RETRACTED: Bullous pemphigoid: Associations and management guidelines

Strategies to Improve Outcomes of Bullous Pemphigoid: A Comprehensive Review of Clinical Presentations, Diagnosis, and Patients' Assessment

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.

Cancer is not a risk factor for bullous pemphigoid: 10-year population-based cohort study

BACKGROUND

Bullous pemphigoid (BP) is the most common autoimmune bullous disease. Whether there is an increased risk for subsequent BP among patients with cancer is still unclear.

OBJECTIVES

To evaluate the risk for subsequent BP in patients with cancer.

METHODS

This nationwide population-based cohort study was based on data obtained from the Taiwan National Health Insurance Database between 2000 and 2011. A total of 36 838 patients with cancer and 147 352 age-, sex- and index-date-matched controls were recruited. The hazard ratio (HR) of subsequent BP in the patients with cancer was analysed using a Fine-Gray competing risk regression model with mortality as the competing event.

RESULTS

The incidence of BP per 100 000 person-years was 17·2 in the patients with cancer and 19·8 in the controls; therefore, the crude incidence rate ratio was 0·87 [95% confidence interval (CI) 0·53-1·36]. The HR of subsequent BP in the patients with cancer was 0·47 (95% CI 0·23-0·94) using the Fine-Gray competing risk regression model. Age (HR 1·05, 95% CI 1·03-1·07), diabetes mellitus (HR 1·69, 95% CI 1·10-2·59) and cerebrovascular disease (HR 2·14, 95% CI 1·36-3·34) were independent risk factors for BP.

CONCLUSIONS

The incidence of BP in patients with cancer was not higher than in the control group. Cancer is not a risk factor for BP.

Association between bullous pemphigoid and malignancy: A meta-analysis

It has been suggested that bullous pemphigoid is associated with an increased risk of malignancy, but the evidence is inconsistent. Therefore, a meta-analysis was conducted to explore this association. PUBMED and Embase were searched for studies investigating the association between bullous pemphigoid and malignancy. This meta-analysis included 16 studies with a total of 9398 cases of bullous pemphigoid. The rate of malignancy in patients with bullous pemphigoid was 11% (95% CI: 9-14, P < 0.001); 9% (95% CI: 6-13, P < 0.003) for women and 13% (95% CI: 9-18, P < 0.03) for men, with a statistically insignificant higher risk in men (OR = 1.30, 95% CI: 0.99-1.71, P = 0.06). The event rate was 9% (95% CI: 5-14, P < 0.001) in the Asian population and 13% (95% CI: 10-17, P < 0.001) in the European population, with a statistically significant lower risk in the Asians population (OR = 0.69, 95% CI: 0.57-0.84; P < 0.001). The event rate of malignancy was higher in patients with bullous pemphigoid than in matched controls (OR = 2.08, 95% CI: 1.22-3.55; P = 0.005). The overall event rate of malignancy was higher in the bullous pemphigoid group than in matched controls. Caution is required when interpreting these results, as potential confounding variables were not controlled for.

BP180 Is Critical in the Autoimmunity of Bullous Pemphigoid

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.

Bullous Pemphigoid: A Review of its Diagnosis, Associations and Treatment

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.

Bullous pemphigoid arising in a patient with acquired perforating dermatosis

A middle-aged Japanese man who had been on haemodialysis treatment for diabetic nephropathy developed multiple itchy papules and nodules, which were histopathologically diagnosed as acquired perforating dermatosis. Two years later he developed oral lesions and subsequently numerous erosive plaques with necrotic crusts on the trunk and extremities. Histopathology of a papule showed a parakeratotic plug intermingled with basophilic, necrotic debris and collagen bundles, along with penetration of collagen bundles across the epidermis and subepidermal blister. Immunoblotting studies revealed IgG autoantibodies in the patient's serum, which reacted with the C-terminal and the NC16a domains of bullous pemphigoid (BP)180, indicating presence of BP. We searched the literature and found no other cases of an autoimmune blistering disease occurring in association with a perforating disorder. Possible injury to the basement membrane zone induced during the process of transepidermal elimination might be involved in the pathogenesis of the pemphigoid disease.

Disease stabilization with pembrolizumab for metastatic acral melanoma in the setting of autoimmune bullous pemphigoid

Background

To date, patients with pre-existing autoimmune conditions have been excluded from immunotherapy trials out of concern for severe autoimmune exacerbations.

Case Presentation

We describe the first case of a patient with metastatic cKIT mutated acral melanoma, brain metastasis, and pre-existing severe autoimmune bullous pemphigoid (BP) with stable and asymptomatic disease 10 months after treatment with pembrolizumab. The patient experienced severe BP exacerbation after therapy with ipilimumab requiring systemic immune suppression, but nonetheless pembrolizumab was administered on further disease progression.

