Manejo práctico de las enfermedades ampollosas autoinmunes más frecuentes

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.

Ocular involvement in pemphigus vulgaris - a retrospective study of a large Spanish cohort

BACKGROUND AND OBJECTIVES

Ocular/periocular involvement in pemphigus vulgaris (OPV) has rarely been reported. The objective of the present study was to investigate the pattern of OPV and define the prognostic value of its manifestation.

PATIENTS AND METHODS

From 1985 to 2014, a total of 167 patients with pemphigus vulgaris (PV) were treated at four tertiary Spanish hospitals. In this retrospective study, we included all patients with OPV. Clinical data and information on associated symptoms were obtained from patients' medical records.

RESULTS

Only 24 (14.3 %) of all PV patients had ocular lesions. In most cases, -ocular involvement was preceded by PV lesions at various other sites (mean duration: 33.7 months). Ocular PV lesions occurred during flares of mucocutaneous pemphigus, and was never the only mucosal manifestation. The most common clinical signs were conjunctival hyperemia (87.5 %), erosions on the eyelids (41.6 %) as well as of the palpebral/bulbar conjunctiva (33.3 %) and at the medial epicanthus (20.8 %). The most relevant associated symptoms included local pain/stinging (71.4 %), irritation (47.6 %), photophobia (38.1 %), and epiphora (23.9 %). Ocular PV improved with systemic and adjuvant topical therapies. Only two patients experienced sequelae.

CONCLUSIONS

In patients with PV, ocular involvement is an exception. Ocular PV is associated with greater disease activity, and usually follows a benign course. Sites affected are the conjunctiva, the eyelids, or both.

Usefulness of a Simple Immunohistochemical Staining Technique to Differentiate Anti-p200 Pemphigoid From Other Autoimmune Blistering Diseases: A Report of 2 Cases

Anti-p200 pemphigoid is a rare autoimmune subepidermal blistering disease characterized by the presence of circulating immunoglobulin G antibodies directed against laminin gamma-1, a 200-kDa protein located in the lamina lucida of the basement membrane. We review the clinical, histopathological and immunological characteristics of the first 2 cases described in Spain. Anti-p200 pemphigoid shares histopathological and immunopathological findings with epidermolysis bullosa acquisita, the main entity in the differential diagnosis. However, its management follows the same guidelines as those used for bullous pemphigoid. The diagnosis is confirmed by immunoblotting, which is a complex technique available in few centers. We propose the immunohistochemical detection of collagen type IV on the floor of the blister, combined with standard immunofluorescence techniques, as a simple, accessible alternative to differentiate anti-p200 pemphigoid from epidermolysis bullosa acquisita.

Rituximab in dermatology

Rituximab was introduced into clinical practice as a medication with considerable potential. Its use in patients with B-cell lymphoma and rheumatoid arthritis revealed numerous indications in autoimmune diseases, many of which involve the skin, thus requiring dermatologists to become familiar with both the characteristics of anti-CD20 antibodies and the role of B cells in multiple skin diseases. Thanks to these developments, we will be able to use rituximab more frequently and appropriately in our patients and draw up consensus guidelines based on large case series. In other words, establishing the indications for rituximab will make it possible to shorten disease course and reduce morbidity due to more specific drugs.

Efficacy and safety of azathioprine and dapsone as an adjuvant in the treatment of bullous pemphigoid

BACKGROUND

Bullous pemphigoid is a chronic, blistering and autoimmune disease, common in old age. The treatment usually includes systemic steroids, however, these cause high morbidity rates, and then different products that function as adjuvants have been tried. At present, there are no studies to determine which adjuvant offers a better efficacy and safety profile.

METHODS

We performed a retrospective study which included the records of patients with bullous pemphigoid, treated either with azathioprine or dapsone. We evaluated the time to achieve complete remission, the time to inhibit disease progression, and the control of pruritus.

RESULTS

Fifteen records of patients were selected, eight (53%) treated with azathioprine and seven (47%) with dapsone. Complete remission was achieved at week six in both groups. We found no difference in the inhibition of disease progression (p=0.083). Pruritus was controlled at four weeks of treatment in both treatments.

CONCLUSIONS

Both products are effective as adjuvant in the treatment of bullous pemphigoid, with an acceptable safety profile.

Management of autoimmune blistering diseases in Spain

Autoimmune blistering diseases (AIBD) are relatively uncommon all over the world. Therefore most physicians and even dermatologists are generally unfamiliar with their diagnosis and treatment. In Spain there are very few dermatologists and dermatology clinics specialized in AIBD. This article provides an overview of the management of AIBD in Spain at the present time.