Drugs used for neurologic and psychiatric conditions increase the risk for bullous pemphigoid: A case-control study

Lymphocyte Transformation Tests and Patch Tests to Identify Drugs Potentially Associated With Bullous Pemphigoid Development

BACKGROUND

Bullous pemphigoid (BP) is the most common autoimmune blistering disease, with a rising incidence in the elderly. BP is associated with multiple triggering factors, including drug exposure. However, evidence in this respect is limited, and the underlying immune mechanisms remain unknown. Our study aims to identify the role of specific drugs in BP pathogenesis using in vitro lymphocyte transformation tests (LTT) and in vivo patch testing, aiding in the differentiation between truly associated drugs and coincidental associations.

METHODS

Thirty-three patients with suspected BP and no ongoing systemic treatment were enrolled. LTT and patch tests were conducted 3 months after diagnosis. BP disease activity was assessed using the Bullous Pemphigoid Disease Activity Index (BPDAI) at diagnosis and at follow-up visits at 3 and 6 months.

RESULTS

LTT results were positive in 60% of patients for dipeptidyl peptidase 4 inhibitors, loop diuretics, hydrochlorothiazide, levetiracetam, nivolumab, enalapril, and amlodipine. Patients showed a reduction in BPDAI over the study period, regardless of LTT results. Although limited by the low sample size, positive LTT patients showed a trend toward clinical improvement when the implicated drug was discontinued. Patch testing was positive in one patient, who also had a corresponding positive LTT.

CONCLUSIONS

Our findings demonstrate the existence of a potential role for certain drugs in BP pathogenesis, suggesting that these drugs may trigger the disease in genetically predisposed individuals. Although further studies are needed, LTT may serve as a useful and available tool in the management of BP patients in the future.

Unraveling the Link Between Bullous Pemphigoid and Neurological Disease: A Single-center Study of 257 Patients

BACKGROUND

Multiple studies have corroborated the association between bullous pemphigoid (BP) and neurological diseases; patients with both diseases (BP-N) have been associated with a worse prognosis and specific clinical and immunological characteristics, defining a different subtype of BP.

OBJECTIVES

We aimed to determine the prevalence and characteristics of BP cases with neurological comorbidities (BP-N) and review the related published literature.

METHODS

We conducted a retrospective, observational study of BP cases treated at a referral center for autoimmune blistering diseases from January 2000 through June 2020.

RESULTS

We collected epidemiological, clinical, histopathological, progression and laboratory data from a total of 257 cases, 102 of which were BP-N. Senile dementia, Alzheimer's disease and vascular dementia were the most frequent neurological comorbidities. Compared with cases without neurological comorbidities, BP-N cases had more intense tissue eosinophilia (p=0.012) and higher concentrations of circulating eosinophils (p=0.000), and anti-BP180 IgG antibodies (p=0.007). At the time of data collection, 78 BP-N were deceased.

CONCLUSIONS

Our case series highlighted the relevance of neurological comorbidities in BP patients; although the pathogenesis is still to be elucidated, the neuroinflammation present in neurodegenerative diseases could explain the neurocutaneous link and the chronological relationship between these entities.

Association of statins, gliptins, and antipsychotics with bullous pemphigoid: A case-control study in the Cretan population

Bullous pemphigoid (BP) is an autoimmune blistering disorder predominantly affecting the elderly. Recently, many studies have shed light on the effect of specific drug intake and comorbidities on the development of BP. The purpose of this study was to investigate the association of specific drug class intake and comorbidities with the development of BP in the Cretan population. Significant associations with BP were found for statins (odds ratio [OR] = 4.06, 95% confidence interval [CI] 1.99-8.27, P < 0.001), gliptins (OR = 4.27, 95% CI 2.33-7.83, P < 0.001), and antipsychotics (OR = 3.33, 95% CI 1.36-8.11, P = 0.006). Higher proportions of use in the BP group vs. control group were found for atorvastatin (OR = 1.86, 95% CI 1.04-3.32, P = 0.035), linagliptin (OR = 6.63, 95% CI 2.17-20.23, P < 0.001), vildagliptin (OR = 3.20, 95% CI 1.73-5.91, P < 0.001), alogliptin (OR = 5.11, 95% CI 1.19-22.04, P = 0.016), and quetiapine (OR = 4.21, 95% CI 1.5-11.85, P = 0.004). The presence of diabetes mellitus in the absence of gliptins did not show any significant effect on BP (OR = 1.60, 95% CI 0.79-3.23, P = 0.188). Metformin intake showed no significant association with BP (OR = 0.48, 95% CI 0.18-1.28, P = 0.143). Our findings confirm and extend previous studies reporting the association of gliptins and antipsychotics on BP in other European populations. The association found for statins is new, thus more studies are needed to corroborate its validity.

