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de Nicolas-Ruanes B, Ballester-Martinez A, Garcia-Mouronte E, Berna-Rico E, Azcarraga-Llobet C, Fernandez-Guarino M. From Molecular Insights to Clinical Perspectives in Drug-Associated Bullous Pemphigoid. Int J Mol Sci 2023; 24:16786. [PMID: 38069109 PMCID: PMC10706090 DOI: 10.3390/ijms242316786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/19/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
Bullous pemphigoid (BP), the most common autoimmune blistering disease, is characterized by the presence of autoantibodies targeting BP180 and BP230 in the basement membrane zone. This leads to the activation of complement-dependent and independent pathways, resulting in proteolytic cleavage at the dermoepidermal junction and an eosinophilic inflammatory response. While numerous drugs have been associated with BP in the literature, causality and pathogenic mechanisms remain elusive in most cases. Dipeptidyl peptidase 4 inhibitors (DPP4i), in particular, are the most frequently reported drugs related to BP and, therefore, have been extensively investigated. They can potentially trigger BP through the impaired proteolytic degradation of BP180, combined with immune dysregulation. DPP4i-associated BP can be categorized into true drug-induced BP and drug-triggered BP, with the latter resembling classic BP. Antineoplastic immunotherapy is increasingly associated with BP, with both B and T cells involved. Other drugs, including biologics, diuretics and cardiovascular and neuropsychiatric agents, present weaker evidence and poorly understood pathogenic mechanisms. Further research is needed due to the growing incidence of BP and the increasing identification of new potential triggers.
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Affiliation(s)
- Belen de Nicolas-Ruanes
- Dermatology Department, Hospital Universitario Ramon y Cajal, 28034 Madrid, Spain (C.A.-L.); (M.F.-G.)
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Hsu YHA, Yang TT, Huang SM, Lan CCE. The effect of dipeptidyl peptidase-4 inhibitor on incidence and clinical course in bullous pemphigoid patients in a tertiary medical center. Kaohsiung J Med Sci 2023; 39:1038-1044. [PMID: 37530673 DOI: 10.1002/kjm2.12731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/20/2023] [Accepted: 06/25/2023] [Indexed: 08/03/2023] Open
Abstract
Several studies have reported an association between dipeptidyl peptidase 4 inhibitor (DPP4i), a commonly prescribed second-line oral antihyperglycemic drug, and bullous pemphigoid (BP). However, the benefits of DPP4i withdrawal in patients with BP remain controversial. This study primarily aimed to evaluate the clinical severity of DPP4i-associated BP by comparing it to those without Type 2 diabetes mellitus (DM). The secondary objective was to determine whether cessation of DPP4i is necessary for all patients with BP. This retrospective case-control study included 83 patients. The participants were divided into three groups according to their diabetic status and the status of discontinuance or continuance of DPP4i. The 12-month follow-up of the monthly dosage of systemic steroids per body weight (kg) and the percentage of systemic steroid off-therapy in these participants were recorded since the diagnosis of BP. Compared to patients with BP without DM, the 1st, 3rd, and 12th systemic prednisolone doses were significantly lower in the DPP4i group (p = 0.01684, 0.02559, and 0.009336, respectively). The 12th systemic prednisolone dose was significantly lower in patients who discontinued DPP4i (p = 0.0338). Nevertheless, several spontaneous remissions with systemic steroid off-therapy were also noted in the DPP4i-continuance group within 12 months of follow-up. This article supports the favorable impact of DPP4i withdrawal in patients with BP and shows that DPP4i may incite or aggravate BP, resulting in a milder disease course.
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Affiliation(s)
| | - Ting-Ting Yang
- Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Dermatology, Pingtung Hospital, Ministry of Health and Welfare, Pingtung, Taiwan
| | - Shu-Mei Huang
- Department of Dermatology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Che Eric Lan
- Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Dermatology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Kokubu H, Takahashi T, Kabuto M, Kouzaki H, Fujimoto N. Analysis of IL-10 and IL-35 in dipeptidyl peptidase-4 inhibitor-related bullous pemphigoid. Exp Dermatol 2023; 32:1569-1574. [PMID: 37424368 DOI: 10.1111/exd.14880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/24/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023]
Abstract
The association between immunoregulatory cytokines, such as interleukin (IL)-10 or IL-35, and dipeptidyl peptidase-4 inhibitor (DPP4i)-related bullous pemphigoid (BP) has not been evaluated. Serum IL-10 and IL-35 levels were measured in 39 patients with BP (24 males and 15 females; 6 DPP4i-related and 33 DPP4i-unrelated BP patients) and 10 healthy controls. The number of CD26+ cells in the dermis around bulla on sections was counted immunohistochemically for 12 patients (six patients with DPP4i-related BP and six randomly sampled patients with DPP4i-unrelated BP). Patients with DPP4i-related BP had lower levels of serum eosinophils (DPP4i-related vs. DPP4i-unrelated BP: 476.1 ± 234.0 vs. 911.3 ± 948.8/μL; p = 0.537) and a higher rate of infiltrating CD26+ cells (32.9 ± 7.1% vs. 15.7 ± 4.4%; p = 0.01). There were no significant differences in serum IL-10 (6.77 ± 0.24 vs. 6.84 ± 0.20 pg/mL), serum IL-35 (2.63 ± 0.17 vs. 2.63 ± 0.21 pg/mL), serum anti-BP180NC16a antibodies (67.31 ± 37.4 vs. 76.18 ± 54.59 U/mL) and Bullous Pemphigoid Disease Area Index before treatment in this study. Serum IL-10 and IL-35 levels do not increase in patients with BP and may not be a candidate for a therapeutic target for BP. An increase in CD26+ cells might be associated with DPP4i-related BP.
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Affiliation(s)
- Hiraku Kokubu
- Department of Dermatology, Shiga University of Medical Science, Otsu, Japan
| | | | - Miho Kabuto
- Department of Dermatology, Shiga University of Medical Science, Otsu, Japan
| | - Hideaki Kouzaki
- Department of Otolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Noriki Fujimoto
- Department of Dermatology, Shiga University of Medical Science, Otsu, Japan
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Huttelmaier J, Benoit S, Goebeler M. Comorbidity in bullous pemphigoid: up-date and clinical implications. Front Immunol 2023; 14:1196999. [PMID: 37457698 PMCID: PMC10346857 DOI: 10.3389/fimmu.2023.1196999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/19/2023] [Indexed: 07/18/2023] Open
Abstract
Bullous pemphigoid is the most common autoimmune blistering disease in industrialized countries and particularly affects the elderly. In this patient population, comorbid diseases are frequent and may complicate management and treatment of bullous pemphigoid. A better understanding why distinct diseases are more frequent in bullous pemphigoid patients may lead to new pathophysiological insights and - as a consequence - result in better patient care. The association of bullous pemphigoid with neurological and psychiatric diseases is well known and confirmed by several case-control studies. Association with further diseases such as malignancy and metabolic diseases are still discussed controversially. In recent years new relationships between bullous pemphigoid and autoimmune as well as inflammatory skin diseases have been reported. This review provides a systematic overview on studies addressing comorbidity in bullous pemphigoid patients. Increasing the awareness of both, common and rare comorbid diseases, may enable clinicians to optimize patient support and individualized treatment of bullous pemphigoid.
