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The Intriguing Links between Psoriasis and Bullous Pemphigoid. J Clin Med 2022; 12:jcm12010328. [PMID: 36615129 PMCID: PMC9821109 DOI: 10.3390/jcm12010328] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 01/03/2023] Open
Abstract
The coexistence of psoriasis with autoimmune bullous diseases (AIBDs), particularly bullous pemphigoid (BP), has been documented in case reports and series, as well as in epidemiological studies. The onset of psoriasis precedes that of BP in the majority of cases. Patients with concomitant BP and psoriasis are generally younger at the onset of BP and present with fewer erosions and blisters as compared with patients suffering from isolated BP. Intriguingly, it has been speculated that some BP cases with comorbid psoriasis can actually correspond to anti-laminin gamma-1 pemphigoid, a rare form that was recently recognized as a distinct entity and which can mimic BP and/or other subepidermal AIBDs. The pathomechanisms underlying the BP-psoriasis association have not yet been identified, although several hypotheses have been proposed. The most credited among such hypotheses involves the so-called "epitope spreading" phenomenon, with tissue injury secondary to a primary inflammatory process (i.e., psoriasis) leading to the exposure of sequestered antigens evoking a secondary autoimmune disease (i.e., bullous pemphigoid). This narrative review aims to give a brief overview of the association between psoriasis and BP, examining epidemiological, clinical, and immunopathological features, the pathomechanisms underlying this association, the treatments for psoriasis incriminated as potential triggers of BP, and the therapeutic management of patients with psoriasis and BP.
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Management of Coexisting Bullous Pemphigoid and Psoriasis: A Review. Am J Clin Dermatol 2022; 23:869-879. [DOI: 10.1007/s40257-022-00719-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 11/01/2022]
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Neema S, Sandhu S, Gupta A, Jagadeesan S, Vasudevan B. Unconventional treatment options in psoriasis: A review. Indian J Dermatol Venereol Leprol 2021; 88:137-143. [PMID: 34623042 DOI: 10.25259/ijdvl_22_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 05/01/2021] [Indexed: 11/04/2022]
Abstract
Psoriasis is a common skin disease that affects 1-3% of the general population. The treatment depends on body surface area involved, quality of life impairment and associated comorbidities. The treatment options include topical therapy, phototherapy, conventional systemic therapy (methotrexate, cyclosporine and acitretin), biologics and oral small molecules (apremilast and tofacitinib). Despite the availability of newer therapies such as biologics and oral small molecules, many a time, there is a paucity of treatment options due to the chronic nature of the disease, end-organ toxicity of the conventional drugs or high cost of newer drugs. In these scenarios, unconventional treatment options may be utilized as stand-alone or adjuvant therapy. In this review, we have discussed these uncommonly used treatment options in the management of psoriasis.
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Affiliation(s)
- Shekhar Neema
- Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Sunmeet Sandhu
- Department of Dermatology, Command Hospital Air Force, Bengaluru, Karnataka, India
| | - Ankan Gupta
- Department of Dermatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Soumya Jagadeesan
- Department of Dermatology, Amrita Institute of Medical Sciences, Cochin, Kerala, India
| | - Biju Vasudevan
- Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India
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Chavez-Alvarez S, Herz-Ruelas M, Villarreal-Martinez A, Ocampo-Candiani J, Garza-Garza R, Gomez-Flores M. Azathioprine: its uses in dermatology. An Bras Dermatol 2020; 95:731-736. [PMID: 33250113 PMCID: PMC7672387 DOI: 10.1016/j.abd.2020.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/19/2020] [Indexed: 01/19/2023] Open
Abstract
This is a narrative review of azathioprine. This medication is immunomodulatory and immunosuppressive, and it has been used widely through different medical specialties to modify disease. It has been proven useful for several dermatoses and it has encountered success when used as an off-label indication for other dermatologic diseases. Its mechanism of action is described thoroughly, as well as precautions for monitoring adequate levels in patients using it. Dermatologists should also be aware of the possible adverse events it may present. In dermatology it can be used in bullous and autoimmune diseases, and in other conditions, including intractable pruritus, atopic dermatitis, photodermatoses, psoriasis, and others. Azathioprine offers an alternative as a steroid-sparing agent and this review helps dermatologists prescribe it safely to all patients who require it.
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Affiliation(s)
- Sonia Chavez-Alvarez
- Department of Dermatology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Maira Herz-Ruelas
- Department of Dermatology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Alejandra Villarreal-Martinez
- Department of Dermatology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Jorge Ocampo-Candiani
- Department of Dermatology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | | | - Minerva Gomez-Flores
- Department of Dermatology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico.
