Mixed immunobullous disease of childhood: a good response to antimicrobials

Management Options for Linear Immunoglobulin A (IgA) Bullous Dermatosis: A Literature Review

Linear immunoglobulin A (IgA) bullous dermatosis (LABD) is an autoimmune condition with various triggers. Because of the lack of randomized controlled trials on LABD treatment, management options are mostly anecdotal. This paper provides a comprehensive review of treatment options from a literature review of reported treatments to arm clinicians with a guideline for the management of LABD in both pediatric and adult patients as well as those recalcitrant to first-line therapy (dapsone and steroids). We additionally illustrate an algorithm to use for the management of LABD to aid clinicians when faced with unique patient circumstances.

Genetic and acquired blistering disorders of pediatric age group: An experience from Eastern India

Introduction

Blistering or vesiculobullous disorders in pediatric population are either immunobullous or mechanobullous. Spectrum was analyzed using demographic details, clinical features, histopathology, direct immunofluorescence (DIF) and Immunofluorescence mapping (IFM).

Methodology

This was a single institution based observational study in children below 18 years. The demographic details were collected using proforma containing particulars of the patient, history, complaints, and other parameters. Punch biopsy of the skin lesion was done. Biopsy samples were examined under light microscope followed by DIF using fluorescent conjugated polyclonal antibody against immunoglobulins IgG, IgM, IgA, and complement C3. The salt-split technique was also used in particular cases. IFM was done using anticytokeratin (CK) 5 & 14, antilaminin 332, anticollagen VII, and anticollagen IV antibodies.

Results

Out of total 50 cases, linear IgA bullous dermatosis (LABD) was the commonest. The average concordance between clinical and final diagnosis (histopathological examination + DIF) was 87.5% and discordance was 12.5%. The agreement between histopathological examination and DIF was found to be substantially significant (κ = 0.6892). IFM depicted epidermolysis bullosa simplex with reduced CK 14 expression, dystrophic epidermolysis bullosa with reduced Collagen VII expression and junctional epidermolysis bullosa with absent laminin 5 expression.

Conclusion

The spectrum of bullous lesions in childhood was properly delineated and subcategorization of EB was done. Histopathological examination showed the hallmarks that were conclusive in most of the cases except in LABD and EB. DIF and IFM proved indispensable in those cases. Thus, DIF is not a substitute for histopathology but complementary to it.

Bullous diseases: Kids are not just little people

Bullous diseases may be rare; however, this does not preclude the clinician from being familiar with their manifestations and treatment. After ruling out infection, genetically inherited blistering diseases are more likely to be the cause of blistering or erosions in the neonatal period, whereas immunobullous diseases are more common in adults. Published literature on immunobullous disorders reflects information gleaned from case reports and open-label case series; prospective studies and evidence-based treatments are limited. Although there may be overlapping clinical features, significant clinical differences exist between adults and children. Evidence-based treatment guidelines are limited, and information from the adult literature cannot be readily generalized to the pediatric population. This paper reviews the approach to blistering conditions and the differences among bullous pemphigoid, linear immunoglobulin A disease, dermatitis herpetiformis, pemphigus foliaceus, pemphigus vulgaris, and paraneoplastic pemphigus in adult versus pediatric patients.

Chronic bullous disease of childhood with IgG predominance: what is the locus standi?

Linear IgA disease (LAD) is an acquired, autoimmune, subepidermal, blistering disease, characterized by linear deposition of IgA along the dermoepidermal junction on immunofluorescence. Some cases known as 'mixed immunobullous disease' show weak staining with other immune reactants like IgG, IgM or C3. We report a rare case of a child having typical manifestations of LAD (chronic bullous disease of childhood), but with IgG predominance rather than IgA. Obviously it is improper to term this as linear IgA disease. Such cases are reported in literature as variants of LAD, with a multitude of terms like mixed immune bullous disease, linear IgG / IgA disease, linear IgA / IgG disease, and so on. In view of the tremendous confusion that these multiple terms cause in the absence of any practical benefit, we propose that the broad term 'chronic bullous disease of childhood' be applied to all childhood cases, irrespective of the nature of the immune deposits.

