Case of bullous pemphigoid under treatment with adalimumab for hidradenitis suppurativa

Successful Treatment of Psoriasis Combined with Bullous Pemphigoid with Dupilumab: A Case Report

Psoriasis is an immune-mediated chronic inflammatory disease that can be combined with complications such as diabetes, cardiovascular disease, obesity, and kidney disease. The comorbidity of psoriasis with autoimmune bullous diseases (AIBD) has been reported previously in several cases, the most frequent of which is bullous pemphigoid (BP). The underlying mechanisms of psoriasis with BP are not clear and there are no uniform treatment criteria. Based on previous case reports, the coexistence of psoriasis and BP may be related to inflammatory activity, medications, phototherapy, and infection. We report a case of a psoriasis patient who developed BP after taking Chinese herbal compounds and was successfully treated with dupilumab, which is the first reported case of applying dupilumab to treat psoriasis with BP comorbidities.

Paradoxical phenomena of bullous pemphigoid induced and treated by identical biologics

Objective

This study aimed to investigate the clinical features of biologics-induced bullous pemphigoid (BP) and the therapeutic effects of those agents for BP, exploring the underlying pathophysiological mechanisms.

Methods

We searched PubMed, Web of Science, and Elsevier for studies involving pemphigoid patients treated with or induced by identical biologics published in English from January 2009 to April 2022.

Results

Seventeen cases of drug-induced BP associated with anti-tumor necrosis factor (aTNF)-α therapies, one with interleukin (IL)-17 inhibitors, and seven with IL-12/IL-23 or IL-23 inhibitors were enrolled. Time to cutaneous toxicity varied among different types of agents, and the characteristics of clinical examinations were similar to idiopathic BP. Discontinuation of the culprit drugs and initiation of topical or systemic corticosteroids were adequate in most cases. Several monoclonal antibodies above have also been reported for the treatment of refractory or recurrent BP, especially concurrent with psoriasis.

Conclusion

Biologics for immune-related diseases, including TNF-α, IL-17, and IL-12/IL-23 or IL-23 inhibitors, can both induce and treat BP, which might be associated with a helper T cells Th1/Th2 imbalance, complicated inflammatory networks, and a specific individual microenvironment, suggestive of a new perspective on the therapeutic algorithms of BP. There have been numerous reports about biologics inducing or treating BP. We have taken note of this phenomenon and focused on biologics with both pathogenetic and therapeutic effects on BP. Our review summarized the clinical characteristics of associated cases, trying to figure out the underlying mechanisms of this paradoxical phenomenon and to provide an integrated perspective and new therapeutic alternatives for BP.

The Intriguing Links between Psoriasis and Bullous Pemphigoid

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.

Bullous pemphigoid induced by biologic drugs in psoriasis: a systematic review

INTRODUCTION

Several therapies for psoriasis have been described as triggers of biologic-induced bullous pemphigoid (BIBP). The real incidence of BIBP in psoriatic patients is still unknown. Hence, we compilated and analyzed current literature to identify the frequency and burden of this adverse event for psoriasis patients treated with biologics.

MATERIAL AND METHOD

We systematically searched literature records involving psoriatic patients developing BIBP. Electronic searches were conducted in Pubmed, EMBASE and Scopus in April 2021. To assess the causal relationship between BP and the biologic drug, we applied the Naranjo adverse reaction probability scale and the Karch-Lasagna algorithm.

RESULTS

Our systematic review identified 586 records through the three electronic databases. We identified 15 case reports of BIBP. These cases implicated two cases induced by adalimumab, three by efalizumab, three by etanercept, six by ustekinumab, and one case by secukinumab. Mean period of latency until the BIBP developed was time 5.12 ± 3.44 weeks for TNF-α blockers, and 28.66 ± 26.27 weeks for ustekinumab (p = .09). Most of the cases were assessed as "probable" consistently in both the Naranjo scale and the Karch-Lasagna algorithm.

CONCLUSION

This work presents an accurate estimation on the frequency and burden of BIBP. Ustekinumab presents with the largest evidence of BIBP, especially in patients with previous failure to TNF-α agents. Distinct patterns in the cytokinic pathways and clinical course exist between the BP induced by TNF-α blockers and ustekinumab. A close monitoring of skin condition is highly advisable in patients receiving biologic therapies for psoriasis. Knowledge of BIBP is of great importance to determine the preventive measures and select optimal treatment options.What's already known about this topic?The widespread use of biologic drugs has led dermatologists to encounter increasing situations of biologic-induced BP (BIBP).A lack of data exists on the real incidence of BIBP in psoriatic patients.BIBP is an important adverse event to know when managing patients with psoriasis using biologics.What does this study add?This work presents an accurate estimation on the raised burden of BIBP.Ustekinumab presents with the largest evidence of BIBP, especially in patients with previous failure to TNF-α agents.Mean period of latency until the BIBP developed was time 5.12 ± 3.44 weeks for TNF-α blockers, and 28.66 ± 26.27 weeks for ustekinumab.Distinct patterns in the cytokine pathways and clinical course exist between the BP induced by TNF-α blockers and ustekinumab.A careful screening of previous history of bullous diseases and a baseline immunologic study in psoriatic patients should be advisable prior to commencing any biologic therapy.A close monitoring of skin condition is highly advisable in patients receiving biologic therapies for psoriasis.