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Concurrence of Bullous Pemphigoid and Psoriasis: A Case Report. SERBIAN JOURNAL OF DERMATOLOGY AND VENEREOLOGY 2019. [DOI: 10.2478/sjdv-2018-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Bullous pemphigoid (BP) and psoriasis are chronic recurrent inflammatory skin diseases. The pathogenesis of concurrence of BP with psoriasis is still unknown. A 39-year-old male with a five-year history of chronic plaque psoriasis developed itchy large tense bullae on the trunk and upper extremities after he had been receiving narrow band ultraviolet B (NBUVB) therapy over five months. Skin biopsy from bulla on the trunk showed typical histological features of BP. Direct immunofluorescent staining showed deposit of immunoglobulin G and C3 in the basement membrane zone (BMZ) which supported the diagnosis of BP. It has been postulated that the autoimmune process responsible for BP lesions might be induced by ultraviolet light therapy and/or the inflammatory processes that occur in psoriasis.
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Abstract
Bullous pemphigoid is the most frequent autoimmune bullous disease and mainly affects elderly individuals. Increase in incidence rates in the past decades has been attributed to population aging, drug-induced cases and improvement in the diagnosis of the nonbullous presentations of the disease. A dysregulated T cell immune response and synthesis of IgG and IgE autoantibodies against hemidesmosomal proteins (BP180 and BP230) lead to neutrophil chemotaxis and degradation of the basement membrane zone. Bullous pemphigoid classically manifests with tense blisters over urticarial plaques on the trunk and extremities accompanied by intense pruritus. Mucosal involvement is rarely reported. Diagnosis relies on (1) the histopathological evaluation demonstrating eosinophilic spongiosis or a subepidermal detachment with eosinophils; (2) the detection of IgG and/or C3 deposition at the basement membrane zone using direct or indirect immunofluorescence assays; and (3) quantification of circulating autoantibodies against BP180 and/or BP230 using ELISA. Bullous pemphigoid is often associated with multiple comorbidities in elderly individuals, especially neurological disorders and increased thrombotic risk, reaching a 1-year mortality rate of 23%. Treatment has to be tailored according to the patient's clinical conditions and disease severity. High potency topical steroids and systemic steroids are the current mainstay of therapy. Recent randomized controlled studies have demonstrated the benefit and safety of adjuvant treatment with doxycycline, dapsone and immunosuppressants aiming a reduction in the cumulative steroid dose and mortality.
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Affiliation(s)
- Denise Miyamoto
- Division of Dermatology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP),
Brazil
| | - Claudia Giuli Santi
- Division of Dermatology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP),
Brazil
| | - Valéria Aoki
- Department of Dermatology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo (SP), Brazil
| | - Celina Wakisaka Maruta
- Department of Dermatology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo (SP), Brazil
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Dainichi T, Kabashima K. Interaction of Psoriasis and Bullous Diseases. Front Med (Lausanne) 2018; 5:222. [PMID: 30135860 PMCID: PMC6092515 DOI: 10.3389/fmed.2018.00222] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 07/20/2018] [Indexed: 12/26/2022] Open
Abstract
Patients with psoriasis are frequently complicated with autoimmune bullous diseases, especially, pemphigoid diseases. It has been known that one-third cases of anti-laminin gamma1 pemphigoid, formerly anti-p200 pemphigoid, are associated with psoriasis whereas bullous pemphigoid is the most frequently associated bullous disease in psoriasis cases regardless of the lack of detectable levels of the accompanying anti-laminin gamma1 autoantibodies. Despite several suggestions, however, the definitive reason of the striking association of psoriasis and these autoimmune bullous diseases remains elusive. In this review, we look over the epidemiological evidence of the association of psoriasis and autoimmune bullous diseases and the information of genetic susceptibilities of each disease, and discuss the possible mechanisms of their complication with reference to the recent understandings of each pathogenesis.
