines and chemokines in skin lesions. In this review, we present what is known about BP pathophysiology, including the role of type 2 inflammation, and discuss how findings from studies of biologics targeting type 2 immune mediators have helped to clarify the biological mechanisms driving BP pathophysiology. Future studies of these targeted therapies and others in development will help to further elucidate the mechanisms underlying BP pathophysiology and potentially provide better treatment options for patients.

Systemic Implications of Bullous Pemphigoid: Bridging Dermatology and Internal Medicine

Background: Bullous pemphigoid is an autoimmune bullous disease that frequently affects a large skin surface area, but it can also present in localized areas. It has been hypothesized that bullous pemphigoid affects the systemic functioning of different organs because inflammatory cells and cytokines circulate throughout numerous organs. Results: Recent clinical and experimental studies have revealed an association between bullous pemphigoid and systemic organ disorders. To avoid the emergence of systemic organ diseases, the significance of systemic treatment in cases of severe bullous pemphigoid should be emphasized. Conclusions: Here, we discuss the specific molecular processes underlying typical systemic organ inflammatory diseases associated with bullous pemphigoids.

Clinical Improvement of Bullous Pemphigoid with Hyperkeratosis and Palmoplantar Keratoderma in Two Patients Treated with Dupilumab

Abstract missing (Short communication)

Serum inflammatory biomarkers associated with disease severity and response to dupilumab treatment in bullous pemphigoid: A cluster analysis

BACKGROUND

Dupilumab, a novel therapy targeting the T helper (Th) 2-mediated inflammation, is showing clinical benefits in treating bullous pemphigoid (BP). However, limited research investigated the serum biomarkers that reflect the inflammation alterations throughout the disease course.

OBJECTIVES

To explore the changes of the serum inflammatory biomarkers under dupilumab therapy in BP and establish their correlations with disease severity and clinical outcomes.

METHODS

This exploratory study evaluated serum samples from 40 patients with BP at baseline, 30 of these patients following 16-week dupilumab therapy, and 20 senior healthy controls. Serum levels of 29 cytokines and chemokines were quantified using the Magnetic Luminex Assay.

RESULTS

Two distinct clusters based on serum inflammatory profiles were identified. The first cluster, characterized by elevated levels of inflammatory activation, exhibited worse disease severity and poorer remission outcomes. Following the 16-week dupilumab therapy regimen, a significant suppression of Th2-mediated inflammation in the serum was observed, alongside a relative upregulation of Th1 responses. Patients treated with adjuvant systemic steroids exhibited an enhanced suppression of B cell activating factor compared to those receiving dupilumab alone. Significant correlations were unveiled between Th2 biomarkers and clinical scores, eosinophil counts, and anti-BP180 immunoglobulin G levels. Baseline levels of CCL18, Periostin, interleukin (IL)-6, and IL-16 constitute an optimal combination to distinguish between inflammatory clusters.

CONCLUSIONS

Cluster analysis of serum inflammatory biomarkers provided novel insights into the heterogeneity of the inflammation profiles in BP. Baseline levels of CCL18, Periostin, IL-6, IL-16 emerged as effective predictors for disease severity and therapy response to dupilumab.

A case of bullous pemphigoid following administration of anti-IL-31 receptor A antibody

Bullous pemphigoid (BP), an autoimmune bullous dermatosis, occurs predominantly in older individuals. Nemolizumab, a humanized monoclonal antibody against the interleukin (IL)-31 receptor A, is used to treat severe atopic dermatitis (AD) in Japan. However, it can cause several adverse events, such as exacerbation of AD, erythema, and eosinophilia. Herein, we describe a case of prurigo-type AD developing BP after nemolizumab administration. A 62-year-old man with prurigo-type AD and asthma presented with serious, refractory itching. After nemolizumab injection, his pruritus was relieved for 2 days. However, on day 3, erythema with blisters and erosions suddenly appeared throughout his body. Pathological examination showed typical BP and the patient's serum anti-BP180-NC16a antibody level was 882.5 U/mL. Oral prednisolone (PSL) was initiated and nemolizumab was never used again. Despite high-dose PSL, new blisters continued to develop, with a rapid elevation of anti-BP180-NC16a antibodies to 6930 U/mL. Adding high-dose cyclosporine and intravenous gamma globulin reduced new blister formation after 9 weeks, and PSL and cyclosporine were gradually tapered. Dupilumab, an anti-IL-4 receptor antibody, was initiated after 16 weeks, resulting in continued remission without PSL and cyclosporine. The sudden occurrence of BP in this case suggested that the patient had occult BP before the nemolizumab initiation and that nemolizumab exacerbated BP and made it overt. Blocking the IL-31 pathway may exacerbate inflammation in AD or BP, resulting in the acceleration of blister formation. This may be countered by blocking the IL-4/13 pathway with dupilumab. To our knowledge, this is the first case of nemolizumab-exacerbated BP.