Linear IgA disease: clinical presentation, diagnosis, and pathogenesis

Linear IgA disease is one of the rarer subepidermal blistering diseases. Linear IgA disease is a chronic, acquired, autoimmune blistering disease that is characterized by subepidermal blistering and linear deposition of IgA basement membrane antibodies. The disease affects both children and adults and, although there are some differences in their clinical presentations, there is considerable overlap with shared immunopathology and immunogenetics.

Unusual clinicopathological and immunological presentation of chronic bullous dermatosis of childhood (linear IgA dermatosis)

Linear IgA bullous dermatosis is a rare sulfone-responsive subepidermal blistering disorder of unknown etiology in which smooth linear deposits of IgA are found in the basement membrane zone. Chronic bullous dermatosis of childhood is equivalent to linear IgA disease of adulthood and is characterized by an abrupt onset of large, widespread and tense bullae on a normal or erythematous base. In this case, we describe an unusual presentation of chronic bullous dermatosis in a 14-month-old Saudi girl. Histopathological examination revealed subepidermal cell poor blisters with linear deposition of IgA, IgG, IgM, and C3 along the dermoepidermal junction. The unusual clinical, histopathological and immunofluorescence findings in this patient are discussed, with an account on the differential diagnosis in such cases along with a detailed review of the relevant literature.

Linear IgA disease: clinical presentation, diagnosis, and pathogenesis

Linear IgA disease is one of the rarer subepidermal blistering diseases. Linear IgA disease is a chronic, acquired, autoimmune blistering disease that is characterized by subepidermal blistering and linear deposition of IgA basement membrane antibodies. The disease affects both children and adults and, although there are some differences in their clinical presentations, there is considerable overlap with shared immunopathology and immunogenetics.

Clinical features, diagnosis, and pathogenesis of chronic bullous disease of childhood

Chronic bullous disease of childhood (CBDC) is the most common acquired autoimmune blistering disorder of childhood and is characterized by linear IgA staining of the basement membrane zone on direct immunofluorescence. This autoimmune attack on structural proteins, usually proteolytic fragments of collagen XVII, renders the dermal-epidermal junction prone to blistering. Diagnosis is confirmed by characteristic histology and direct immunofluorescence. Prognosis is generally favorable, with spontaneous remission usually occurring by puberty; however, cases with severe morbidity and cases persisting into adulthood have been reported. This article discusses the clinical features, diagnosis, and pathogenesis of CBDC in more detail.

Allergic skin reactions in the tropics

Cutaneous allergic reactions are relatively common in tropical countries, with some caused by the tropical environment and others by changes in the traditional living conditions combined with poverty. HIV infection is a major contributory factor. A large number of reactions are eczematous. Atopic dermatitis is on the increase together with contact allergic reactions. Available products are often of inferior quality and contain irritants and allergens that may be forbidden elsewhere in the world. The extensive and uncontrolled use of drugs and indigenous medications together with an increase in HIV prevalence leads to drug eruptions such as the Stevens-Johnson syndrome and toxic epidermal necrolysis. Poverty plays an important role in the prevalence of insect bites and resulting papular urticaria and possibly in acropustulosis infantum. Many unexplained environmentally induced blistering diseases occur, ranging from phytophotodermatitis to fogo selvagem and from pemphigus foliaceus to chronic bullous dermatosis of childhood. This article describes the allergic conditions that occur in the tropics. Special attention is given to those cases of eczema and eruptions that are specific to tropical countries. Available treatments are also discussed.

Penfigoide ampolloso en lactante tras vacunación

Bullous pemphigoid (BP) is a disease that characteristically affects the elderly, although cases have been described in children. We present a case of BP in a two-month-old infant with bullous lesions on the palms and soles, which appeared one week after receiving the first dose of the hepatitis B, polio, DTP and HiB vaccine. She was treated with sulphated water, dexamethasone and fusidic acid, and the lesions disappeared. One month later, she presented with a new, more generalized outbreak, three days after the second dose of the same vaccine. The skin eruption completely subsided 3 months after treatment with deflazacort was initiated (1 mg/kg/day). After five years of follow up, the patient has not presented with lesions again, despite having received the rest of the vaccines on the official schedule.