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Affiliation(s)
- Teruki Dainichi
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenji Kabashima
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Singapore Immunology Network and Institute of Medical Biology, Agency for Science, Technology and Research (ASTAR), Singapore, Singapore
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Mahajan VK. Psoriasis treatment: Unconventional and non-standard modalities in the era of biologics. World J Dermatol 2016; 5:17-51. [DOI: 10.5314/wjd.v5.i1.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/25/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
Psoriasis is a potentially debilitating inflammatory dermatosis affecting 0.2%-4.8% of the population worldwide causing a significant occupational, personal or psychosocial morbidity to these patients for life. The basic aim of psoriasis therapy is to control the disease to maximum possible extent and improve the patient’s quality of life. Management of triggers for flare-ups, lifestyle modifications, and dietary supplements are often recommended. Intermittent or rotational therapy with frequent alterations in treatment options is usually needed to reduce toxicity of anti-psoriatic drugs in the absence of safer alternatives. Currently, several biological agents categorized as either T-cell targeted (e.g., Alefacept, Efalizumab) or cytokine modulating (e.g., Adalimumab, Infliximab, Etanercept) are available for treating severe psoriasis. However, their high cost is often precluding for most patients. The usefulness of systemic (methotrexate, cyclosporine, acitretin or several other therapeutic agents) or topical (tar, anthralin, corticosteroids or calcipotriol ointments, phototherapy with or without psoralens) therapies has been well established for the management of psoriasis. The literature is also replete with benefits of less used non-standard and unconventional treatment modalities (hydroxycarbamide, azathioprine, leflunomide, mycophenolate mofetil, isotretinoin, fumarates, topical calcineurin inhibitors, peroxisome proliferator-activated receptors agonists, statins, sulfasalazine, pentoxifylline, colchicine, grenz ray therapy, excimer laser, climatotherapy and balneophototherapy, peritoneal dialysis, tonsillectomy, ichthyotherapy, etc.). These can be used alternatively to treat psoriasis patients who have mild/minimal lesions, are intolerant to conventional drugs, have developed side effects or achieved recommended cumulative dose, where comorbidities pose unusual therapeutic challenges, or may be as intermittent, rotational or combination treatment alternatives.
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Abstract
Although most psoriasis patients respond to standard therapies, many circumstances warrant the use of nonstandard or off-label treatments. For instance, patients with treatment-resistant psoriasis or those who have had multiple adverse effects to other therapies may be good candidates for off-label treatments. Similarly, patients with unusual and hard-to-treat forms of psoriasis such as pustular psoriasis and palmoplantar psoriasis or specific comorbidities may benefit from certain nonstandard therapies. Drugs that may be used as alternatives to standard therapies include mycophenolate mofetil, tacrolimus or pimecrolimus, isotretinoin, colchicine, sulfasalazine, paclitaxel, dapsone, azathioprine, and hydroxyurea. Other unconventional therapies include climatotherapy at the Dead Sea and grenz ray therapy.
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Affiliation(s)
- Caroline P Halverstam
- Department of Dermatology, Mount Sinai School of Medicine, Box 1048, New York, NY 10029-6574, USA
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Rallis E, Anyfantakis V. Coexistent psoriasis and bullous pemphigoid responding to mycophenolate mofetil monotherapy. Skinmed 2008; 7:101-2. [PMID: 18327004 DOI: 10.1111/j.1751-7125.2008.07318.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A 73-year-old woman with a 50-year history of psoriasis was referred to our clinic with a 4-month duration of tense bullae on erythematous base and erosions localized on her lower extremities and torso (Figure 1A). Neither the oral nor the ocular mucosa had been involved. The lesions were intensively pruritic, significantly affecting the quality of her life. At the time of the examination, the patient presented with psoriatic plaques with adherent scales confined on the scalp (Figure 2A). According to the patient's history, her limited psoriasis was partially controlled with occasional topical medications (topical corticosteroids, calcipotriol, and tar shampoo). She also had insulin-dependent diabetes mellitus, asthmatic bronchitis, and partially controlled hypertension with hyperlipidemia. A biopsy specimen was taken from lesional skin on her feet, and a histological examination showed a subepidermal blister with an inflammatory cell infiltrate in the upper dermis. No drugs were incriminated, and diagnosis of bullous pemphigoid was confirmed by Western immunoblotting of serum. Laboratory investigation revealed mild thrombocytopenia of 110,000/mm(3), cholesterol 279 mg/dL, and triglycerides 210 mg/dL. The patient could not tolerate prednisolone and cyclosporine because of hypertension and diabetes, or azathioprine because of the mild thrombocytopenia; she did not consent to receiving biologics. Mycophenolate mofetil (MMF) was then considered a choice. The patient agreed, and she was initially administered 1000 mg/d. After 2 weeks, the dosage increased to 1000 mg twice a day because of the formation of new blisters. Within 8 weeks of treatment with MMF 2000 mg/d, marked improvement was observed and her pruritus resolved. Complete remission of bullous pemphigoid and psoriasis was achieved within 3 and 4 months, respectively. Routine laboratory studies were performed before treatment and every month during therapy, and MMF was tolerated without side effects. The treatment was continued for 6 months with no subsequent relapse of the dermatoses (Figure 1B and Figure 2B).
