Neonatal pemphigus vulgaris with extensive mucocutaneous lesions from a mother with oral pemphigus vulgaris

Pregnancy in pemphigus vulgaris: A systematic review

PROBLEM

Pemphigus vulgaris may worsen during pregnancy, leading to both maternal and fetal complications. The relationship between pemphigus vulgaris and pregnancy remains unclear, and the outcomes and treatments of pemphigus vulgaris during pregnancy have not been extensively discussed.

METHOD OF STUDY

This article systematically reviews the literature, focusing on the relationship between pemphigus vulgaris and pregnancy. We conducted comprehensive searches in PubMed, Embase, Cochrane Library, and Web of Science databases, identifying 42 studies reporting the disease course, pregnancy outcomes, and management of both pregnancy and pemphigus vulgaris.

RESULTS

A total of 57 cases were included in the analysis, categorized into three distinct forms: pemphigus vulgaris onset before pregnancy (n = 33), onset during pregnancy (n = 20), and onset during the postpartum period (n = 4). Fifty four cases reported treatment strategies, among them, 44 cases (81.5%) initially received systemic corticosteroid therapy during pregnancy. Out of these cases, 7 (15.9%) did not achieve successful remission and required alternative treatment approaches. In terms of pregnancy outcomes, 23 out of 62 neonates (37.1%) exhibited skin lesions or tested positive for anti-dsg IgG in their serum, while 16 neonates (25.8%) experienced other complications.

CONCLUSIONS

These findings highlight the importance of effectively managing pemphigus vulgaris during pregnancy to ensure optimal outcomes.

Updates on the dermatopathology of pregnancy-associated skin conditions

Pathologists provide valuable input in the dermatological care of pregnant patients in various contexts. This article provides dermatopathology updates on cutaneous changes associated with pregnancy, organized based on the following classification system: physiological skin changes in pregnancy, specific dermatoses of pregnancy, dermatoses modified in pregnancy, and skin neoplasms in pregnancy. Awareness of the impact of pregnancy on the skin by pathologists is important, as this is an opportunity to contribute to diagnostic precision in this patient population.

Autoimmune bullous diseases in pregnancy: clinical and epidemiological characteristics and therapeutic approach

Autoimmune bullous dermatoses are a heterogeneous group of diseases with autoantibodies against structural skin proteins. Although the occurrence of autoimmune bullous dermatoses during pregnancy is low, this topic deserves attention, since the immunological and hormonal alterations that occur during this period can produce alterations during the expected course of these dermatoses. The authors review the several aspects of autoimmune bullous dermatoses that affect pregnant women, including the therapeutic approach during pregnancy and breastfeeding. Gestational pemphigoid, a pregnancy-specific bullous disease, was not studied in this review.

Pemphigus and pregnancy. Analysis and summary of case reports over 49 years

Pemphigus is a group of immune-mediated bullous disorders, which often cause fragile blisters and extensive lesions of the skin or mucous membranes, such as in the mouth. This disease could be life-threatening in some cases. During pregnancy, its condition will become more complicated due to the change in the mother’s hormone level and the effect of drug therapy on both the mother and her fetus. Thus, it will be more difficult to identify the clinical manifestations and to establish the treatment plan. In this article, we present a comprehensive review of pemphigus and pregnancy by analyzing 47 cases of pemphigus reported between 1966 and 2014, with diagnosis before or during pregnancy. The aim of this study is to make a comprehensive review of pemphigus and pregnancy, provide organized and reliable information for obstetricians, dermatologists, physicians, and oral medicine specialists.

Blistering diseases in neonates

PURPOSE OF REVIEW

Neonatal blistering diseases are rare yet potentially fatal. Therefore, it is crucial for clinicians to know its broad range of differential diagnoses. This review discusses the recent literature on the causes and the most appropriate clinical approach to neonatal blistering diseases.

RECENT FINDINGS

Neonatal infections are the commonest causes for neonatal blistering. On the other hand, autoimmune blistering diseases are extremely rare with the literature limited to case reports and one systematic review only. Inherited genodermatoses are also rare, with recent developments in epidermolysis bullosa classification.