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Yanai Y, Kori Y, Fujimoto T, Imajo I, Yanai R, Yamada T. Dipeptidyl peptidase-4 inhibitor-related bullous pemphigoid diagnosed by oral manifestation. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY, MEDICINE, AND PATHOLOGY 2023. [DOI: 10.1016/j.ajoms.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Dipeptidyl Peptidase-4 Inhibitor-Related Bullous Pemphigoid: Clinical, Laboratory, and Histological Features, and Possible Pathogenesis. Int J Mol Sci 2022; 23:ijms232214101. [PMID: 36430582 PMCID: PMC9692886 DOI: 10.3390/ijms232214101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/11/2022] [Accepted: 11/12/2022] [Indexed: 11/17/2022] Open
Abstract
Dipeptidyl peptidase-4 inhibitor (DPP4i) is a widely used antidiabetic agent. Emerging cases of DPP4i-associated bullous pemphigoid (DBP), whose pathogenesis remains unclear, have been reported. Thus, a retrospective study was conducted from January 2016 to June 2021 to determine the clinical, laboratory, and histopathological features of DBP and idiopathic bullous pemphigoid (IBP). We set up in vitro experiments using vildagliptin-treated HaCaT keratinocytes to validate what we found by analyzing published RNA sequencing data about the genes related to the dermal-epidermal junction. We also observed IL-6 expression by HaCaT cells treated with vildagliptin. We enrolled 20 patients with DBP and 40 patients with IBP. The total Bullous Pemphigoid Disease Area Index (BPDAI) score was similar in both groups. However, the BPDAI score of erosions and blisters in DBP was significantly higher than that in IBP (24.6 vs. 16.68, p = 0.0189), and the score for urticaria and erythema was lower in DBP (12 vs. 19.05, p = 0.0183). The pathological features showed that the mean infiltrating eosinophil number per high-power field was significantly lower in DBP than in IBP (16.7 vs. 27.08, p = 0.023). The expression of LAMA3, LAMB3, LAMC2, DST, and COL17A1 decreased significantly in vildagliptin-treated human keratinocytes. On the other hand, IL-6, the hallmark cytokine of bullous pemphigoid (BP) severity, was found to be upregulated in HaCaT cells by vildagliptin. These experimental findings imply less of a requirement for eosinophil infiltration to drive the inflammatory cascades in DBP blistering. Both immunologic and non-immunologic pathways could be employed for the development of DBP. Our findings may help explain the higher incidence of non-inflammatory BP that was observed in DBP.
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Nakagawa Y, Toyoda M, Saito N, Kaneyama N, Shimizu T, Mabuchi T, Fukagawa M. Clinical Phenotypes and the Clinical Course of Bullous Pemphigoid Receiving Dipeptidyl Pepitidase-4 Inhibitor Treatment: An Analysis of Cases in a Single Japanese Center. Intern Med 2022. [PMID: 36328578 DOI: 10.2169/internalmedicine.0815-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Objective Several studies have shown an increased risk of bullous pemphigoid (BP) when receiving dipeptidyl pepitidase-4 inhibitor (DPP-4i) treatment. The present study explored the associations of DPP-4i treatment with the clinical phenotypes and clinical course of BP. Methods We analyzed data of 146 patients with BP at Tokai University School of Medicine from December 1, 2009, to December 31, 2021. We obtained data by a retrospective medical record review and compared the bullous pemphigoid disease area index (BPDAI) between diabetes patients receiving DPP-4i treatment and those not receiving DPP-4i treatment. We employed multivariable linear regression models to explore the association between the DPP-4i treatment and the BPDAI scores. Results Among 53 BP patients with diabetes, 33 had developed BP during treatment with DPP-4i agents, among which vildagliptin was the most frequently used. The urticaria/erythema scores of the BPDAI were significantly lower in patients who developed BP while receiving DPP-4i treatment than among others. Of note, 69.2% of the patients who stopped DPP-4i treatment experienced complete remission, and the clinical course was more favorable in patients with lower scores for urticaria/erythema than among others. Conclusion These findings suggest that, in patients who developed BP while receiving DPP-4i treatment, a noninflammatory phenotype may indicate a high likelihood that DPP-4i treatment contributes to the development of BP. The discontinuation of DPP-4i should be carefully considered in close consultation with dermatologists.
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Affiliation(s)
- Yosuke Nakagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Japan
| | - Masao Toyoda
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Japan
| | - Nobumichi Saito
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Japan
| | - Noriko Kaneyama
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Japan
| | - Tomomichi Shimizu
- Department of Dermatology, Tokai University School of Medicine, Japan
| | - Tomotaka Mabuchi
- Department of Dermatology, Tokai University School of Medicine, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Japan
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[Artículo traducido] Asociación entre eosinófilos de sangre periférica y cutáneos con la gravedad del penfigoide ampolloso y los resultados terapéuticos. ACTAS DERMO-SIFILIOGRAFICAS 2022. [DOI: 10.1016/j.ad.2022.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Dikmen HO, Yilmaz K, Benoit S, Bernard P, Drenovska K, Gerdes S, Gläser R, Günther C, Homey B, Horváth ON, Huilaja L, Joly P, Kiritsi D, Meller S, Patsatsi A, Sárdy M, Schauer F, Shahid M, Sticherling M, Tasanen K, Vassileva S, Worm M, Zillikens D, Sadik CD, van Beek N, König IR, Schmidt E. Serum autoantibody reactivity in bullous pemphigoid is associated with neuropsychiatric disorders and the use of antidiabetics and antipsychotics: a large prospective cohort study. J Eur Acad Dermatol Venereol 2022; 36:2181-2189. [PMID: 35796163 DOI: 10.1111/jdv.18414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP), the by far most frequent autoimmune blistering skin disease (AIBD), is immunopathologically characterized by autoantibodies against the two hemidesmosomal proteins BP180 (collagen type XVII) and BP230 (BPAG1 or dystonin). Several comorbidities and potentially disease-inducing medication have been described in BP, yet, a systematic analysis of these clinically relevant findings and autoantibody reactivities has not been performed. OBJECTIVE To determine associations of autoantibody reactivities with comorbidities and concomitant medication. METHODS In this prospective multicenter study, 499 patients diagnosed with BP in sixteen European referral centers were included. The relation between anti-BP180 NC16A and anti-BP230 IgG ELISA values at the time of diagnosis as well as comorbidities and concomitant medication collected by a standardized form were analyzed. RESULTS An association between higher serum anti-BP180 reactivity and neuropsychiatric but not atopic and metabolic disorders was observed as well as with the use of insulin or antipsychotics but not with dipeptidyl peptidase-4 (DPP4) inhibitors, inhibitors of platelet aggregation and L-thyroxine. The use of DPP4 inhibitors was associated with less anti-BP180 and anti-BP230 reactivity compared to BP patients without these drugs. This finding was even more pronounced when compared with diabetic BP patients without DPP4 inhibitors. Associations between anti-BP180 and anti-BP230 reactivities were also found in patients using insulin and antipsychotics, respectively, compared with patients without this medication, but not for the use of inhibitors of platelet aggregation, and L-thyroxine. CONCLUSION Taken together, these data imply a relation between autoantibody reactivities at the time of diagnosis and both neuropsychiatric comorbidities as well as distinct concomitant medication suggesting a link between the pathological immune mechanisms and clinical conditions that precede the clinically overt AIBD.