Serum Biomarkers in Bullous Pemphigoid: A Systematic Review

INTRODUCTION

Bullous pemphigoid (BP) is the most common type of subepidermal blistering disease, usually observed in the elderly population, with a mean age of presentation between 66 and 83 years. BP is a psychosocially ladened disease, with many patients experiencing negative body image, social isolation, and depression. The identification and validation of biomarkers in BP may further the understanding of disease pathogenesis, provide objective measures in assessing efficacy in clinical trials, and identify new targets for targeted therapy.

METHODS/RESULTS

Two databases (Medline and Embase) were searched from database inception to September 2023. All published articles reporting on biomarker levels of BP patients in serum compared to healthy controls were included. A total of 877 unique articles were identified, resulting in the inclusion of 62 case-control studies reporting on a total of 1837 patients and 140 unique biomarkers. Biomarkers were categorized into T-cell mediated, B-cell mediated, innate immune system, and coagulation cascade pathway. The most notable biomarkers identified include increases in anti-BP180/230 immunoglobulin (Ig)G/E, total IgE, TNF-α, B-cell activating factor, interleukin-31, eosinophil cationic protein, MMP-9, and coagulation cascade biomarker levels. The results of this review provide the greatest support for a role of anti-BP180/230 autoantibodies, Th2 cells, eosinophils, and the coagulation cascade in the pathogenesis of BP.

CONCLUSIONS

The pathogenesis of BP has an underlying autoimmune etiology centred around the production of autoantibodies against BP180/230, but increased Th2, eosinophil and coagulation cascade activity may be contributory.

Omalizumab and Dupilumab for the Treatment of Bullous Pemphigoid: A Systematic Review

Background: Bullous pemphigoid (BP) is an autoimmune disease characterized by the appearance of very pruritic subepidermal blisters. It appears mostly in the elderly and is associated with multiple comorbidities, which makes its management and treatment difficult. The purpose of this systematic review is to compile current information on published cases of BP treated with omalizumab (omalizumab) and dupilumab (dupilumab) in order to obtain information on clinical efficacy and safety data available. Methods: A literature search of all cases of BP treated with omalizumab/dupilumab published in the literature up to January 2024 was performed using the Pubmed database. After an exhaustive search, a total of 61 studies encompassing 886 patients met the inclusion criteria and were included in the review. Results: The majority of patients with BP treated with omalizumab/dupilumab presented a significant improvement in symptomatology, being very safe drugs with minimal side effects. The main limitation of the presented review is the quality of the included studies, most of them being case series or individual cases. The development of studies with a higher level of scientific evidence in the near future would be of great interest. Conclusions: Both omalizumab and dupilumab appear to be effective options for treating BP in patients refractory to other pharmacological therapies. They are drugs with a good safety profile and the adverse reactions associated with their use are infrequent and generally mild.

Case report: Dupilumab: a promising treatment option for adult linear IgA bullous dermatosis with severe pruritus

Linear IgA bullous dermatosis (LABD) is an acquired autoimmune subepidermal blistering disorder. Diagnosis always relies on skin pathology and direct immunofluorescence (DIF), with typical linear deposits of IgA along the basement membrane zone (BMZ). The typical clinical manifestation is tense bullae arranged like the "string of pearls" companied with severe pruritus. Dapsone is often considered first-line therapy for LABD, and it is necessary to test the HLA-B*1301 gene to prevent the occurrence of dapsone-induced hypersensitivity syndrome (DHS). Here we report a case of LABD resistant to corticosteroid and sulfasalazine, while waiting for HLA-B*1301 gene test results, dupilumab was used to control severe pruritus.

Fast Itch Relief during Dupilumab Predicts Clinical Efficacy in Bullous Pemphigoid: A Retrospective Cohort Study

INTRODUCTION

Dupilumab has emerged as a promising treatment option for bullous pemphigoid (BP). Rapid identification of responders could avoid the need for additional immunosuppressive treatments that are associated with increased morbidity and mortality.