Associated factors related to production of autoantibodies and dermo-epidermal separation in bullous pemphigoid

Bullous pemphigoid (BP) is a debilitating autoimmune skin blistering disease, characterized by the deposition of specific autoantibodies at the dermal-epidermal junction. This leads to an inflammatory cascade involving the activation of complement proteins, mast cell degranulation, immune cell recruitment, and the release of proteases by granulocytes. While several cytokines and signaling pathways have been implicated in the pathogenesis of BP, the precise mechanism behind autoantibody production remains unclear. A variety of factors, including natural aging, genetic polymorphisms, microbiota, medications, vaccinations, and infection, may contribute to disease onset. Recent evidence also suggests that both vaccination against severe acute respiratory syndrome coronavirus-2 and infection with severe acute respiratory syndrome coronavirus-2 may also play a role in BP's development. This review aims to elucidate the mechanism underlying the production of autoantibodies in BP, address gaps in understanding disease progression, and explore opportunities for improving diagnosis and prognosis to enhance patient care.

From Psychiatric Care to Dermatologic Dilemmas: A Case Report of Risperidone-Induced Bullous Pemphigoid

The patient, a 64-year-old male with a history of delusional disorder, first experienced symptoms of suspicion toward his spouse at age 34. He was treated with psychotropic drugs for two years, leading to complete symptom remission and discontinuation of medication. After years of stability, delusions resurfaced two years ago. Amisulpride was ineffective, and risperidone was started but led to itching and plaques on his thighs, which evolved into fluid-filled and hemorrhagic lesions. Diagnosed with bullous pemphigoid (BP) via skin biopsy, he received corticosteroids, dapsone, and antibiotics. Risperidone was discontinued, but delusions reappeared, prompting its reintroduction. New bullous lesions emerged, suggesting risperidone's role in triggering them. Risperidone was replaced with aripiprazole, and melatonin improved sleep. The patient responded well, with both delusional symptoms and skin condition well-managed. This case highlights the need to consider drug-induced BP in elderly patients on antipsychotic medications.

Update: Protective and risk factors for Parkinson disease

We review the epidemiologic literature on potential protective and risk factors in Parkinson's Disease (PD). Prior research identified numerous possible protective and risk factors. Potential protective factors include tobacco abuse, physical activity, urate levels, NSAID use, calcium channel blocker use, statin use, and use of some α1-adrenergic antagonists. Some potential protective factors could be products of reverse causation, including increased serum urate, tobacco abuse, and coffee-tea-caffeine consumption. Potential risk factors include traumatic brain injury, pesticide exposure, organic solvent exposure, lead exposure, air pollution, Type 2 Diabetes, some dairy products, cardiovascular disease, and some infections including Hepatitis C, H. pylori, and COVID-19. Potential non-environmental risk factors include bipolar disorder, essential tremor, bullous pemphigoid, and inflammatory bowel disease. There is an inverse relationship with PD and risk of most cancers. Though many potential protective and risk factors for PD were identified, research has not yet led to unique, rigorous prevention trials or successful disease-modifying interventions. While efforts to reduce exposure to some industrial toxicants are well justified, PD incidence might be most effectively reduced by mitigation of risks, such as Type 2 Diabetes, air pollution, traumatic brain injury, or physical inactivity, that are general public health intervention targets.