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Affiliation(s)
| | - Kaan Yilmaz
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Sandrine Benoit
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | | | - Kossara Drenovska
- Department of Dermatology, Medical University Sofia, Sofia, Bulgaria
| | - Sascha Gerdes
- Department of Dermatology, Venerology and Allergology, University of Kiel, Kiel, Germany
| | - Regine Gläser
- Department of Dermatology, Venerology and Allergology, University of Kiel, Kiel, Germany
| | - Claudia Günther
- Department of Dermatology, University of Dresden, Dresden, Germany
| | - Bernhard Homey
- Department of Dermatology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Orsolya N Horváth
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Laura Huilaja
- PEDEGO Research Unit, Department of Dermatology, Medical Research Unit, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Pascal Joly
- Department of Dermatology, University of Rouen, Rouen, France
| | - Dimitra Kiritsi
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stephan Meller
- Department of Dermatology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Aikaterini Patsatsi
- 2nd Dermatology Department, Aristotle University School of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Miklós Sárdy
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany.,Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - Franziska Schauer
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Shahid
- Department of Dermatology, Medical University Sofia, Sofia, Bulgaria
| | | | - Kaisa Tasanen
- PEDEGO Research Unit, Department of Dermatology, Medical Research Unit, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Snejina Vassileva
- Department of Dermatology, Medical University Sofia, Sofia, Bulgaria
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | | | - Nina van Beek
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Inke R König
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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Association of Peripheral Blood and Cutaneous Eosinophils With Bullous Pemphigoid Disease Severity and Treatment Outcomes. ACTAS DERMO-SIFILIOGRAFICAS 2022; 113:881-887. [DOI: 10.1016/j.ad.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/05/2022] [Accepted: 05/29/2022] [Indexed: 11/20/2022] Open
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Sugiyama S, Yamamoto T, Aoyama Y. Clinical features of dipeptidyl peptidase-4 inhibitor-associated bullous pemphigoid in Japan: A nationwide retrospective observational study. J Dermatol 2022; 49:697-702. [PMID: 35478414 DOI: 10.1111/1346-8138.16394] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 03/20/2022] [Accepted: 03/30/2022] [Indexed: 12/28/2022]
Abstract
Many cases of bullous pemphigoid (BP) have been reported in patients taking dipeptidyl peptidase-4 inhibitors (DPP-4i), which are the most widely used antidiabetic drug for type 2 diabetes mellitus. However, no large-scale survey has been conducted in Japan. This retrospective study investigated the incidence, clinical presentation, and clinical course of DPP-4i-associated BP (DPP-4i-BP) using epidemiological data from a nationwide registry for BP. In 2016, 713 new BP patients at 94 dermatological institutes were registered, 243 (34.1%) with DPP-4i-BP and 461 (64.7%) with non-DPP-4i-BP. The male-to-female ratio was 1.9 and 0.84, respectively. Patients with DPP-4i-BP were predominantly male. Non-inflammatory BP was more common in DPP-4i-BP (33.3%) than in non-DPP-4i-BP (14.6%), while inflammatory BP was common in both. No specific subtype or difference in disease severity was evident in DPP-4i-BP. The most common gliptins administered to DPP-4i-BP patients were vildagliptin (37.2%) and linagliptin (23.8%). DPP-4i intake was discontinued in 79.9% of cases after diagnosis. Some DPP-4i-BP patients (17.6%) achieved spontaneous remission after discontinuing DPP-4i without requiring the use of systemic corticosteroids and/or adjuvant therapy. Mean duration to achieve disease control was 2.87 months. The odds ratio for non-inflammatory BP requiring systemic corticosteroids and/or adjuvant therapy was low (0.52), suggesting that remission was achieved easily with supportive care in that phenotype. Non-inflammatory and mild cases of DPP-4i-BP may resolve spontaneously with supportive care, including the discontinuation of DPP-4i and no oral corticosteroid therapy.
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Affiliation(s)
- Seiko Sugiyama
- Department of Dermatology, Kawasaki Medical School General Medical Center, Okayama, Japan.,Department of Dermatology, Kawasaki Medical School, Kurashiki, Japan
| | - Takenobu Yamamoto
- Department of Dermatology, Kawasaki Medical School General Medical Center, Okayama, Japan.,Department of Dermatology, Kawasaki Medical School, Kurashiki, Japan
| | - Yumi Aoyama
- Department of Dermatology, Kawasaki Medical School, Kurashiki, Japan
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Niebel D, Wilsmann-Theis D, Bieber T, Berneburg M, Wenzel J, Braegelmann C. Bullous Pemphigoid in Patients Receiving Immune-Checkpoint Inhibitors and Psoriatic Patients—Focus on Clinical and Histopathological Variation. Dermatopathology (Basel) 2022; 9:60-81. [PMID: 35323203 PMCID: PMC8947168 DOI: 10.3390/dermatopathology9010010] [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: 01/14/2022] [Revised: 03/10/2022] [Accepted: 03/16/2022] [Indexed: 12/07/2022] Open
Abstract
Background: The most common autoimmune blistering disease, bullous pemphigoid (BP), shows an increased prevalence in psoriatic patients and oncologic patients undergoing immune-checkpoint blockade (ICB). Even though the same autoantigens (BP180/BP230) are detectable, it remains obscure whether clinical or histopathological differences exist between these different groups of BP patients. In this study, we strived to analyze this matter based on own data and previously published reports. Methods: We performed an institutional chart review from 2010–2020 to identify BP patients with psoriasis (n = 6) or underlying ICB (n = 4) and matched them with idiopathic cases of BP (n = 33). We compared clinical characteristics, subtypes, and dermatopathological determinants (e.g., tissue eosinophilia/neutrophilia, papillary edema, lymphocytic infiltration) among the groups. Results: ICB-associated BP affects men more often and might show mucosal involvement more frequently. We found no statistically significant dermatopathological differences among the groups. Conclusions: Clinicians should be aware of an increased risk of BP in patients with psoriasis and oncologic patients receiving ICB; atypical pruritic skin lesions should prompt a workup including a skin biopsy for histopathology and direct immunofluorescence in these patients. Larger studies might be necessary to detect slight dermatopathological variation.
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Affiliation(s)
- Dennis Niebel
- Department of Dermatology, University Hospital Regensburg, 93053 Regensburg, Germany;
- Correspondence: ; Tel.: +49-941-944-9620
| | - Dagmar Wilsmann-Theis
- Department of Dermatology and Allergy, University Hospital Bonn, 53105 Bonn, Germany; (D.W.-T.); (T.B.); (J.W.); (C.B.)
| | - Thomas Bieber
- Department of Dermatology and Allergy, University Hospital Bonn, 53105 Bonn, Germany; (D.W.-T.); (T.B.); (J.W.); (C.B.)
| | - Mark Berneburg
- Department of Dermatology, University Hospital Regensburg, 93053 Regensburg, Germany;
| | - Joerg Wenzel
- Department of Dermatology and Allergy, University Hospital Bonn, 53105 Bonn, Germany; (D.W.-T.); (T.B.); (J.W.); (C.B.)
| | - Christine Braegelmann
- Department of Dermatology and Allergy, University Hospital Bonn, 53105 Bonn, Germany; (D.W.-T.); (T.B.); (J.W.); (C.B.)
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Salemme A, Fania L, Scarabello A, Caproni M, Marzano AV, Cozzani E, Feliciani C, De Simone C, Papini M, Satta RR, Parodi A, Mariotti F, Lechiancole S, Genovese G, Passarelli F, Festa F, Bellei B, Provini A, Donatella Sordi, Pallotta S, Abeni D, Mazzanti C, Didona B, Di Zenzo G. Gliptin-associated bullous pemphigoid shows peculiar features of anti-BP180 and -BP230 humoral response: results from a multicenter study. J Am Acad Dermatol 2022; 87:56-63. [PMID: 35240229 DOI: 10.1016/j.jaad.2022.02.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/25/2022] [Accepted: 02/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recently, several case-control studies demonstrated an association between gliptins and bullous pemphigoid (BP) occurrence. Data on clinical and immunological features of gliptin-associated bullous pemphigoid (GABP) are controversial. OBJECTIVE This study aims to clinically and immunologically characterize a large cohort of GABP patients to get insight into the pathophysiology of this emerging drug-induced variant of BP. METHODS Seventy-four GABP patients were prospectively enrolled and characterized from nine different Italian Dermatology Units between 2013 and 2020. RESULTS Our findings demonstrate that in GABP patients: i) the non-inflammatory phenotype which is characterized by low amounts of circulating and skin infiltrating eosinophils is frequently found; ii) IgG, IgE and IgA humoral response to BP180 and BP230 antigens is reduced in frequency and titers when compared with idiopathic BP; iii) IgG reactivity targets multiple BP180 epitopes other than NC16A. LIMITATIONS A limitation of the study is the control group that did not comprise only type 2 diabetes mellitus BP patients. CONCLUSIONS GABP patients show peculiar features of anti-BP180 and -BP230 humoral response laying the foundations for diagnostic improvements and to get novel insights into understanding the mechanism of BP onset.