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Patel AA, Swerlick RA, McCall CO. Azathioprine in dermatology: The past, the present, and the future. J Am Acad Dermatol 2006; 55:369-89. [PMID: 16908341 DOI: 10.1016/j.jaad.2005.07.059] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Revised: 02/25/2005] [Accepted: 07/23/2005] [Indexed: 01/19/2023]
Abstract
For several decades, dermatologists have utilized azathioprine to treat numerous debilitating skin diseases. This synthetic purine analog is derived from 6-mercaptopurine. It is thought to act by disrupting nucleic acid synthesis and has recently been found to interfere with T-cell activation. The most recognized uses of azathioprine in dermatology are for immunobullous diseases, generalized eczematous disorders, and photodermatoses. In this comprehensive review, the authors present recent advancements in the understanding of azathioprine and address aspects not covered in prior reviews. They (1) summarize the history of azathioprine; (2) discuss metabolism, integrating information from recent publications; (3) review the mechanism of action with attention paid to the activities of azathioprine not mediated by its 6-mercaptopurine metabolites and review new data about inhibition by azathioprine of the CD28 signal transduction pathway; (4) thoroughly examine thiopurine s-methyltransferase genetics, its clinical relevance, and interethnic variations; (5) review prior uses of azathioprine in the field of dermatology and grade the level of evidence; (6) discuss the use of azathioprine in pregnancy and pediatrics; review (7) key drug interactions and (8) adverse effects; (9) suggest a dosing and monitoring approach different from prior recommendations; and (10) explore the future of azathioprine, focusing on laboratory considerations and therapeutic application.
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Affiliation(s)
- Akash A Patel
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA 30322-0001, USA
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Abstract
A variety of therapeutic options are available to treat psoriasis and atopic dermatitis (AD). Local agents typically are used to treat localized and milder forms of disease, whereas phototherapy and systemic agents are used for more generalized and severe disease. Various combinations and sequences of topical or systemic therapies, or both, have been utilized in the treatment of psoriasis and, less frequently, of AD. Conventional systemic therapies for psoriasis, such as corticosteroids, oral calcineurin inhibitors, antimetabolites, and retinoids, are limited by their propensity to cause serious side effects. More recently, a number of immunobiologic agents, such as monoclonal antibodies, recombinant cytokines, and fusion proteins, have been approved by the Food and Drug Administration or are undergoing development as systemic antipsoriatic treatments. In many of these categories, a number of exciting new therapies are in development that may augment the existing armamentarium available to clinicians for the treatment of inflammatory skin diseases.
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Affiliation(s)
- Alice B Gottlieb
- Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, New Brunswick, NJ 08901, USA.
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Najarian DJ, Gottlieb AB. Connections between psoriasis and Crohn's disease. J Am Acad Dermatol 2003; 48:805-21; quiz 822-4. [PMID: 12789169 DOI: 10.1067/mjd.2003.540] [Citation(s) in RCA: 160] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
UNLABELLED The prevalence of psoriasis in patients with Crohn's disease (CD) is higher than chance would allow if they were mutually exclusive diseases. A close examination reveals genetic and pathologic connections between these diseases. An appreciation for the role of tumor necrosis factor-alpha in both diseases has proven very important. Increased levels of this inflammatory cytokine have been measured in CD lesions, and in 1997 a clinical trial demonstrated the response of this disease to infliximab, a monoclonal antibody specific for tumor necrosis factor-alpha. A subsequent clinical trial evaluated infliximab in a patient with CD and psoriasis, another disease in which increased levels of tumor necrosis factor-alpha are seen in lesions. Scientists noticed the marked skin improvement of this patient and later demonstrated the efficacy of infliximab for psoriasis in a randomized, double-blind, placebo-controlled trial. Thus, an appreciation for connections between psoriasis and CD can suggest novel therapeutic strategies with ensuing benefits to patients. This article reviews epidemiologic, genetic, and pathologic connections between psoriasis and CD and discusses pharmaceuticals targeting inflammatory mediators common to each disease. (J Am Acad Dermatol 2003;48:805-21.) LEARNING OBJECTIVE At the completion of this learning activity, participants should understand how psoriasis and Crohn's disease are related at epidemiologic, genetic, and pathological levels and should appreciate how to use this knowledge to treat these diseases.
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Affiliation(s)
- Rokea A El-Azhary
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Mimouni D, Nousari HC. Inhibitors of purine and pyrimidine synthesis: mycophenolate, azathioprine, and leflunomide. Dermatol Ther 2002. [DOI: 10.1046/j.1529-8019.2002.01539.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Pasić A, Ljubojević S, Lipozencić J, Marinović B, Loncarić D. Coexistence of psoriasis vulgaris, bullous pemphigoid and vitiligo: a case report. J Eur Acad Dermatol Venereol 2002; 16:426-7. [PMID: 12224717 DOI: 10.1046/j.1468-3083.2002.00570_12.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Mycophenolic mofetil, azathioprine, thioguanine, methotrexate, and cyclophosphamide were initially used for the treatment of malignancies. Because of their immunosuppressive activity, the range of diseases responsive to these medications has expanded to include various autoimmune-related diseases. Discussion includes a historical perspective of each medication, recent updates on responsive dermatologic conditions, dosages, monitoring guidelines, and medication expense.
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Affiliation(s)
- N G Silvis
- Section of Dermatology, Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
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