From Molecular Insights to Clinical Perspectives in Drug-Associated Bullous Pemphigoid

Bullous pemphigoid (BP), the most common autoimmune blistering disease, is characterized by the presence of autoantibodies targeting BP180 and BP230 in the basement membrane zone. This leads to the activation of complement-dependent and independent pathways, resulting in proteolytic cleavage at the dermoepidermal junction and an eosinophilic inflammatory response. While numerous drugs have been associated with BP in the literature, causality and pathogenic mechanisms remain elusive in most cases. Dipeptidyl peptidase 4 inhibitors (DPP4i), in particular, are the most frequently reported drugs related to BP and, therefore, have been extensively investigated. They can potentially trigger BP through the impaired proteolytic degradation of BP180, combined with immune dysregulation. DPP4i-associated BP can be categorized into true drug-induced BP and drug-triggered BP, with the latter resembling classic BP. Antineoplastic immunotherapy is increasingly associated with BP, with both B and T cells involved. Other drugs, including biologics, diuretics and cardiovascular and neuropsychiatric agents, present weaker evidence and poorly understood pathogenic mechanisms. Further research is needed due to the growing incidence of BP and the increasing identification of new potential triggers.

Psychiatric medications and the risk of autoimmune and immune-mediated inflammatory diseases: A systematic review and meta-analysis of observational studies

BACKGROUND

Pharmacovigilance reports have suggested that certain commonly used medications may trigger autoimmune diseases (ADs) and immune-mediated inflammatory diseases (IMIDs). We systematically reviewed the literature to evaluate whether psychiatric medication use is associated with ADs and IMIDs.

METHODS

The protocol was registered in PROSPERO (CRD42022296524) before the start of the study. We searched Medline Ovid and Scopus up to November 28th, 2021, for comparative studies, with any psychiatric medication as exposure and ADs and IMIDs as outcomes. Meta-analysis was performed using DerSimonian-Laird random-effects modeling. The PRISMA 2020 guidelines were followed in reporting. Study-level risk of bias was assessed using the Newcastle-Ottawa Scale, and the overall certainty of evidence using GRADE.

RESULTS

There were 7,265 citations from which 31 studies were eligible, all from high-income countries, covering 15 distinct immune diseases. The evidence for the association between selective serotonin reuptake inhibitor (SSRI) use and higher risk of microscopic colitis (meta-OR 2.60, 95% CI 1.05-6.39, I2 97.5%, 6 studies) was of low certainty. A subgroup analysis by the histological type of microscopic colitis showed a statistically significant association only with lymphocytic colitis (meta-OR 2.88, 95% CI 2.60-3.18, I2 00.00%, three studies). In two case-control studies, SSRI use had no significant association with psoriasis (meta-OR 0.80, 95% CI 0.58-1.10, I2 82.4%). The risk of acute pancreatitis was slightly increased with exposure to SSRIs (meta-OR 1.13, 95% CI 1.01-1.26, I2 00.0%), as was the risk of bullous pemphigoid after exposure to antipsychotics (meta-OR 1.79, 95% CI 1.17-2.73, I2 0%).

CONCLUSIONS

We reviewed the literature on whether psychiatric medications associate with the risk of ADs and IMIDs and concluded that, despite several signals, the credibility of evidence remains low at best. Prospective cohort studies would be needed as the next step to confirm the suggestions of increased risk.

Bullous pemphigoid in a patient with a neuropsychological disorder and a possible novel drug trigger: A case report and review of the literature

A 59-year-old woman with schizoaffective disorder presented with an itchy, blistering generalised rash. One month prior, she had started empagliflozin, a sodium glucose transporter-2 (SGLT-2) inhibitor, used in type-2-diabetes. She was already established on paliperidone, an atypical antipsychotic, for 1 year. Serology at presentation was positive for anti-pemphigoid antibodies. Histology demonstrated subepidermal blistering, perivascular inflammation and eosinophils. Direct immunofluorescence was characteristic of bullous pemphigoid (BP), with linear IgG and C3 at the basement membrane. Both empagliflozin and paliperidone were discontinued. However, the blisters persisted. Treatment included: topical Dermovate and Eumovate ointment for the body and face respectively, alongside oral doxycycline 200 mg and prednisolone 40 mg for a week (reducing by 5 mg/week over 8 weeks). Nevertheless, new blisters continued developing, hence dapsone 50 mg was introduced, with significant improvement. Increasingly, several neurological and psychiatric disorders have been linked with BP, complicating aetiology and management. The underlying mechanism for these associations is not fully understood. Bullous pemphigoid autoantigens BP180 and BP230 are expressed in the central nervous system and it is thought that neurodegeneration may expose antigens to the immune system, generating a cross-reactive immune response. However, there also appears to be bidirectional causality between BP and neuropsychological conditions. Furthermore, as there was an association of empagliflozin initiation and BP onset, this further complicates the aetiology and presents a potential novel drug cause of BP. This case emphasises the neuropsychological issues associated with managing complex BP cases, a possible novel cause of drug-induced BP and highlights the likelihood of these issues becoming increasingly prevalent for the future.