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Affiliation(s)
- Adele Salemme
- Molecular and Cell Biology Laboratory, IDI-IRCCS, Rome, Italy
| | - Luca Fania
- First Dermatology Clinic, IDI-IRCCS, Rome, Italy
| | | | - Marzia Caproni
- Rare Diseases Unit, Section of Dermatology, Department of Health Sciences, USL Toscana Centro, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Emanuele Cozzani
- DiSSal, Dermatology Clinic, University of Genoa, San Martino Policlinic Hospital-IRCCS, Genoa, Italy
| | - Claudio Feliciani
- Dermatology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Clara De Simone
- Institute of Dermatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università del Sacro Cuore, Rome, Italy
| | - Manuela Papini
- Dermatologic Clinic of Terni, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Rosanna Rita Satta
- Department of Medical, Surgical, and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Aurora Parodi
- DiSSal, Dermatology Clinic, University of Genoa, San Martino Policlinic Hospital-IRCCS, Genoa, Italy
| | | | | | - Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | | | | | - Barbara Bellei
- Laboratory of Cutaneous Physiopathology and Integrated Center for Metabolomics Research, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
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14
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Ujiie H, Yamagami J, Takahashi H, Izumi K, Iwata H, Wang G, Sawamura D, Amagai M, Zillikens D. The pathogeneses of pemphigus and pemphigoid diseases. J Dermatol Sci 2021; 104:154-163. [PMID: 34916040 DOI: 10.1016/j.jdermsci.2021.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/22/2021] [Accepted: 11/06/2021] [Indexed: 12/21/2022]
Abstract
Autoimmune bullous diseases (AIBDs) are skin disorders which are mainly induced by autoantibodies against desmosomal or hemidesmosomal structural proteins. Previous studies using patients' samples and animal disease models identified target antigens and elucidated the mechanisms of blister formation. Pemphigus has been the subject of more active clinical and basic research than any other AIBD. These efforts have revealed the pathogenesis of pemphigus, which in turn has led to optimal diagnostic methods and novel therapies, such as rituximab. In bullous pemphigoid (BP), studies with passive-transfer mouse models using rabbit anti-mouse BP180 antibodies and studies with passive-transfer or active mouse models using autoantigen-humanized mice elucidated the immune reactions to BP180 in vivo. Recently, dipeptidyl peptidase-4 inhibitors have attracted attention as a trigger for BP. For epidermolysis bullosa acquisita (EBA), investigations using mouse models are actively under way and several molecules have been identified as targets for novel therapies. In this review, we give an overview and discussion of the recent progress in our understanding of the pathogenesis of pemphigus, BP, and EBA. Further studies on the breakdown of self-tolerance and on the identification of key molecules that are relevant to blister formation may expand our understanding of the etiology of AIBDs and lead to the development of novel therapeutic strategies.
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Affiliation(s)
- Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Jun Yamagami
- Department of Dermatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hayato Takahashi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Izumi
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Gang Wang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Daisuke Sawamura
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Detlef Zillikens
- Center for Research on Inflammation of the Skin (CRIS), University of Lübeck, Lübeck, Germany; Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany, University of Lübeck, Lübeck, Germany
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15
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Ständer S, Schmidt E, Zillikens D, Ludwig RJ, Kridin K. Immunologische Merkmale und Faktoren im Zusammenhang mit dem mukokutanen bullösen Pemphigoid - eine retrospektive Kohortenstudie. J Dtsch Dermatol Ges 2021; 19:1289-1296. [PMID: 34541798 DOI: 10.1111/ddg.14494_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 02/20/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Enno Schmidt
- Klinik für Dermatologie, Universität zu Lübeck.,Lübecker Institut für experimentelle Dermatologie, Universität zu Lübeck
| | | | - Ralf J Ludwig
- Klinik für Dermatologie, Universität zu Lübeck.,Lübecker Institut für experimentelle Dermatologie, Universität zu Lübeck
| | - Khalaf Kridin
- Lübecker Institut für experimentelle Dermatologie, Universität zu Lübeck.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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16
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Roy A, Sahoo J, Narayanan N, Merugu C, Kamalanathan S, Naik D. Dipeptidyl peptidase-4 inhibitor-induced autoimmune diseases: Current evidence. World J Diabetes 2021; 12:1426-1441. [PMID: 34630898 PMCID: PMC8472501 DOI: 10.4239/wjd.v12.i9.1426] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/12/2021] [Accepted: 07/19/2021] [Indexed: 02/06/2023] Open
Abstract
Dipeptidyl peptidase-4 inhibitors (DPP-4i) have an important place in the management of type 2 diabetes. The DPP-4 enzyme is ubiquitously distributed throughout the human body and has multiple substrates through which it regulates several important physiological functions. DPP-4 regulates several immune functions, including T-cell activation, macrophage function, and secretion of cytokines. Studies have reported an increase in autoimmune diseases like bullous pemphigoid, inflammatory bowel disease, and arthritis with DPP-4i use. The relationship of DPP-4i and autoimmune diseases is a complex one and warrants further research into the effect of DPP-4 inhibition on the immune system to understand the pathogenesis more clearly. Whether a particular cluster of autoimmune diseases is associated with DPP-4i use remains an important contentious issue. Nevertheless, a heightened awareness from the clinicians is required to identify and treat any such diseases. Through this review, we explore the clinical and pathophysiological characteristics of this association in light of recent evidence.
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Affiliation(s)
- Ayan Roy
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Jodhpur 342005, India
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Jayaprakash Sahoo
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Niya Narayanan
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Chandhana Merugu
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Sadishkumar Kamalanathan
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Dukhabandhu Naik
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
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17
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Suezawa M, Dainichi T, Kaku Y, Izumi M, Kataoka K, Ishii N, Koga H, Izumi K, Nishie W. Dipeptidyl peptidase 4 inhibitor-associated mucous membrane pemphigoid. J Dermatol 2021; 48:1584-1587. [PMID: 34265108 DOI: 10.1111/1346-8138.16061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/20/2021] [Indexed: 11/27/2022]
Abstract
Dipeptidyl peptidase 4 inhibitors (DPP-4i) are associated with an increased risk of developing bullous pemphigoid (BP) in patients with diabetes. Autoantibodies targeting epitopes on the processed BP180, 120-kDa (LAD-1), and 97-kDa (LABD97) linear immunoglobulin (Ig)A dermatosis antigens are the major autoantibodies in DPP-4i-associated BP. However, no case of mucous membrane pemphigoid (MMP) developing during treatment with DPP-4i has been reported. We report a case of MMP associated with DPP-4i. A man in his late 70s presented with oral mucous membrane erosion and a few blisters on his upper chest and back. He had used linagliptin for diabetes for over 1 year when he presented. The immunological characteristics were similar to DPP4i-associated BP: higher reactivity to LAD-1 and LABD97 than to the full-length BP180. The aphthae achieved remission after oral linagliptin was replaced with sitagliptin. However, 6 months later, the aphthae relapsed and any DPP-4i was discontinued. The aphthae disappeared, and now he is completely free from lesions associated with MMP. This case suggests that the DPP-4i may have shared roles in the production of IgG antibodies to LAD-1 or to LABD97 in the pathogenesis of DPP-4i-associated BP and MMP. Our case highlights the possibility of overlooking the mild MMP in DPP-4i-treated diabetes patients with mucosal lesions.
