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Vander Does A, Gamret AC, Yosipovitch G. Nail Loss in Mild to Moderate Pemphigus Vulgaris. Skin Appendage Disord 2022; 8:504-507. [PMID: 36407650 PMCID: PMC9672869 DOI: 10.1159/000525462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/05/2022] [Indexed: 07/27/2023] Open
Abstract
Introduction Symptoms of pemphigus vulgaris (PV) rarely include nail findings. When ungual involvement does occur, the most common manifestations are paronychia and onychomadesis. Onycholysis is very uncommon, and complete nail loss has not been reported in the literature. Ungual involvement is thought to be closely correlated with disease severity, with only severe PV cases demonstrating nail symptoms. Case Presentation We report a case of a 34-year-old female presenting with mild to moderate PV yet severe onycholysis of her first toe leading to secondary nail loss in conjunction with paronychia of her bilateral thumbs. Oral tofacitinib and rituximab infusions led to strikingly rapid improvement in her nail symptoms. Discussion/Conclusion This case illustrates the importance of a thorough history and physical exam, as a primary complaint of nail symptoms in these patients may lead to unrecognized PV by even the most skilled practitioners. Tofacitinib and rituximab in combination may rapidly improve nail involvement.
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Affiliation(s)
| | | | - Gil Yosipovitch
- Dr. Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, Miami, Florida, USA
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Cao S, Cui X, Li J, Pan F, Yan X, Yang Q, Chen M, Zhou S, Du D, Wang W, Sun Y, Shi Z, Wu M, Yang B, Zhang F. Nail changes in pemphigus and bullous pemphigoid: A single-center study in China. Front Med (Lausanne) 2022; 9:933608. [PMID: 36203762 PMCID: PMC9530441 DOI: 10.3389/fmed.2022.933608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
Abstract
Common autoimmune bullous diseases (AIBDs) include pemphigus and bullous pemphigoid (BP), which are primarily caused by IgG autoantibodies against the structural proteins of desmosomes at the cell–cell junction and hemidesmosomes at the epidermal–dermal junction. Few studies have assessed nail changes in patients with pemphigus or BP. In the present study, we collected the clinical data of 191 patients with AIBDs (108 patients with pemphigus and 83 patients with BP) and 200 control subjects. Nail changes were observed in 77.0% (147/191), 77.8% (84/108), and 75.9% (63/83) of patients with AIBDs, pemphigus, and BP, respectively, and 14.5% (29/200) of control subjects. Beau's lines and paronychia were the most common nail involvement, observed in 22.5% (43/191) and 22.5% (43/191) of patients with AIBDs, 25.0% (27/108) and 25.9% (28/108) of patients with pemphigus, 19.3% (16/83) and 18.1% (15/83) of patients with BP, respectively. The autoimmune bullous skin disorder intensity score (ABSIS) and the onset time of patients with pemphigus or BP with nail changes were different. Onychomycosis accounted for 21.5% (41/191) of all patients with AIBDs. The ABSIS was correlated with nail involvement in patients with BP (r = 0.46, p < 0.001), and weakly correlated with nail involvement in patients with AIBDs (r = 0.37, p < 0.001), pemphigus (r = 0.29, p = 0.009), and pemphigus vulgaris (PV; r = 0.35, p = 0.008). No correlation was observed between nail involvement and disease antibody titers. In conclusion, nail changes are frequently observed in patients with pemphigus and BP. The type and onset time of nail changes may indicate the severity of pemphigus and BP, which warrants the attention of dermatologists.