Serum autoantibody reactivity in bullous pemphigoid is associated with neuropsychiatric disorders and the use of antidiabetics and antipsychotics: a large prospective cohort study

BACKGROUND

Bullous pemphigoid (BP), the by far most frequent autoimmune blistering skin disease (AIBD), is immunopathologically characterized by autoantibodies against the two hemidesmosomal proteins BP180 (collagen type XVII) and BP230 (BPAG1 or dystonin). Several comorbidities and potentially disease-inducing medication have been described in BP, yet, a systematic analysis of these clinically relevant findings and autoantibody reactivities has not been performed.

OBJECTIVE

To determine associations of autoantibody reactivities with comorbidities and concomitant medication.

METHODS

In this prospective multicenter study, 499 patients diagnosed with BP in sixteen European referral centers were included. The relation between anti-BP180 NC16A and anti-BP230 IgG ELISA values at the time of diagnosis as well as comorbidities and concomitant medication collected by a standardized form were analyzed.

RESULTS

An association between higher serum anti-BP180 reactivity and neuropsychiatric but not atopic and metabolic disorders was observed as well as with the use of insulin or antipsychotics but not with dipeptidyl peptidase-4 (DPP4) inhibitors, inhibitors of platelet aggregation and L-thyroxine. The use of DPP4 inhibitors was associated with less anti-BP180 and anti-BP230 reactivity compared to BP patients without these drugs. This finding was even more pronounced when compared with diabetic BP patients without DPP4 inhibitors. Associations between anti-BP180 and anti-BP230 reactivities were also found in patients using insulin and antipsychotics, respectively, compared with patients without this medication, but not for the use of inhibitors of platelet aggregation, and L-thyroxine.

CONCLUSION

Taken together, these data imply a relation between autoantibody reactivities at the time of diagnosis and both neuropsychiatric comorbidities as well as distinct concomitant medication suggesting a link between the pathological immune mechanisms and clinical conditions that precede the clinically overt AIBD.

Bullous Dermatoses and Depression: A Systematic Review

IMPORTANCE

There is a lack of evidence synthesis on the association between bullous skin disease and depression.

OBJECTIVE

To synthesize and interpret the current evidence on the association between bullous skin disease and depression.

EVIDENCE REVIEW

This review was conducted according to PRISMA guidelines and reviewed literature related to bullous skin disease and depression in the PubMed, Embase, PsycInfo, and Cochrane databases published between 1945 and February 2021. The quality of each included article was assessed via the Newcastle-Ottawa Scale. This review was registered with PROSPERO (CRD42021230750).

FINDINGS

A total of 17 articles were identified that analyzed a total of 83 910 patients (55.2% female; specifically, 6951 patients with bullous pemphigoid, 1669 patients with pemphigus, and 79 patients with epidermolysis bullosa were analyzed). The prevalence of depressive symptoms among patients with bullous dermatoses ranged from 40% to 80%. The prevalence of depression diagnosis among patients with bullous dermatoses ranged from 11.4% to 28%.

CONCLUSIONS AND RELEVANCE

In this systematic review, high rates of depression and depressive symptoms existed among patients with bullous skin disease. Adequate treatment of bullous dermatoses may be associated with a decrease in mental health burden on patients.