SUMMARY

In conclusion, as neonatal infections are the commonest cause for blistering, any neonate with blistering should have their blister fluid investigated for infection, while an antimicrobial should be initiated early. Autoimmune blistering diseases should be considered in neonates with a maternal history of autoimmune blistering disease. Although pemphigus and bullous pemphigoid have overall good prognoses, linear IgA bullous dermatoses has a poor prognosis and requires aggressive treatment. Inherited genodermatoses should be suspected when there is a family history of genodermatoses or consanguinity. In this case, the clinician should not hesitate to seek dermatology advice, perform a skin biopsy and consider genetic testing.

Neonatal Autoimmune Blistering Disease: A Systematic Review

We aimed to better understand the pathogenesis, clinical features, prognosis, and treatment of neonatal autoimmune blistering diseases (AIBDs). We searched Medline, Embase, PubMed, Latin American and Caribbean Health Sciences Literature, and reference lists of identified articles. Inclusion criteria were articles published from 1946 to December 2014 in any language. Exclusion criteria were age greater than 4 weeks and no confirmed AIBD diagnosis. We identified 51 cases of neonatal AIBDs: 34 cases of pemphigus (31 pemphigus vulgaris [PV], 3 pemphigus foliaceus [PF]) and 17 cases of pemphigoid diseases (9 bullous pemphigoid [BP], 5 linear immunoglobulin A bullous dermatosis [LABD], 1 BP and LABD, 1 epidermolysis bullosa acquisita, 1 bullous systemic lupus erythematosus). Pemphigoid diseases had a higher male predominance (male:female ratio 4.6:1) than pemphigus (male:female ratio 1:1.06) (p = 0.004). Pemphigus had a higher proportion presenting at birth (79.4%) than pemphigoid diseases (29.4%) (p = 0.008). The most common sites involved were the trunk (63.0%), followed by the head and neck (60.9%). The mucosal membranes were involved in 32.6% of cases (27.6% in pemphigus, 41.6% in pemphigoid diseases). Only 33.3% used systemic therapy, and 75.5% achieved control within 3 weeks. Most PV, PF, and BP cases, but not LABDs, reported maternal disease. In pemphigus cases, 75.0% of mothers had active disease and 25.0% were in control. Pregnant women with PV, PF, and PG of any severity can passively transfer autoantibodies leading to neonatal AIBD. Pemphigoid diseases are more likely to present after birth and may be more male predominant. The presentation of LABDs may be different from that of all other AIBDs.

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.

Autoimmune blistering diseases in females: a review

The autoimmune blistering diseases (AIBDs) are a group of heterogeneous skin diseases with autoantibodies directed against structural proteins in the skin. A new interest in the female bias towards autoimmune diseases in general has led to our attention to focus on how and why this female bias manifests in AIBD. The authors aim to review and explore the various aspects of AIBD affecting females more than males, including the higher prevalence, worse quality of life, and complex management issues such as pregnancy and lactation.

What is already known on this topic?

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Echoing autoimmune diseases in general, most autoimmune blistering diseases (AIBDs) have a female predominance, but the exact level of predominance is unknown.

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Pregnancy raises several complicated management issues for females with an AIBD.

What does this article add to our knowledge?

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Review of sex-specific epidemiology and etiology of each AIBD.

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Exploration and explanation of the key factors underlying the detrimental impacts of AIBD on women’s quality of life (QOL).

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Discussion of management issues in pregnancy and lactation for females with an AIBD.

How does this information impact clinical practice and/or change patient care?

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An awareness and understanding of the female predominance in AIBDs will ensure more appropriate diagnosis, evaluation, and future research.

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Emphasizing holistic care targeting the debilitating effects of AIBDs on women’s QOL.

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Informing the reader of optimal, yet safe interventions for pregnant women with an AIBD.