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Autoimmune bullous skin diseases, pemphigus and pemphigoid. J Allergy Clin Immunol 2020; 145:1031-1047. [DOI: 10.1016/j.jaci.2020.02.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023]
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De D, Kumar S, Handa S, Mahajan R. Fingernail involvement in pemphigus and its correlation with disease severity and other clinicodemographic parameters. Br J Dermatol 2018; 180:662-663. [DOI: 10.1111/bjd.17136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- D. De
- Department of Dermatology, Venereology and Leprology Postgraduate Institute of Medical Education and Research Chandigarh 160012 India
| | - S. Kumar
- Department of Dermatology, Venereology and Leprology Postgraduate Institute of Medical Education and Research Chandigarh 160012 India
| | - S. Handa
- Department of Dermatology, Venereology and Leprology Postgraduate Institute of Medical Education and Research Chandigarh 160012 India
| | - R. Mahajan
- Department of Dermatology, Venereology and Leprology Postgraduate Institute of Medical Education and Research Chandigarh 160012 India
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Gopal V, Shenoy MM, Bejai V, Nargis T. Nail changes in autoimmune blistering disorders: A case-control study. Indian J Dermatol Venereol Leprol 2018; 84:373. [PMID: 29327699 DOI: 10.4103/ijdvl.ijdvl_19_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Pemphigus and pemphigoid disorders produce blistering cutaneous lesions. Earlier case reports state that nail involvement is uncommon in these autoimmune blistering disorders. Aims and Objectives To study nail changes in autoimmune blistering disorders. Methods A case-control study was conducted where 40 cases and 40 controls were evaluated for nail changes. Results Nail changes were seen in 72.5% of cases and 17.5% of controls. The most common nail findings were paronychia and onychorrhexis. Limitations Small sample size; short study duration; nail biopsy could not be done. Conclusion Our findings indicate that the inflammatory nature of the blistering cutaneous disease is often reflected conspicuously in the nails.
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Affiliation(s)
- Vaishnavi Gopal
- Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
| | - Manjunath Mala Shenoy
- Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
| | - Vishal Bejai
- Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
| | - Thansiha Nargis
- Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
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Pietkiewicz P, Bowszyc-Dmochowska M, Gornowicz-Porowska J, Dmochowski M. Involvement of Nail Apparatus in Pemphigus Vulgaris in Ethnic Poles Is Infrequent. Front Med (Lausanne) 2018; 5:227. [PMID: 30155468 PMCID: PMC6102408 DOI: 10.3389/fmed.2018.00227] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/25/2018] [Indexed: 11/21/2022] Open
Abstract
Pemphigus vulgaris lesions have a tendency to localize around natural body orifices. The aim here was to analyze the involvement of nail apparatus in pemphigus vulgaris. Sixty seven ethnic Poles suffering from pemphigus vulgaris on photographic files archiving initial presentation were retrospectively evaluated. Pemphigus vulgaris was diagnosed using combination of clinical data, H+E histology, direct immunofluorescence of plucked scalp hair and/or perilesional tissue also for IgG1 and IgG4 deposits evaluation, indirect immunofluorescence on mosaic substrate and/or monkey esophagus, mono-analyte ELISA with desmoglein 1/3 or multi-analyte ELISA. The nail apparatus involvement was found in 9 of 67 patients (13.4%; 3 females and 6 males). Periungual fingernail lesions were found in 6 patients (2 females, 4 males), whereas periungual toenail lesions in just 3 patients (1 female, 2 males). Our patients nail apparatus changes included, by order of frequency, paronychia, nail discoloration, onychorrhexis, Beau lines, periungual hemorrhages, onychomadesis, cross-ridging, onycholysis, and trachyonychia. The average time between the onset, as recalled by patients, and the diagnosis of pemphigus vulgaris with direct immunofluorescence was not statistically different in PV patients with and without nail apparatus lesions. In this article the molecular and immunological rationale for of periungual involvement is discussed. Our single-center study suggests that nail apparatus involvement is infrequent in pemphigus vulgaris in ethnic Poles. Due to the fact that nail apparatus lesions in pemphigus vulgaris may clinically resemble onychomycosis, giving the proper diagnosis can be difficult particularly when other lesions are overlooked or misinterpreted.