Childhood bullous pemphigoid: report of a case with life-threatening course during homeopathy treatment

Bullous pemphigoid (BP) is an autoimmune blistering disorder that may very rarely occur in childhood. We describe a 9-month-old child who developed bullous pemphigoid while she was being treated for presumptive atopic eczema with a homeopathic regimen comprising sulfur, mercury, cantharides, and Rhus (Toxicodendron). She had generalized bullae and a progressive worsening of her general condition with asthenia, dehydration, malnutrition. While the role of homeopathy in triggering the disease remains unclear, our observation attests to the potential life-threatening course of childhood BP in instances where appropriate treatment is withheld.

Linear IgA disease: the IgA and IgG response to the epidermal antigens demonstrates that intermolecular epitope spreading is associated with IgA rather than IgG antibodies, and is more common in adults

BACKGROUND

Linear IgA disease (LAD; adult and childhood) is a dapsone-responsive, acquired immunobullous disorder mediated by IgA antibodies directed at target antigens within the epithelial basement membrane. These antigens have not been completely characterized.

OBJECTIVES

To identify the target antigens in LAD, and to correlate these with the antibody isotype.

METHODS

We used 101 LAD sera without IgG antibodies detected by indirect immunofluorescence. The sera were analysed by immunoblotting for IgA (65 adults and 36 children) and IgG (61 adults and 34 children) autoantibodies, on salt-split, urea-extracted epidermal tissue extracts.

RESULTS

Antigens were targeted in LAD by IgA antibodies (54 adults and 23 children), IgG antibodies (34 adults and 19 children), and both isotypes (30 adults and 16 children). Three major antigens were recognized by IgA antibodies: LAD285 (22 adults and three children), BP230 (30 adults and eight children) and BP180 (collagen XVII), including the 97-kDa ectodomain (52 adults and 20 children). Seven 'minor' antigens were occasionally detected (18 adults and 13 children). IgA antibodies bound multiple antigens (33 adults and nine children) more frequently than single antigens (21 adults and 14 children), but the binding to multiple antigens was more restricted in children than in adults. IgG antibodies mainly bound a single antigen (29 adults and 16 children), predominantly BP180.

CONCLUSIONS

There was variation in the autoantibody response within the disease and the patient, with regard to target molecules and autoantibody class. The finding that IgG as well as IgA autoantibodies predominantly target BP180 supports a pivotal role for collagen XVII in adult and childhood LAD. The IgG response was very restricted compared with IgA autoantibodies (P < 0.01). Autoantibodies from children had a more restricted antigen repertoire than from adults (P < 0.05). Epitope spreading is common in LAD and is affected by the class of autoantibody and age of the patient.

[Blistering autoimmune diseases of childhood]

Autoimmune blistering skin diseases are exceedingly rare in children. In most cases, they are characterized by circulating autoantibodies directed against adhesion structures of the skin which subsequently induce blistering at the dermoepidermal junction or intraepidermally. The most frequent paediatric immunobullous disease is linear IgA dermatosis; all others such as pemphigoid, epidermolysis bullosa acquisita, dermatitis herpetiformis and pemphigus are less common than in adults. In children, mucous membranes are involved more frequently. Recent advances in the identification of the autoantigens have improved diagnostic approach and therapeutic management of blistering diseases. In most cases, treatment requires systemic immunosuppression. With respect to the chronic course of the diseases and potential complications of treatment, cooperation between dermatologists and paediatricians seems advisable.

Linear IgA disease: successful treatment with erythromycin

Conventional first-line treatments for linear IgA disease (and the related chronic immunobullous disease of childhood) include topical steroids and dapsone, both of which may be associated with potentially serious side-effects. Alternative anti-inflammatory therapies such as tetracycline and macrolide antibiotics, have been used to treat other immunobullous disorders and we now report an adult case of linear IgA disease and a paediatric case of mixed immunobullous disease of childhood that both responded to the macrolide antibiotic erythromycin. The mode of action is speculative and anti-inflammatory mechanisms are unclear. Nevertheless, from a clinical perspective, erythromycin may have a role in the treatment of linear IgA disease and could be considered ahead of many other, perhaps potentially more toxic, therapies.