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Affiliation(s)
- Mei Suezawa
- School of Medicine, Kagawa University Faculty of Medicine, Kagawa, Japan
| | - Teruki Dainichi
- Department of Dermatology, Kagawa University Faculty of Medicine, Kagawa, Japan
| | - Yo Kaku
- Department of Dermatology, Kagawa University Faculty of Medicine, Kagawa, Japan
| | - Maiko Izumi
- Department of Dermatology, Kagawa University Faculty of Medicine, Kagawa, Japan
| | - Koki Kataoka
- Department of Dermatology, Kagawa University Faculty of Medicine, Kagawa, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan
| | - Hiroshi Koga
- Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan
| | - Kentaro Izumi
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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18
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Ständer S, Schmidt E, Zillikens D, Ludwig RJ, Kridin K. Immunological features and factors associated with mucocutaneous bullous pemphigoid - a retrospective cohort study. J Dtsch Dermatol Ges 2021; 19:1289-1295. [PMID: 34164921 DOI: 10.1111/ddg.14494] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 02/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES The features of bullous pemphigoid (BP) patients presenting with mucosal lesions are not established. We aimed to elucidate the clinical and immunological features of BP patients with mucosal involvement, and to identify factors associated with mucosal lesions. PATIENTS AND METHODS A retrospective study encompassing all consecutive patients diagnosed with BP throughout the years 2009-2019 in a tertiary referral center. RESULTS The study encompassed 273 patients with BP, of whom 31 (11.4 %) presented with mucosal lesions. The oral mucosa was the most frequently affected mucosal surface (71.0 %), followed by the genital (25.8 %) and the nasal (22.6 %) mucosae. Relative to other patients with BP, patients with mucosal involvement had a more prominent palmoplantar involvement (67.7 % vs. 37.2 %; P = 0.001); lower seropositivity rate (18.2 % vs. 54.2 %; P = 0.027) and lower levels (29.3 ± 64.5 vs. 129.5 ± 304.4 U/ml; P = 0.016) of anti-BP230 autoantibodies; and decreased peripheral eosinophil counts (760.0 ± 638.6 vs. 1296.3 ± 1013.7; P < 0.001). Absence of anti-BP230 autoantibodies (OR, 5.32; 95 % CI, 1.07-26.32; P = 0.026) and lack of peripheral eosinophilia (OR, 4.31; 95 % CI, 1.14-16.39; P = 0.021) were associated with the presence of mucosal involvement in BP. CONCLUSIONS Mucosal involvement is present in a notable subgroup of patients with BP and is associated with the absence of both anti-BP230 antibodies and peripheral eosinophilia.
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Affiliation(s)
- Sascha Ständer
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Ralf J Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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19
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Ständer S, Hammers CM, Vorobyev A, Schmidt E, Zillikens D, Ghorbanalipoor S, Bieber K, Ludwig RJ, Kridin K. The impact of lesional inflammatory cellular infiltrate on the phenotype of bullous pemphigoid. J Eur Acad Dermatol Venereol 2021; 35:1702-1711. [PMID: 33896060 DOI: 10.1111/jdv.17303] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/10/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND The influence of cutaneous cellular infiltration on the phenotype of bullous pemphigoid (BP) remains to be established. OBJECTIVES To evaluate the main histopathological characteristics of patients with BP and to assess the association between the composition of lesional inflammatory infiltrate and the various clinical, immunological and immunopathological aspects of the disease. METHODS Retrospective study encompassing patients diagnosed with BP throughout the years 2009-2020 in a specialized tertiary referral centre. RESULTS The study encompassed 136 patients with BP, of whom 27 (19.9%) demonstrated a cell-poor inflammatory infiltrate in lesional skin specimens. Overall, 78 (57.4%), 71 (52.2%) and 5 (3.7%) specimens were found to include eosinophil-predominant, lymphocyte-predominant and neutrophil-predominant inflammatory infiltrates, respectively. Relative to the remaining patients with BP, those with an eosinophil-predominant inflammatory infiltrate had higher (90.8% vs. 77.2%; P = 0.030) whilst those with a cell-poor inflammatory infiltrate lower (70.3% vs. 88.7%; P = 0.017) seropositivity of anti-BP180 NC16A IgG. The latter subgroup presented with higher prevalence of mucosal involvement (25.9% vs. 8.3%; P = 0.011) and a non-inflammatory clinical phenotype (50.0% vs. 17.1%; P = 0.041). Patients with lymphocyte-predominant inflammatory infiltrate manifested with higher severity BPDAI scores and a lower frequency of the non-inflammatory subtype (11.1% vs. 36.4%; P = 0.035), whilst those with a neutrophilic infiltrate presented with lower mean (SD) levels of anti-BP180 NC16A IgG [269.3 (227.6) vs. 722.7 (1499.6) U/mL; P = 0.003]. CONCLUSIONS Eosinophil-predominance and high cellularity in the lesional inflammatory infiltrate of BP skin are associated with increased seropositivity of anti-BP180 NC16A IgG. Lymphocyte-predominant infiltrates predict a more severe phenotype, pointing towards a pathogenic role of autoreactive lymphocytes.
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Affiliation(s)
- S Ständer
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - C M Hammers
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - A Vorobyev
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lűbeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - S Ghorbanalipoor
- Lűbeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - K Bieber
- Lűbeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - R J Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lűbeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - K Kridin
- Lűbeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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20
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Sun C, Feng S. Recent developments in the pathogenesis of pruritus in bullous pemphigoid. Int J Dermatol 2021; 60:1441-1448. [PMID: 34037252 DOI: 10.1111/ijd.15589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/04/2021] [Accepted: 03/23/2021] [Indexed: 11/29/2022]
Abstract
Bullous pemphigoid (BP) is a common autoimmune bullous disease which mainly affects the elderly. The incidence of BP is gradually increasing and associated with high mortality. This disease is clinically characterized by intensely pruritic and widespread bullous lesions. Alternative therapy options for pruritus in patients with BP are limited primarily because pathophysiological mechanisms of itching in BP are still unclear. This review aims to explain crucial concepts of the pathogenesis of pruritus in BP. Vital findings in recent years will be summarized, and cofactors of the pathogenesis of pruritus will be discussed in detail. We will summarize knowledge on pathogenic factors in the immunologic level conducing to skin pruritus in BP.
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Affiliation(s)
- Chao Sun
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
| | - Suying Feng
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
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21
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Nieto-Benito LM, Bergón-Sendín M, Pulido-Pérez A, Rosell-Díaz ÁM, Parra-Blanco V, Suárez-Fernández R. Defining dipeptidyl peptidase-4 inhibitors-related bullous pemphigoid: A single-centre retrospective study. Exp Dermatol 2021; 30:1345-1351. [PMID: 34028898 DOI: 10.1111/exd.14387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/09/2021] [Accepted: 05/09/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Many studies have corroborated the association of dipeptidyl peptidase-4 inhibitors (DPP4i) use with bullous pemphigoid (BP). It has been speculated that this drug-induced variant presents with a different clinical spectrum than conventional BP. OBJECTIVE To determine the prevalence of DPP4i-induced cases of BP and to evaluate whether gliptin-related BP has specific clinicopathological and immunological features. METHODS We conducted a retrospective, observational study of BP cases attended at our centre between January 2000 and June 2020. Epidemiological, clinical, histopathological and laboratory data were collected. RESULTS A total of 257 cases of BP were collected; 51 (24.3%) were on treatment with DPP4i. When analysing DPP4i-induced BP cases, generalized BP was the predominant pattern and scalp/mucosal involvement was found in 13 patients. Gliptin-related BP cases were associated to a decrease in the eosinophilic infiltrate (p = 0.000) and both the detection rate and concentration of anti-BP180 IgG were lower (p = 0.004, p = 0.001, respectively) than non-DPP4i cases. LIMITATIONS Retrospective, single-centre study. CONCLUSION Our large DPP4i-induced BP case series has highlighted that DPP4i-induced BP is characterized by generalized lesions and scalp involvement. Lower titres of anti-BP180 antibodies and a decrease in eosinophils infiltrating into the skin may be distinct features of DPP4i-related BP.
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Affiliation(s)
| | - Marta Bergón-Sendín
- Department of Dermatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Pulido-Pérez
- Department of Dermatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Verónica Parra-Blanco
- Department of Dermatopathology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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22
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Clinical, Laboratory and Histological Features of Dipeptidyl Peptidase-4 Inhibitor Related Noninflammatory Bullous Pemphigoid. J Clin Med 2021; 10:jcm10091916. [PMID: 33925042 PMCID: PMC8125701 DOI: 10.3390/jcm10091916] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/15/2021] [Accepted: 04/21/2021] [Indexed: 12/11/2022] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease of elderly patients that has shown increasing incidence in the last decades. Higher prevalence of BP may be due to more frequent use of provoking agents, such as antidiabetic dipeptidyl peptidase-4 inhibitor (DPP4i) drugs. Our aim was to assess DPP4i-induced bullous pemphigoid among our BP patients and characterize the clinical, laboratory and histological features of this drug-induced disease form. In our patient cohort, out of 127 BP patients (79 females (62.2%), 48 males (37.7%)), 14 (9 females and 5 males) were treated with DPP4i at the time of BP diagnosis. The Bullous Pemphigoid Disease Area Index (BPDAI) urticaria/erythema score was significantly lower, and the BPDAI damage score was significantly higher in DPP4i-BP patients compared to the nonDPP4i group. Both the mean absolute eosinophil number and the mean periblister eosinophil number was significantly lower in DPP4i-BP patients than in nonDPP4i cases (317.7 ± 0.204 vs. 894.0 ± 1.171 cells/μL, p < 0.0001; 6.75 ± 1.72 vs. 19.09 ± 3.1, p = 0.0012, respectively). Our results provide further evidence that DPP4i-associated BP differs significantly from classical BP, and presents with less distributed skin symptoms, mild erythema, normal or slightly elevated peripheral eosinophil count, and lower titers of BP180 autoantibodies. To our knowledge, this is the first case series of DPP4i-related BP with a non-inflammatory phenotype in European patients.