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Affiliation(s)
- Pawel Pietkiewicz
- Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
- Surgical Oncology and General Surgery Clinic I, Greater Poland Cancer Center, Poznan, Poland
| | | | | | - Marian Dmochowski
- Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
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Zawar V, Pawar M, Kumavat S. Recurrent Paronychia as a Presenting Manifestation of Pemphigus Vulgaris: A Case Report. Skin Appendage Disord 2017; 3:28-31. [PMID: 28611998 DOI: 10.1159/000455881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 12/21/2016] [Indexed: 11/19/2022] Open
Abstract
Nail involvement in pemphigus vulgaris (PV) is an unusual clinical finding. The most common clinical manifestations include chronic paronychia and onychomadesis. We report an adult female patient with PV who initially presented with chronic paronychia of multiple fingernails and toenails before the onset of vesiculobullous eruptions. Later on, after complete resolution, there was recurrence of pemphigus presenting as hemorrhagic paronychia of the left index finger. Systemic treatment with corticosteroids and azathioprine led to complete resolution of mucocutaneous lesions as well as nail manifestations. Thus, chronic treatment-resistant paronychia may be an early and important sign of generalized pemphigus in certain patients.
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Beau lines, onychomadesis, and retronychia: A unifying hypothesis. J Am Acad Dermatol 2015; 73:849-55. [DOI: 10.1016/j.jaad.2015.08.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/01/2015] [Accepted: 08/05/2015] [Indexed: 11/22/2022]
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El-Komy MM, Abdel Halim DM, Samir N, Hegazy RA, Gawdat HI, Shoeb SA. Nail changes in female pemphigus vulgaris patients on immunosuppressive therapy. Int J Womens Dermatol 2015; 1:82-84. [PMID: 28491963 PMCID: PMC5418749 DOI: 10.1016/j.ijwd.2015.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 01/28/2015] [Accepted: 01/28/2015] [Indexed: 11/30/2022] Open
Abstract
Background Pemphigus vulgaris (PV) patients receiving immunosuppressive therapy may develop nail alterations resulting from infection, skin disorder, or drug regimen. Objective This study aims to describe nail changes in PV female patients receiving immunosuppressive therapy and to report the frequency of associated fungal and bacterial growth in the patients’ nails. Methods Twenty-five female PV patients who had at least one acquired finger or toenail abnormality and had been administered at least one immunosuppressive drug were included in the study. Nail alterations were recorded. Nail scrapings were collected from abnormal nails for fungal and bacterial examination. Results Positive fungal and bacterial cultures were detected in 20 (80%) of patients’ nail samples. Five patients reported nail alterations coinciding with disease onset, whereas 13 reported nail changes after administration of immunosuppressive therapy. Limitations Lack of a control group (patients on similar immunosuppressive medications for conditions other than PV) which would have further supported the findings demonstrated in this observational study. Conclusion Nail abnormalities in severe PV patients are frequently associated with fungal and bacterial growth. Immunosuppressive therapy potentially initiates such changes. What is already known on this topic? Pemphigus vulgaris (PV) patients receiving immunosuppressive therapy may develop nail alterations resulting from infection, skin disorder, or drug regimen.
What does this article add to our knowledge? The duration of disease in severe PV appears to dictate the longevity of nail changes in patients, and immunosuppressive therapy may initiate these nail changes either alone or as a result of opportunistic bacterial and/or fungal growth affecting the nail unit. Accordingly, prompt treatment of PV utilizing a multidisciplinary approach (combined or sequential therapy) would presumably decrease the incidence of nail affection in PV patients on immunosuppressive therapy. Limitations of the present work include lack of a control group (patients on similar immunosuppressive medications for conditions other than PV), which would have further supported the findings demonstrated in this observational study.