Conclusions

This case suggests that pembrolizumab may confer more benefit than risk even in patients with known severe autoimmune conditions who require intermittent systemic immunosuppression.

Bullous pemphigoid: What's ahead?

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering skin disease mainly affecting older individuals. Pathogenic autoantibodies preferentially target the non-collagenous 16A domain of collagen XVII (also called BP antigen 2, BPAG2) present in hemidesmosomes. The pathogenic anti-BPAG2 antibodies cause the dermal-epidermal separation in neonatal and adult mice as well as in cryosections of human skin. These experimental BP models stress a pivotal role for neutrophils and the Fcγ receptor of immunoglobulins. Mice that have been genetically manipulated in the pathogenic domain of BPAG2 spontaneously develop subepidermal blistering with pruritus and eosinophilic infiltration. BPAG2 is physiologically and aberrantly expressed in neuronal tissue and internal malignancies, and the associations of BP with Parkinson's disease, stroke and internal malignancies invites new investigations into the immunological dysregulation behind the comorbidity.

A case of bullous pemphigoid in a patient with metastatic melanoma treated with pembrolizumab

The innovative blockade of immune checkpoints with targeted immunotherapies, such as monoclonal antibodies against programmed cell death-1, is pioneering the treatment for advanced melanoma. Potential adverse events of particular interest associated with immunotherapy are of an inflammatory or immune-related nature. Reported dermatological side effects mostly comprise nonspecific rash and pruritus. This is a report of a 75-year-old man with metastatic melanoma who was initially administered pembrolizumab at 10 mg/kg every 3 weeks. He developed spongiotic dermatitis that was partially treated with topical steroids after cycle 3. Pembrolizumab cycles were stopped because of disease progression after cycle 6. On the 30-day follow-up, the patient presented with extensive erythematous papules and plaques, in addition to a few intact and ruptured vesicles and bullae over the upper and lower limbs, especially over the knees and elbows. Both punch skin biopsies (haematoxylin and eosin and direct immunofluorescence studies) confirmed a bullous pemphigoid diagnosis. He was treated with a tapering dose of oral prednisone, resulting in rapid clinical improvement after only a week of treatment, which was switched to dexamethasone following the diagnosis of new brain metastases.

Role of physical factors in the pathogenesis of bullous pemphigoid: Case report series and a comprehensive review of the published work

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disease affecting mainly the elderly. The subtype of the disease induced by physical agents represents a rare and, therefore, insufficiently characterized form. In the present study, we aimed to contribute to a better understanding of the pathogenetic mechanisms involved in the onset of BP induced by different trigger factors. We have retrospectively analyzed nine cases of BP. All patients were characterized based on clinical, epidemiological and immunological parameters. For each case, the trigger factor involved was specified. In addition to our retrospective analysis, a comprehensive review of the 59 published cases was conducted, regarding the involvement of trigger factor in BP, and clinical, epidemiological and immunological data were collected. In the local study, conducted on nine patients diagnosed with BP, various trigger factors were identified: contrast substance injection, surgical procedure, mechanical trauma, insect bite, thermal burn, radiotherapy and ultraviolet exposure associated with pre-existing psoriasis. The autoantibodies from all patients were shown to activate granulocytes and induce dermal-epidermal split. Different hypotheses regarding the pathogenetic mechanism involving the trigger factors have been discussed. In regard of the pathogenetic mechanism, we believe that the most reliable hypothesis is that BP patients already have low titers of anti-basement membrane autoantibodies which activate the granulocytes. However, more studies are needed for a better understanding of the pathogenetic mechanism of the intervention of trigger factors.

Bullous pemphigoid after bilateral forefoot surgery

The case of a 76-year-old woman who developed blisters on both forefeet within 2 weeks of bilateral forefoot surgery is reported; the diagnosis of bullous pemphigoid was made by histological and immunofluorescence studies. The pathogenesis and management of this autoimmune condition, which occurs mainly in patients older than 70 years and may occasionally be associated with surgical wounds, are reviewed. It is important for foot and ankle specialists to be aware of and consider the diagnosis when a bullous contact dermatitis-like eruption persists at a surgical site.

LEVEL OF EVIDENCE

Therapeutic Level IV: Case report.

[Bullous pemphigoid: diagnosis and therapy]

Bullous pemphigoid is the most common autoimmune bullous skin disease which occurs more often at higher age. Clinically it presents with tense blisters and eczematous lesions combined with severe pruritus. The pemphigoid-like diseases include mucous membrane pemphigoid, pemphigoid gestationis and linear IgA disease. Diagnosis is based on immunofluorescence microscopy and confirmatory tests (ELISA, immunoblotting). Classical bullous pemphigoid presents with IgG autoantibodies against BP180 and BP230. Treatment includes topical and systemic corticosteroids and adjuvant immunosuppressants.