Analysis of Anti-desmoglein 1 Autoantibodies in 68 Healthy Mother/Neonate Pairs from a Highly Endemic Region of Fogo Selvagem in Brazil

Objectives

Fogo Selvagem (FS) in Limao Verde (LV), Brazil shows clinical and histological features of pemphigus foliaceus (PF) and shares pathogenic IgG4 anti-desmoglein 1 (Dsg1) autoantibodies. Previously, our group reported that mothers with active FS deliver babies with normal skin and low/negative titers of IgG4 autoantibodies by indirect immunofluorescence. It was postulated that maternal pathogenic IgG4 autoantibodies do not cross the placenta due to differential receptor mediated transplacental passage of IgG subclasses. It was also thought that placental Dsg1 may immunoadsorb pathogenic autoantibodies from the mother; hence pathogenic IgG4 autoantibodies do not reach the baby.

In this study we use a Dsg1-specific ELISA to test anti-Dsg1 autoantibodies of the IgM, IgG and the IgG subclasses in the sera of 68 pairs of normal mothers and their neonates living in a highly endemic area of FS. Determination of these baseline anti-Dsg1 autoantibodies will allow us to follow and predict in this and other cohorts the appearance of preclinical serological markers of FS.

Methods

The sera of mothers and neonates living in the endemic region were tested by ELISA for IgM, IgG and IgG subclasses using recombinant Dsg1 and anti-IgG subclass-specific monoclonal antibodies.

Results

The index values of anti-Dsg1 IgG1, IgG2 and IgG3 are similar in mothers and neonates (all p>0.18), while the index values of IgM, total IgG and IgG4 are higher in mothers (all p<0.001).

Conclusions

Narrowing the IgM, IgG and IgG subclasses of mothers and neonates to autoantibodies against Dsg1, we found, as expected, that IgM remains only in maternal circulation. In three mothers and two neonates we detected IgG4 anti-Dsg1 autoantibodies above the normal range. The remaining IgG subclasses show low values. The results of the neonatal sera will serve as a baseline for ongoing seroepidemiological studies of children and adults in the endemic regions of FS.

IgG placental transfer in healthy and pathological pregnancies

Placental transfer of maternal IgG antibodies to the fetus is an important mechanism that provides protection to the infant while his/her humoral response is inefficient. IgG is the only antibody class that significantly crosses the human placenta. This crossing is mediated by FcRn expressed on syncytiotrophoblast cells. There is evidence that IgG transfer depends on the following: (i) maternal levels of total IgG and specific antibodies, (ii) gestational age, (iii) placental integrity, (iv) IgG subclass, and (v) nature of antigen, being more intense for thymus-dependent ones. These features represent the basis for maternal immunization strategies aimed at protecting newborns against neonatal and infantile infectious diseases. In some situations, such as mothers with primary immunodeficiencies, exogenous IgG acquired by intravenous immunoglobulin therapy crosses the placenta in similar patterns to endogenous immunoglobulins and may also protect the offspring from infections in early life. Inversely, harmful autoantibodies may cross the placenta and cause transitory autoimmune disease in the neonate.

Pemphigus vulgaris in pregnancy: analysis of current data on the management and outcomes

OBJECTIVES

The occurrence of pemphigus vulgaris (PV) during pregnancy is rare. The purpose of this review was to describe management of PV in the mother, and report maternal and perinatal outcomes associated with the disease.

DATA SOURCES

A search of PubMed was conducted using the phrases "pemphigus and pregnancy" and "neonatal pemphigus." The bibliographies of retrieved articles were also searched for relevant reports. Only articles in English and in which the diagnosis of pemphigus had been made on the basis of histology or immunopathology were included.

TABULATION, INTEGRATION, AND RESULTS

In 38 reports, pregnancies from 49 women with PV were described. Among the 40 patients in whom clinical profiles were provided, 33 had active disease and 7 were disease free. Prednisone was used in 37 of 49 (75%) patients with doses ranging from 5 to 300 mg/day (mean 152.5 mg). Concomitant therapies included plasmapheresis, plasma exchange, and dapsone in 1 patient each, and azathioprine in 5. Of the 44 live births, 20 (45%) neonates had PV lesions at birth and 24 (55%) were lesion-free. Five stillbirths were reported. In all neonates, PV lesions resolved within 1 to 4 weeks, either spontaneously or with mild topical corticosteroids treatment. Of the 5 intrauterine deaths, 1 was due to umbilical cord prolapse, 1 attributed to placental dysfunction, and 1 to cytomegalovirus pneumonitis. In the remaining 2, the cause was unknown. One neonate died 2 days after delivery due to meconium aspiration syndrome. Thus the aggregate perinatal mortality rate was 12% (6/49).