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Affiliation(s)
- M M El-Komy
- Dermatology Department, Faculty of Medicine, Cairo University
| | - D M Abdel Halim
- Dermatology Department, Faculty of Medicine, Cairo University
| | - N Samir
- Dermatology Department, Faculty of Medicine, Cairo University
| | - R A Hegazy
- Dermatology Department, Faculty of Medicine, Cairo University
| | - H I Gawdat
- Dermatology Department, Faculty of Medicine, Cairo University
| | - S A Shoeb
- Microbiology and Immunology Department, Faculty of Medicine, Cairo University
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Hardin J, Haber R. Onychomadesis: literature review. Br J Dermatol 2015; 172:592-6. [DOI: 10.1111/bjd.13339] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2014] [Indexed: 12/29/2022]
Affiliation(s)
- J. Hardin
- Division of Dermatology; Richmond Road Diagnostic and Treatment Centre; University of Calgary; 1820 Richmond Road SW Calgary AB T2T5C7 Canada
| | - R.M. Haber
- Division of Dermatology; Richmond Road Diagnostic and Treatment Centre; University of Calgary; 1820 Richmond Road SW Calgary AB T2T5C7 Canada
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Anal involvement in pemphigus vularis. Autoimmune Dis 2013; 2013:609181. [PMID: 24298388 PMCID: PMC3835701 DOI: 10.1155/2013/609181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 09/19/2013] [Indexed: 11/17/2022] Open
Abstract
Background. Pemphigus vulgaris (PV) is an autoimmune blistering disease of the skin and mucosa. Anal mucosa may be involved in PV, but the frequency and clinical profile are not fully ascertained. Objective. The aim was to investigate the involvement of the anal area in newly diagnosed PV patients. Patients and Methods. A total of 168 consecutive newly diagnosed PV patients were enrolled. Anal symptoms and signs, involvement of other body sites, and severity of disease were recorded. Results. A total of 47 out of 168 patients (27.9%) had involvement of the anal area. Anal involvement was significantly associated with PV lesions in ophthalmic (P = 0.03), nasal (P = 0.02), and genital mucosa (P < 0.001) but not the oral cavity (P = 0.24). There was a significant association between number of involved mucosal sites and anal involvement (P < 0.001). Anal involvement was associated with oral severity (P = 0.02). Constipation was the most frequent symptom (73.8%) followed by pain on defecation (50%). Seventeen patients (36%) were symptom-free. Erosion was the most frequent sign (91.5%). Conclusion. Anal involvement in PV seems to be more frequent than previously assumed. Routine anal examination is recommended even in asymptomatic patients as anal involvement appears to correlate with the severity of PV.
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Benhiba H, Hamada S, Guerouaz N, Saidi A, Senouci K, Hassam B. [Pemphigus vulgaris: an unusual clinical presentation]. Ann Dermatol Venereol 2013; 140:116-9. [PMID: 23395493 DOI: 10.1016/j.annder.2012.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 10/10/2012] [Accepted: 11/13/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pemphigus vulgaris is a bullous auto-immune disease affecting the skin and mucosa. It is characterised by acantholysis that results in the formation of intraepithelial bullous lesions. Herein we report a case distinguished by its unusual clinical presentation. PATIENTS AND METHODS A 45-year-old man, a chronic smoker, consulted for hyperkeratotic lesions of the toes on the right foot present for 5 months. Examination revealed a violet colour of the toes associated with localised yellowish keratoderma on the sole of the foot and impaired toe nails, as well as impairment on the nails of the first, third and fourth fingers on the right hand. In addition, two hyperkeratotic plaques with crusts were noted on the patient's forehead. Histological examination of a biopsy sample taken from the nail bed of the fourth toe on the right foot showed suprabasal acantholysis with a characteristic tombstone appearance. Direct immunofluorescence confirmed the diagnosis of pemphigus. Oral corticosteroid therapy was initiated consisting of prednisone 1.5mg/kg per day. Improvement of the nail lesions and subsidence of the lesions on the patient's forehead occurred after three months of treatment. DISCUSSION During the course of pemphigus, the nail findings most commonly reported in the literature are paronychia, onychomadesis and onycholysis. However, these signs are generally seen in patients with known pemphigus vulgaris and only rarely indicate bullous disease. The case we report illustrates a special situation in which pemphigus vulgaris was revealed by unusual skin and nail lesions.
