Mucous membrane pemphigoid

Mucous membrane pemphigoid

Mucous membrane pemphigoid (MMP) is a clinically and immunopathologically heterogenous disease with an incidence of about 2/million inhabitants/year in central Europe. Pemphigoid diseases are characterized by autoantibodies against structural proteins of the epidermis and/or surface-close epithelia. MMP has been defined as pemphigoid disease with predominant mucosal lesions. Most frequently, the oral cavity and the conjunctivae are affected. Lesions outside the mouth tend to heal with scarring leading to visual impairment and finally blindness, as well as, more rarely, impairment of breathing and food intake. Autoantibodies target BP180 (collagen type XVII), laminin 332, BP230 (nearly always in conjunction with other antigens), and type VII collagen in about 75%, 10-20%, 10-30%, and <5% of MMP patients, respectively. While the main autoantibody isotype is IgG, additional, and less frequently, exclusive IgA autoantibodies can be detected in the majority of patients. Assaying for anti-laminin 332 reactivity is pivotal, since in about a quarter of patients with anti-laminin 332 MMP, a malignancy, mainly solid cancers, is associated. The pathophysiology of MMP is yet incompletely understood. A recent mouse model of anti-laminin 332 MMP replicating characteristic clinical and immunopathological findings of the human disease may be helpful to close this knowledge gap. Diagnosis is established by the clinical picture with predominant mucosal lesions and visualization of tissue-bound anti-basement membrane zone antibodies by direct immunofluorescence microscopy. In recent S3 guidelines initiated by the European Academy of Dermatology and Venereology, the clinical spectrum and diagnostic strategies are detailed. In addition, treatment regimens for different clinical situations including patients with exclusive oral or ocular involvement are outlined. Future studies are needed to better understand the clinal complexity and associations as well as to establish widely available diagnostic assays and evidence-based therapeutic strategies.

Oral mucosal diseases: evaluation and management

Oral mucosal diseases encompass several common conditions that affect the general population. Some of these disorders present with signs and symptoms that are pathognomonic for the condition, whereas others present with similar features that can make clinical diagnosis difficult to achieve. It is important for physicians to have a clear understanding of these disorders to provide appropriate care to patients. This article reviews clinical aspects of common oral mucosal disorders, including candidiasis, herpes simplex viral infections, aphthous stomatitis, lichen planus, pemphigus vulgaris, and mucous membrane pemphigoid.

Mucous membrane pemphigoid

Mucous membrane pemphigoid (MMP) is chronic and frequently associated with exacerbations and remissions of clinical signs and symptoms. Clinicians should use pathologic and immunonologic techniques to help diagnose patients. Multidisciplinary collaboration is often necessary for the diagnosis and proper treatment of MMP. Systemic adjuvant immunosuppressive therapy is necessary for patients with progressive disease. In spite of the advances in available immunosuppressive medications and biologics, scarring is a significant complication in many cases. Surgical intervention is not curable; however, it may be necessary for restoring function and improving quality of life.

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

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

The Lichenoid Tissue Reactions of the Oral Mucosa: Oral Lichen Planus and Other Lichenoid Lesions

Lichenoid changes in the oral mucosa can be encountered in a wide range of lesions and can have varied etiologies. Immune-mediated disorders, including lichen planus, mucous membrane pemphigoid, discoid lupus erythematosus, and graft-versus-host disease, can have clinical and histologic overlaps. Lichenoid reactions to dental materials, such as amalgam, or to many systemic drugs are also well documented. Dysplasia of the oral cavity at times can also express a lichenoid histology, which may mask the potentially cancerous component. Proliferative verrucous leukoplakia, an unusual clinical disease, mimics oral lichen planus clinically and requires careful correlation of the clinical and pathologic features.

Low-level laser therapy in the treatment of mucous membrane pemphigoid: a promising procedure

BACKGROUND

Mucous membrane pemphigoid is a heterogeneous group of autoimmune, subepithelial, blistering diseases. A combination of topical and systemic steroid treatment is often used when managing patients with mucous membrane pemphigoid. The use of systemic steroids presents an increased risk of adverse side effects. Consequently, effective alternative modalities of therapy should be considered, such as the application of low-level laser therapy (LLLT).

METHODS

A patient presented with mucous membrane pemphigoid and was successfully treated with the application of local corticosteroids and LLLT using an 810-nm diode laser. The lesions were treated by LLLT over a period of 7 days using a continuous waveform for 40 seconds and an energy density of 5 J/cm(2).

RESULTS

After treatment, a significant improvement in tissue color and consistency was observed. The patient was followed every month for a period of 12 months, and the lesions healed uneventfully.

CONCLUSION

The results reported in this case show that the healing of mucous membrane pemphigoid was achieved when LLLT was used as an adjunct to the application of a local corticosteroid.

Clinical implications of aging skin: cutaneous disorders in the elderly

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