METHODS

To investigate the course of itch as an early indicator of treatment response, data of 12 BP patients treated with dupilumab at the University Hospital of Zurich were retrospectively evaluated. Disease severity was assessed by bullous pemphigoid disease area index (BPDAI) and pruritus by a numeric rating scale (NRS, 0-10) at baseline; days 1, 3, 14; months 1, 2; and the last follow-up.

RESULTS

A total of 8/12 patients (67%) had complete response, and 4/12 patients (33%) had partial response during dupilumab treatment. Notably, a highly significant reduction of pruritus (p < 0.0001) was observed already on day 1 with further improvement at later time points. Moreover, fast relief of itch could predict treatment response with a significant correlation to clinical response on day 14 (Spearman correlation R 0.70, p value 0.025), with a positive but non-significant trend on day 3 (R 0.63, p value 0.091). Additionally, 92% (11/12 patients) were on dupilumab monotherapy at the last follow-up without any concomitant systemic or topical treatment for BP.

CONCLUSIONS

The rapid and significant decline in BP-associated pruritus observed with dupilumab correlated significantly with disease remission. Early evaluation of pruritus response could change how BP is treated in the future and avoid additional immunosuppressive treatment in BP.

Single-cell transcriptomics analysis of bullous pemphigoid unveils immune-stromal crosstalk in type 2 inflammatory disease

Bullous pemphigoid (BP) is a type 2 inflammation- and immunity-driven skin disease, yet a comprehensive understanding of the immune landscape, particularly immune-stromal crosstalk in BP, remains elusive. Herein, using single-cell RNA sequencing (scRNA-seq) and in vitro functional analyzes, we pinpoint Th2 cells, dendritic cells (DCs), and fibroblasts as crucial cell populations. The IL13-IL13RA1 ligand-receptor pair is identified as the most significant mediator of immune-stromal crosstalk in BP. Notably, fibroblasts and DCs expressing IL13RA1 respond to IL13-secreting Th2 cells, thereby amplifying Th2 cell-mediated cascade responses, which occurs through the specific upregulation of PLA2G2A in fibroblasts and CCL17 in myeloid cells, creating a positive feedback loop integral to immune-stromal crosstalk. Furthermore, PLA2G2A and CCL17 contribute to an increased titer of pathogenic anti-BP180-NC16A autoantibodies in BP patients. Our work provides a comprehensive insight into BP pathogenesis and shows a mechanism governing immune-stromal interactions, providing potential avenues for future therapeutic research.

Exacerbation of clinical manifestations of bullous pemphigoid after treatment with dupilumab

The article presents an adverse event that occurred after the induction phase of dupilumab, administered in another country to a patient affected by bullous pemphigoid.

Advancements in Bullous Pemphigoid Treatment: A Comprehensive Pipeline Update

ABASTRACT

Bullous pemphigoid (BP) is a common autoimmune bullous disease affecting mainly the elderly, with rising incidence due to increased life expectancy. This disease is characterized by tense bullous lesions on normal or erythematous skin, accompanied by pruritus. BP pathogenesis involves autoantibodies against hemidesmosomal proteins BP180 and BP230, leading to detachment at the dermo-epidermal junction as well as blister formation. BP is associated with coexisting comorbidities and drug exposure, and its management often requires high doses or chronic use of systemic glucocorticoids, posing risks of adverse effects. This review focuses on novel treatment options for BP, exploring therapies targeting different immune pathways. Rituximab, a CD20 monoclonal antibody, depletes B-lymphocytes and has shown efficacy in severe cases. Dupilumab, targeting interleukin (IL)-4 receptor α and thus blocking IL-4 and IL-13, downregulates type 2 helper (Th2) responses and has demonstrated promising results. Targeting eosinophil-related molecules using bertilimumab and AKST4290 has yielded positive results in clinical trials. Omalizumab, an immunoglobulin (Ig) E antibody, can reduce disease severity and allows corticosteroid tapering in a number of cases. Complement inhibitors such as nomacopan and avdoralimab are being investigated. IL-17 and IL-23 inhibitors such as secukinumab and tildrakizumab have shown potential in a limited number of case reports. Neonatal Fc receptor antagonists such as efgartigimod are under investigation. Additionally, topical therapies and Janus kinase inhibitors are being explored as potential treatments for BP. These novel therapies offer promising alternatives for managing BP, with potential to improve outcomes and reduce high cumulative doses of systemic corticosteroids and related toxicities. Further research, including controlled clinical trials, is needed to establish their efficacy, safety, and optimal dosing regimens for BP management.