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23
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Ujiie I, Iwata H, Yoshimoto N, Izumi K, Shimizu H, Ujiie H. Clinical characteristics and outcomes of bullous pemphigoid patients with versus without oral prednisolone treatment. J Dermatol 2021; 48:502-510. [PMID: 33600037 DOI: 10.1111/1346-8138.15816] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/31/2021] [Indexed: 11/30/2022]
Abstract
Bullous pemphigoid (BP) varies in severity and stratified treatments are needed. However, there are no definitive standards for choosing appropriate treatments. To elucidate the factors involved in choosing treatments and the clinical outcomes of BP, we retrospectively reviewed the clinical records of 78 BP patients at a single center. Of the 78 patients, 49 (62.8%) were treated with oral prednisolone (PSL) and 29 (37.2%) were treated without PSL. The patients with older age, lower Bullous Pemphigoid Disease Area Index (BPDAI), and/or lower anti-BP180NC16a antibody titer at onset tended to be treated without oral PSL. Notably, only 9.1% patients without PSL experienced relapse, whereas 36.7% patients with oral PSL experienced relapse when the PSL was around 0.1 mg/kg. It suggests that the patients with mild disease severity could be well controlled without oral PSL. Receiver-operator curve analysis demonstrated that the cut-off value for the use of oral PSL was 31 for total BPDAI and was 7 for BPDAI skin urticaria/erythema, with a high (>0.9) area under the curve. Notably, none of the patients who were negative for the anti-BP180NC16a antibody at onset experienced relapse even though they were treated without PSL. In conclusion, in BP patients who were negative for anti-BP180NC16a antibody at onset, with a total BPDAI score of less than 31 or with an urticaria/erythema score of less than 7 can be treated without PSL. When the PSL is tapered to around 0.1 mg/kg, we should carefully monitor the patients to detect relapse.
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Affiliation(s)
- Inkin Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Norihiro Yoshimoto
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kentaro Izumi
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Shimizu
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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24
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Bieber K, Kridin K, Emtenani S, Boch K, Schmidt E, Ludwig RJ. Milestones in Personalized Medicine in Pemphigus and Pemphigoid. Front Immunol 2021; 11:591971. [PMID: 33505392 PMCID: PMC7829330 DOI: 10.3389/fimmu.2020.591971] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/16/2020] [Indexed: 12/20/2022] Open
Abstract
Pemphigus and pemphigoid diseases are autoimmune bullous diseases characterized and caused by autoantibodies targeting adhesion molecules in the skin and/or mucous membranes. Personalized medicine is a new medical model that separates patients into different groups and aims to tailor medical decisions, practices, and interventions based on the individual patient`s predicted response or risk factors. An important milestone in personalized medicine in pemphigus and pemphigoid was achieved by verifying the autoimmune pathogenesis underlying these diseases, as well as by identifying and cloning several pemphigus/pemphigoid autoantigens. The latter has become the basis of the current, molecular-based diagnosis that allows the differentiation of about a dozen pemphigus and pemphigoid entities. The importance of autoantigen-identification in pemphigus/pemphigoid is further highlighted by the emergence of autoantigen-specific B cell depleting strategies. To achieve this goal, the chimeric antigen receptor (CAR) T cell technology, which is used for the treatment of certain hematological malignancies, was adopted, by generating chimeric autoantigen receptor (CAAR) T cells. In addition to these more basic science-driven milestones in personalized medicine in pemphigus and pemphigoid, careful clinical observation and epidemiology are again contributing to personalized medicine. The identification of clearly distinct clinical phenotypes in pemphigoid like the non-inflammatory and gliptin-associated bullous pemphigoid embodies a prominent instance of the latter. We here review these exciting developments in basic, translational, clinical, and epidemiological research in pemphigus and pemphigoid. Overall, we hereby aim to attract more researchers and clinicians to this highly interesting and dynamic field of research.
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Affiliation(s)
- Katja Bieber
- Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Shirin Emtenani
- Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Katharina Boch
- Department of Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
- Department of Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Ralf J. Ludwig
- Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
- Department of Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
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25
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Ständer S, Schmidt E, Zillikens D, Ludwig RJ, Kridin K. More Severe Erosive Phenotype Despite Lower Circulating Autoantibody Levels in Dipeptidyl Peptidase-4 Inhibitor (DPP4i)-Associated Bullous Pemphigoid: A Retrospective Cohort Study. Am J Clin Dermatol 2021; 22:117-127. [PMID: 33026629 PMCID: PMC7847447 DOI: 10.1007/s40257-020-00563-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The clinical and immunological profile of patients with dipeptidyl peptidase-4 inhibitor (DPP4i)-associated bullous pemphigoid (BP) is inconsistent in the current literature. OBJECTIVES The aims were to investigate the clinical and immunological features of patients with DPP4i-associated BP and to examine whether there are intraclass differences between different DPP4i agents. METHODS A retrospective cohort study was conducted, including all consecutive patients diagnosed with BP throughout the years 2009-2019 in a tertiary referral center. RESULTS The study encompassed 273 patients with BP (mean age at diagnosis 79.1 ± 9.9 years), of whom 24 (8.8%) were associated with DPP4i. Sitagliptin was the prescribed agent for 17 patients (70.8%), and vildagliptin was prescribed in seven patients (29.2%). Relative to other patients with BP, patients with DPP4i-associated BP had more prominent truncal involvement (95.8% vs. 73.9%; P = 0.017), greater erosion/blister Bullous Pemphigoid Disease Area Index (BPDAI) subscore (29.8 ± 17.4 vs. 20.6 ± 14.4; P = 0.018), and lower levels of anti-BP180 NC16A (279.2 ± 346.1 vs. 572.2 ± 1352.0 U/ml; P = 0.009) and anti-BP230 (25.5 ± 47.8 vs. 128.6 ± 302.9 U/ml; P = 0.009) antibodies. Relative to patients with sitagliptin-associated BP, those with vildagliptin-associated BP had a lower seropositivity rate (57.1% vs. 94.1%, P = 0.031) and lower levels (96.7 ± 139.0 vs. 354.5 ± 376.5; P = 0.023) of anti-BP180 NC16A antibodies, and tended to present with higher erosion/blister BPDAI subscore (36.3 ± 9.6 vs. 25.8 ± 19.7; P = 0.095). CONCLUSIONS DPP4i-associated BP is characterized by a more severe blistering and erosive presentation despite lower levels of typically pathogenic antibodies.
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Affiliation(s)
- Sascha Ständer
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Ralf J Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.
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26
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Armanious M, AbuHilal M. Gliptin-Induced Bullous Pemphigoid: Canadian Case Series of 10 Patients. J Cutan Med Surg 2020; 25:163-168. [PMID: 33176433 DOI: 10.1177/1203475420972349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is a chronic immune-mediated vesiculobullous disorder. Recently, several reports have described dipeptidyl peptidase-4 inhibitors, also known as gliptins, as causative agents for drug-induced BP. OBJECTIVE To report and describe clinical and histologic characteristics of 10 cases of gliptin-induced BP. RESULTS We identified 10 patients with gliptin-induced BP. Nine were secondary to linagliptin, and 1 case was attributed to sitagliptin. All patients showed significant improvement after withdrawal of gliptin medications and proper medical treatment. There has been no evidence of relapse after 4 months of follow-up. CONCLUSION This report supports the proposed association between gliptins and BP. Physicians should be aware of this potential adverse effect, as gliptin-induced BP can be reversible once identified and the responsible medication is stopped. Early withdrawal of the offending drug and proper treatment can lead to rapid improvement and reduced morbidity.