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Affiliation(s)
- H Benhiba
- Dermatologie-vénéréologie, université Mohamed V, CHU Ibn Sina, avenue Ahmed-Balafrej, 10000 Rabat, Maroc.
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Affiliation(s)
- Luis Dehesa
- University of Miami Hospital/Florida Academic Dermatology Center; Miami; Florida
| | - Antonella Tosti
- Department of Dermatology & Cutaneous Surgery; University of Miami Miller School of Medicine; Miami; Florida
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Tosti A, André M, Murrell DF. Nail Involvement in Autoimmune Bullous Disorders. Dermatol Clin 2011; 29:511-3, xi. [DOI: 10.1016/j.det.2011.03.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
The diagnosis of onychodystrophy has increased in dermatology consultation. This could be due to its esthetic effect, pain or disability, physician awareness for detecting the disease in the context of dermatologic or systemic diseases, or a greater incidence. One of the first differential diagnoses that should be considered when an onychodystrophic nail is observed is onychomycosis, which is the cause in 50% of cases.
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Affiliation(s)
- Miguel Angel José Allevato
- Department of Dermatology, Universidad de Buenos Aires, UBA, Paraguay 2345, CABA (1121), Buenos Aires, Argentina.
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Sass U, Kolivras A, Richert B, Moulonguet I, Goettmann-Bonvallot S, Anseeuw M, Theunis A, André J. Acantholytic tumor of the nail: acantholytic dyskeratotic acanthoma. J Cutan Pathol 2009; 36:1308-11. [DOI: 10.1111/j.1600-0560.2009.01276.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Patsatsi A, Sotiriou E, Devliotou-Panagiotidou D, Sotiriadis D. Pemphigus vulgaris affecting 19 nails. Clin Exp Dermatol 2009; 34:202-5. [DOI: 10.1111/j.1365-2230.2008.02824.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Habibi M, Mortazavi H, Shadianloo S, Balighi K, Ghodsi SZ, Daneshpazhooh M, Valikhani M, Ghassabian A, Pooli AH, Chams-Davatchi C. Nail changes in pemphigus vulgaris. Int J Dermatol 2008; 47:1141-4. [DOI: 10.1111/j.1365-4632.2008.03796.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Pemphigus is an infrequent, organ-specific, autoimmune bullous disease, which affects the skin, mucous membranes and appendages. Histopathologically, it is characterized by acantholysis. Pemphigus has classically been divided into two major groups, pemphigus vulgaris and pemphigus foliaceus, with their respective clinical variants pemphigus vegetans and pemphigus erythematosus. In recent years, new variants of pemphigus have been described: paraneoplastic pemphigus, IgA pemphigus and pemphigus herpetiformis. This article reviews the epidemiology, etiopathogenesis, clinical symptoms, diagnosis, treatment and prognosis of pemphigus. Advances in molecular biology techniques have made it possible to more precisely identify the different antigens against which antibodies are directed, and to fine-tune ELISA diagnostic techniques. Treating pemphigus vulgaris and foliaceus with general steroids has modified their prognosis; it is estimated that mortality in recent decades is less than 10 %. Managing the clinical complications that appear during the evolution of the pemphigus has contributed to reducing morbidity and mortality.
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Abstract
Acute paronychia, the suppurative inflammation involving the paronychium of the nails, is usually caused by bacterial or fungal infection and has been rarely reported as a presentation of pemphigus vulgaris (PV). We report a woman with PV who presented with suppurative paronychia of multiple fingernails and toenails, which preceded the exacerbation of other mucocutaneous lesions. A biopsy specimen of the paronychium revealed suprabasal vesicles due to acantholysis. Systemic corticosteroids and adjuvant immunosuppressants were effective in treating mucocutaneous lesions as well as nail disease. We conclude that in patients with PV, acute paronychia could be a manifestation of the disease per se, rather than an infectious process. Only the precise diagnosis with adequate immunosuppressive treatment can lead to good control of disease activity.
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Affiliation(s)
- H E Lee
- Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Taiwan
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