Bipolar Patients and Bullous Pemphigoid after Risperidone Long-Acting Injectable: A Case Report and a Review of the Literature

Neuropsychiatric disorders are found to be associated with bullous pemphigoid (BP), an autoimmune subepidermal blistering disease. Antipsychotics have emerged as possible inducing factors of BP. However, large sample studies concerning BP associated with antipsychotics, as well as with specific mental disorders, are still lacking. Our review retrieved a few clinical studies and case reports on the topic, producing controversial results. We report for the first time a bipolar patient case presenting BP following five-month therapy with risperidone long-acting injectable (LAI). We hypothesize that the dermatological event is associated with the medication administered. The issue emerged during psychiatric consultation and was confirmed by histological examination, direct and indirect immunofluorescence studies, plus positive plasma and cutaneous BP180 and BP230 IgG. Neurodegeneration or neuroinflammation might represent a primary process leading to a cross-reactive immune response between neural and cutaneous antigens and contributing to self-tolerance failure. Furthermore, the time sequence of the shared biological mechanisms leading to clinical manifestations of the neuropsychiatric disorder and BP remains undefined. BP comorbid with bipolar disorder might occasionally represent a serious health risk and affect patients' physical and psychosocial quality of life. Thus, clinicians treating psychiatric patients should consider BP as a possible adverse effect of psychotropic medications.

Bullous Pemphigoid: Trigger and Predisposing Factors

Bullous pemphigoid (BP) is the most frequent autoimmune subepidermal blistering disease provoked by autoantibodies directed against two hemidesmosomal proteins: BP180 and BP230. Its pathogenesis depends on the interaction between predisposing factors, such as human leukocyte antigen (HLA) genes, comorbidities, aging, and trigger factors. Several trigger factors, such as drugs, thermal or electrical burns, surgical procedures, trauma, ultraviolet irradiation, radiotherapy, chemical preparations, transplants, and infections may induce or exacerbate BP disease. Identification of predisposing and trigger factors can increase the understanding of BP pathogenesis. Furthermore, an accurate anamnesis focused on the recognition of a possible trigger factor can improve prognosis by promptly removing it.

Psychiatric comorbidity in individuals with bullous pemphigoid and all bullous disorders in the Danish national registers

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune blistering skin disease that takes a profound physical and mental toll on those affected. The aim of the study was to investigate the bidirectional association between BP and all bullous disorders (ABD) with a broad array of psychiatric disorders, exploring the influence of prescribed medications.

METHODS

This nationwide, register-based cohort study encompassed 6,470,450 individuals born in Denmark and alive from 1994 to 2016. The hazard ratios (HRs) of a subsequent psychiatric disorder in patients with BP/ABD and the reverse exposure and outcome were evaluated.

RESULTS

Several psychiatric disorders were associated with increased risk of subsequent BP (4.18-fold for intellectual disorders, 2.32-fold for substance use disorders, 2.01-fold for schizophrenia and personality disorders, 1.92-1.85-1.49-fold increased risk for organic disorders, neurotic and mood disorders), independent of psychiatric medications. The association between BP and subsequent psychiatric disorders was not significant after adjusting for BP medications, except for organic disorders (HR 1.27, CI 1.04-1.54). Similar results emerged with ABD.

CONCLUSION

Psychiatric disorders increase the risk of a subsequent diagnosis of BP/ABD independent of medications, whereas medications used for the treatment of BP/ABD appear to account for the subsequent onset of psychiatric disorders. Clinically, an integrated approach attending to both dermatological and psychiatric symptoms is recommended, and dermatologists should remain vigilant for early symptoms of psychiatric disorders to decrease mental health comorbidity.

Association Between Medication Use and Bullous Pemphigoid: A Systematic Review and Meta-analysis

Importance

The association between the use of medications and the development of bullous pemphigoid (BP) is unclear.

Objective

To assess the associations between previous exposure to certain medications and BP.

Data Sources

For this systematic review and meta-analysis, PubMed, the Cochrane Central Register of Controlled Trials, and Embase were searched for relevant studies from inception to February 20, 2020.

Study Selection

Case-control or cohort studies and randomized clinical trials that examined the odds or risk of BP in patients with previous medication use were included. No geographic or language limitations were imposed.