CONCLUSIONS

The outcome of pregnancies complicated by pemphigus is generally good, but achieving good outcomes likely depends on the collaborative efforts of the dermatologist and obstetrician. The available data suggest that the rate of perinatal mortality is increased, but these data may be subject to publication bias.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this educational activity, the participant should be better able to describe appropriate medical therapies for pemphigus vulgaris complicating pregnancy, and plan the management of pregnancies complicated by pemphigus vulgaris.

Pemphigus: a treatment update

Pemphigus is an uncommon but potentially life-threatening chronic autoimmune bullous disorder. Antibodies are directed against antigens (desmoglein 1 and 3) in the desmosomes linking keratinocytes and against acetylcholine receptors. Conventional treatment with high-dose corticosteroids, sometimes with adjuvant immunosuppressive agents, may be associated with very serious adverse effects. There is an urgent need to establish the evidence for the safest and most effective form of treatment. A literature review has revealed 11 controlled (9 randomized) trials of treatment for pemphigus. The numbers of participants in the individual trials are small and the data cannot be pooled as they evaluate different forms of treatment. The results of these trials suggest that very high doses of corticosteroids, either as pulse therapy or in daily dosage, are not superior to moderate daily doses. Based on evidence from the available trials, addition of an immunosuppressive agent generally does not appear to offer substantial benefit in terms of clinical response. However, a recent study demonstrated a significant reduction in corticosteroid requirements among patients receiving immunosuppressive agents. Newer therapies, such as biologic agents (in particular rituximab), calcineurin inhibitors, or immunoadsorption appear promising but there are inadequate controlled trials to establish their role clearly. Initial open-label studies suggest that specific peptide immunotherapy may offer a safe and novel approach to the treatment of pemphigus in the future. At present, treatment of an individual patient with pemphigus requires clinical judgment and should not be based purely on guidelines or on the inadequate available evidence alone. There is an urgent need for large randomized, controlled, multicenter trials of treatment in patients with pemphigus.

Neonatal pemphigus vulgaris in an infant born to a mother with pemphigus vulgaris in remission

Neonatal pemphigus vulgaris is a rare autoimmune disease that is caused by transplacental passage of pemphigus vulgaris autoantibodies. The association of maternal pemphigus vulgaris with neonatal disease pemphigus vulgaris has been only rarely reported. We describe an infant with pemphigus vulgaris born to a mother whose disease was in remission.

Gingival lesions as a first symptom of pemphigus vulgaris in pregnancy

The erosive gingival lesions associated with vesiculobullous diseases can be an important early clinical manifestation of serious diseases such as pemphigus vulgaris (PV). PV is a vesiculobullous disease of the skin and mucosa which tends to be chronic and which normally affects people of 40-60 years of age. Its incidence varies from 0.5 to 3.2 cases per 100,000 per year. Mucosal lesions are located mainly in the oral and pharyngeal mucosa, although conjunctiva, larynx, nasal mucosa, vulva, vagina, cervix, and ano-rectal mucosa may also be involved. It is a serious mucocutaneous disease of an autoimmune nature, whose appearance during pregnancy is extremely rare.

Paraneoplastic pemphigus: A brief update

First described in 1990, paraneoplastic pemphigus is an autoimmune condition that causes considerable morbidity, is resistant to therapy and is frequently fatal. Clinical heterogeneity is being recognized as more cases are reported and the documented auto-antigen profile is also increasing. Target antigens are now known to be not restricted to the skin, suggesting that this condition is part of a paraneoplastic autoimmune multiorgan syndrome.

[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.