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Affiliation(s)
- Miriam Armanious
- 3710 Division of Dermatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mohn'd AbuHilal
- 3710 Division of Dermatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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27
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Clinical Features and Outcomes of Dipeptidyl Peptidase-4 Inhibitor-Associated Bullous Pemphigoid (DPP4i-Associated BP) in Thai Patients. Case Rep Endocrinol 2020; 2020:8832643. [PMID: 33101737 PMCID: PMC7569454 DOI: 10.1155/2020/8832643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/25/2020] [Accepted: 09/30/2020] [Indexed: 12/21/2022] Open
Abstract
The use of dipeptidyl peptidase-4 inhibitors (DPP4i) appears to be associated with a small but significantly elevated risk of bullous pemphigoid (BP). Although the pathogenic mechanism of DPP4i-associated BP remains unclear, this adverse event is reported with multiple gliptins, suggesting a class effect. However, previous studies from various countries showed that vildagliptin had been implicated in most cases. The aim of this study was to illustrate a case series of DPP4i-associated BP in Thai patients. We conducted a retrospective study from consecutive cases of BP in people with type 2 diabetes mellitus (T2DM) from January 2008, the year in which the first DPP4i was introduced in Thailand, until December 2019. During the study period, 10 BP patients with T2DM were identified. A total of 5 DPP4i-associated BP (3 on vildagliptin, 1 on linagliptin, and 1 on sitagliptin) were found. All patients were male with a mean age at BP development of 80.4 years (73–86 years). All patients had a long-standing duration of diabetes (median duration 34 years), and mean A1C was 7.5 ± 1.4%. The median time to BP development after the introduction of DPP4i was 64 months (range 20–128 months). The severity of BP was classified as mild in 2 cases. In all cases, the association between the drug intake and BP onset was classified as “possible” according to the Naranjo causality scale. All of the patients continued taking DPP4i after BP diagnosis, and one patient died of lung cancer 18 months after BP diagnosis. Only 2 patients could achieve complete remission at least 2 months after stopping DPP4i. Our case series demonstrated a potential link between DPP4i and the development of BP, which mainly occurred in very elderly male patients. The latency period from an introduction of DPP-4i could be several years, and the clinical course after DPP4i discontinuation varied. Clinicians prescribing DPP4i should be aware of this association and consider stopping this medication before a refractory disease course ensues.
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28
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Muramatsu K, Zheng M, Yoshimoto N, Ito T, Ujiie I, Iwata H, Shimizu H, Ujiie H. Regulatory T cell subsets in bullous pemphigoid and dipeptidyl peptidase-4 inhibitor-associated bullous pemphigoid. J Dermatol Sci 2020; 100:23-30. [PMID: 32843228 DOI: 10.1016/j.jdermsci.2020.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Regulatory T (Treg) cells play an essential role in peripheral immune tolerance. Bullous pemphigoid (BP) is the most common blistering disease and is caused by autoantibodies to two BP antigens: type XVII collagen and BP230. Recently, we reported that Treg cell dysfunction may cause the production of autoantibodies to BP antigens. Several studies have suggested an association between Treg cells and BP pathogenesis. However, Treg cells are heterogeneous in humans, leading to inconsistent results in previous studies. OBJECTIVE To assess functional Treg subsets in BP. METHODS We examined three distinct Treg subsets in conventional BP (cBP) patients before versus after systemic corticosteroid treatment, dipeptidyl peptidase-4 inhibitor-associated BP (DPP-4i-BP) patients, younger controls and older controls. RESULTS We found that total Treg cells and all Treg cell subsets were increased in cBP patients before treatment and decreased by systemic corticosteroid treatment. In contrast, neither total Treg cells nor all Treg subsets were increased in DPP-4i-BP. Notably, CD45RA- Foxp3hi effector Treg cells positively correlated with disease severity in cBP, whereas CD45RA+Foxp3lo naïve Treg cells positively correlated with the disease severity in DPP-4i-BP. CONCLUSION These findings suggest that Treg cells are differently involved in the pathogeneses of cBP and DPP-4i-BP.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Autoantibodies/immunology
- Autoantibodies/metabolism
- Autoantigens/immunology
- CD4 Lymphocyte Count
- Case-Control Studies
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/drug therapy
- Dipeptidyl-Peptidase IV Inhibitors/adverse effects
- Dystonin/immunology
- Female
- Glucocorticoids/administration & dosage
- Healthy Volunteers
- Humans
- Male
- Middle Aged
- Non-Fibrillar Collagens/immunology
- Pemphigoid, Bullous/blood
- Pemphigoid, Bullous/chemically induced
- Pemphigoid, Bullous/diagnosis
- Pemphigoid, Bullous/immunology
- Severity of Illness Index
- T-Lymphocyte Subsets/drug effects
- T-Lymphocyte Subsets/immunology
- T-Lymphocyte Subsets/metabolism
- T-Lymphocytes, Regulatory/drug effects
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/metabolism
- Collagen Type XVII
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Affiliation(s)
- Ken Muramatsu
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Miao Zheng
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Norihiro Yoshimoto
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takamasa Ito
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Inkin Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Shimizu
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
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29
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Kridin K. Dipeptidyl-peptidase IV inhibitors (DPP4i)-associated bullous pemphigoid: Estimating the clinical profile and exploring intraclass differences. Dermatol Ther 2020; 33:e13790. [PMID: 32506731 DOI: 10.1111/dth.13790] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/26/2020] [Accepted: 06/04/2020] [Indexed: 12/19/2022]
Abstract
Data regarding the clinical characteristics of patients with dipeptidyl-peptidase IV inhibitors (DPP4i)-associated BP is inconclusive. We aimed to characterize the clinical features of patients with DPP4i-associated BP, and to assess whether there are phenotypic differences associated with different agents belonging to the DPP4i class. A retrospective prevalence study was performed, including all consecutive patients diagnosed with BP throughout the years 2000 to 2019. The study included 397 patients with BP, of whom 58 (14.6%) were DPP4i-associated. Compared to other patients with BP, patients with DPP4i-associated BP had a more prominent male preponderance (60.3% vs 41.0%; P = .006), presented more frequently with extensive disease (60.3% vs 46.3%; P = .049), had greater truncal (96.6% vs 85.5%; P = .019) and cephalic (51.7% vs 33.6%; P = .008) involvement, and had less frequent peripheral eosinophilia (25.9% vs 51.9%; P < .001). Compared to patients with vildagliptin-associated BP, those with linagliptin-associated BP were managed by higher dosage of systemic corticosteroids in order to achieve disease control (prednisone > 1 mg/kg: 68.2% vs 40.0%; P = .046). In conclusion, DPP4i-associated BP seems to have a unique clinical profile characterized by male predominance, extensive disease, truncal and cephalic involvement, and less peripheral eosinophilia. Linagliptin may be associated with a harder course necessitating more aggressive therapy.
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Affiliation(s)
- Khalaf Kridin
- Clalit Health Services, Haifa, Israel.,Lübeck Institute of Experimental, Dermatology, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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30
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Kimura K, Kawai K. Doxycycline as an initial treatment of bullous pemphigoid in Japanese patients. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2020. [DOI: 10.1002/cia2.12126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Kiyoto Kimura
- Department of Dermatology Kido Hospital Niigata Japan
- Division of Dermatology Niigata University Graduate School of Medical and Dental Sciences Niigata Japan
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31
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Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disorder with substantial morbidity and mortality. BP is regarded as a disorder driven by IgG due to BP180 and BP230 IgG autoantibodies, yet, new advances highlight the function of eosinophils and IgE autoantibodies in BP. Evidence supports that eosinophils are involved in BP pathogenesis, notably, these include the presence of IL-5, eotaxin, and eosinophil-colony stimulating factor in blister fluid, peripheral blood eosinophilia is present in nearly 50% of affected patients, eosinophils are found against the dermo-epidermal junction (DEJ) when BP serum is present, metalloprotease-9 is secreted by eosinophils at blister sites, blister fluid of BP patients contains eosinophil granule proteins which are located along the lamina lucida of the BMZ in patients with BP and correspond with disease clinically, eosinophil extracellular traps (EET) have been linked to DEJ splitting, IL-5 activated eosinophils cause DEJ separation when BP serum is present, and eosinophils are requisite to drive anti-BP180 IgE mediated blistering of the skin. Yet, the mechanism whereby eosinophils contribute to the pathogenesis of BP remains to be explored. In this review, we examine the role of eosinophils in BP while offering a basis to explain the pathomechanisms of eosinophils in BP.