Data Extraction and Synthesis

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guideline was followed. The Newcastle-Ottawa Scale was used to evaluate the risk of bias of included observational studies; Cochrane Collaboration's tool was used for randomized clinical trials. Aggregate data were used to conduct a random-effects model meta-analysis if the included studies were sufficiently homogenous. Subgroup analyses were performed for use of various medications of the same category.

Main Outcomes and Measures

Odds ratio (OR), hazard ratio, and risk ratio of bullous pemphigoid in association with medication use.

Results

This meta-analysis included 13 case-control studies, 1 cohort study, and 1 randomized clinical trial with a total of 285 884 participants. The meta-analysis of case-control studies showed a significant association of BP with previous use of aldosterone antagonists (pooled OR, 1.75; 95% CI, 1.28-2.40), dipeptidyl peptidase 4 inhibitors (pooled OR, 1.92; 95% CI, 1.55-2.38), anticholinergics (pooled OR, 3.12; 95% CI, 1.54-6.33), and dopaminergic medications (pooled OR, 2.03; 95% CI, 1.34-3.05). One cohort study found an increased risk of BP among patients receiving dipeptidyl peptidase 4 inhibitors (hazard ratio, 2.38; 95% CI, 1.16-4.88; P = .02). One trial found a higher occurrence of BP in patients with diabetes receiving linagliptin (0.2% in diabetes group vs 0% in the placebo group).

Conclusions and Relevance

The findings of this systematic review and meta-analysis suggest that aldosterone antagonists, dipeptidyl peptidase 4 inhibitors, anticholinergics, and dopaminergic medications are associated with BP. These medications should be judiciously prescribed, particularly in high-risk patients who are elderly and have disabling neurologic disorders.

Depression and Anxiety in Patients with Bullous Pemphigoid: Impact and Management Challenges

Bullous pemphigoid is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. It is also associated with high mortality and poor prognosis due to advanced age of the patients and coexisting comorbidities. There is a dearth of data in the literature regarding depression and anxiety among those patients. The objective of this brief review is to discuss the intertwining relationship between depression and anxiety with bullous pemphigoid.

Dipeptidyl Peptidase-4 Inhibitor-Associated Bullous Pemphigoid

Bullous pemphigoid (BP) is an organ-specific autoantibody-mediated blistering skin disease that mainly affects the elderly. Typical clinical features include the widespread blisters, often preceded by and/or associated with itchy urticarial or eczema-like lesions. BP patients have circulating autoantibodies against BP180 and/or the plakin family protein BP230 both of which are components of hemidesmosomes in basal keratinocytes. Most BP autoantibodies particularly target the epitopes within the non-collagenous NC16A domain of BP180. Clinical findings and murine models of BP have provided evidence of a pathogenic role of anti-NC16A autoantibodies. However, it is largely unknown what triggers the breakage of immunotolerance against BP180 in elderly individuals. The incidence of BP has been increased over the past two decades in several countries. Aside from aging populations, the factors behind this phenomenon are still not fully understood. Neurodegenerative diseases such as multiple sclerosis, Parkinson's disease, and certain dementias are independent risk factors for BP. Recently several case reports have described BP in patients with diabetes mellitus (DM) patients who have been treated with dipeptidyl peptidase-4 inhibitors (DPP-4i or gliptins), which are a widely used class of anti-DM drugs. The association between the use of DPP-4is, particularly vildagliptin, and BP risk has been confirmed by several epidemiological studies. Evidence suggests that cases of gliptin-associated BP in Japan display certain features that set them apart from cases of “regular” BP. These include a “non-inflammatory” phenotype, targeting by antibodies of different immunodominant BP180 epitopes, and a specific association with the human leukocyte antigen (HLA) types. However, recent studies in European populations have found no major differences between the clinical and immunological characteristics of gliptin-associated BP and “regular” BP. The DPP-4 protein (also known as CD26) is ubiquitously expressed and has multiple functions in various cell types. The different effects of the inhibition of DPP-4/CD26 activity include, for example, tissue modeling and regulation of inflammatory cells such as T lymphocytes. Although the pathomechanism of gliptin-associated BP is currently largely unknown, investigation of the unique effect of gliptins in the induction of BP may provide a novel route to better understanding of how immunotolerance against BP180 breaks down in BP.