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Affiliation(s)
- Virginia A Jones
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA
| | - Payal M Patel
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA
| | - Kyle T Amber
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA -
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32
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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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33
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Affiliation(s)
- Jun Usami
- General Medicine, Aichi Medical University, Japan
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34
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Hung CT, Liu JS, Cheng CY, Chung CH, Chiang CP, Chien WC, Wang WM. Increased risk of bullous pemphigoid in dipeptidyl peptidase 4 inhibitors: A nationwide, population-based, cohort study in Taiwan. J Dermatol 2019; 47:245-250. [PMID: 31885117 DOI: 10.1111/1346-8138.15195] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 11/26/2019] [Indexed: 12/13/2022]
Abstract
Recent studies revealed the risk of bullous pemphigoid (BP) in patients with diabetes mellitus (DM) taking dipeptidyl peptidase 4 (DPP-4) inhibitors. To clarify the relationship between taking DPP-4 inhibitors and the risk of BP among patients with DM, we conducted a cohort study by using the National Health Insurance Research Database of Taiwan from 1 January 2009 to 31 December 2015. We identified 6340 patients with DM taking DPP-4 inhibitors and 25 360 DM patients who had not taken DPP-4 inhibitors during the 7-year follow-up period. Compared with the non-DPP-4 inhibitor group, patients taking DDP-4 inhibitors had a higher risk of BP (adjusted hazard ratio [aHR], 2.382; 95% confidence interval (CI), 1.163-4.883; P = 0.017]. Among the DPP-4 inhibitors available in Taiwan, vildagliptin showed the highest risk of BP (aHR, 2.849; 95% CI, 1.893-4.215; P < 0.001), followed by saxagliptin (aHR, 2.657; 95% CI, 1.770-3.934; P < 0.001). Subgroup analysis revealed that the higher risk of BP was observed in patients older than 65 years (aHR, 2.403; 95% CI, 1.590-3.627; P < 0.001). This study revealed that treatment with DPP-4 inhibitors, especially vildagliptin, was significantly associated with an increased risk of BP among DM patients.
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Affiliation(s)
- Chih-Tsung Hung
- Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Jhih-Syuan Liu
- Division of Endocrine and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, Taipei, Taiwan
| | - Cheng-Yi Cheng
- Department of Nuclear Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Hsiang Chung
- School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan
| | - Chien-Ping Chiang
- Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Ming Wang
- Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
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35
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Hayashi M, Tsunoda T, Sato F, Yaguchi Y, Igarashi M, Izumi K, Nishie W, Ishii N, Okamura K, Suzuki T, Hashimoto T. Clinical and immunological characterization of 14 cases of dipeptidyl peptidase‐4 inhibitor‐associated bullous pemphigoid: a single‐centre study. Br J Dermatol 2019; 182:806-807. [DOI: 10.1111/bjd.18516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- M. Hayashi
- Department of Dermatology Yamagata University Faculty of Medicine Yamagata Japan
| | - T. Tsunoda
- Department of Dermatology Yamagata University Faculty of Medicine Yamagata Japan
- Division of Dermatology Yamagata City Hospital Saiseikan Yamagata Japan
| | - F. Sato
- Division of Dermatology Yamagata City Hospital Saiseikan Yamagata Japan
| | - Y. Yaguchi
- Department of Dermatology Yamagata University Faculty of Medicine Yamagata Japan
- Division of Dermatology Yamagata City Hospital Saiseikan Yamagata Japan
| | - M. Igarashi
- Division of Diabetes and Endocrinology Yamagata City Hospital Saiseikan Yamagata Japan
| | - K. Izumi
- Department of Dermatology Hokkaido University Graduate School of Medicine Sapporo Japan
| | - W. Nishie
- Department of Dermatology Hokkaido University Graduate School of Medicine Sapporo Japan
| | - N. Ishii
- Department of Dermatology Kurume University School of Medicine Kurume Japan
| | - K. Okamura
- Department of Dermatology Yamagata University Faculty of Medicine Yamagata Japan
| | - T. Suzuki
- Department of Dermatology Yamagata University Faculty of Medicine Yamagata Japan
| | - T. Hashimoto
- Department of Dermatology Osaka City University Graduate School of Medicine Osaka Japan
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36
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García Castro R, Godoy Gijón E, González Pérez AM, Román Curto C. Bullous pemphigoid and DPP4 inhibitors. Med Clin (Barc) 2019; 153:368-371. [PMID: 31327556 DOI: 10.1016/j.medcli.2019.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/19/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Rubén García Castro
- Servicio de Dermatología, Hospital Clínico Universitario de Salamanca, Salamanca, España.
| | - Elena Godoy Gijón
- Servicio de Dermatología, Hospital Clínico Universitario de Salamanca, Salamanca, España
| | | | - Concepción Román Curto
- Servicio de Dermatología, Hospital Clínico Universitario de Salamanca, Salamanca, España
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37
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Risque de pemphigoïde bulleuse confirmé avec les gliptines. Ann Dermatol Venereol 2019; 146:764-766. [DOI: 10.1016/j.annder.2019.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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38
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Reolid A, Muñoz-Aceituno E, Rodríguez-Jiménez P, González-Rojano E, Llamas-Velasco M, Fraga J, Daudén E. Bullous pemphigoid associated with dipeptidyl peptidase-4 inhibitors. A case series and analysis of cases reported in the Spanish pharmacovigilance database. Int J Dermatol 2019; 59:197-206. [PMID: 31605541 DOI: 10.1111/ijd.14658] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/01/2019] [Accepted: 08/29/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) has been associated with dipeptidyl peptidase-4 inhibitors (DPP4i). Clinical features, outcomes, and risk of BP for new DPP4i (linagliptin, saxagliptin, and alopgliptin) are not well established. Comparison of risk of BP appearance for DPP4i and other oral antidiabetic drugs (OADs) such as sodium glucose cotransporter 2 inhibitors has not been studied to date. OBJECTIVES To describe the prevalence, sociodemographic, clinical, and histopathological characteristics, and outcome after drug withdrawal in DPP-4i-associated BP cases from our hospital. To review all Spanish spontaneous notifications of BP where DPP4i or OADs were included as suspected drugs and calculate the reporting odds ratios (RORs). METHODS A retrospective observational study was performed examining the association between DDP4i and BP. Clinical features and RORs were analyzed. Data from the Spanish Pharmacovigilance System (SEFV) are included. RESULTS In our center, 28 of 89 patients with BP (31.5%) were under DPP4i treatment; 53.6% were male, and mean age was 80.8 years. BP debuted the first year after DPP4i in 57.2%. BP control was achieved within 3.7 months after drug withdrawal. Regarding SEFV, 22 of 972 spontaneous notifications were related to BP and DPP4i. RORs were superior for DPP4i compared to other OADs. Vildagliptin had the highest ROR. CONCLUSIONS We present the largest DPP4i-induced BP case series in a single center, with a detailed study of the sociodemographic, clinical, and histopathological characteristics of each patient, and their treatment and outcome. Vildagliptin had the highest risk. DPP4i-associated BP does not seem to have specific clinical characteristics.
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Affiliation(s)
- Alejandra Reolid
- Department of, Dermatology, Instituto de Investigación Sanitaria la Princesa (IIS-IP), Hospital Universitario la Princesa, Madrid, Spain
| | - Ester Muñoz-Aceituno
- Department of, Dermatology, Instituto de Investigación Sanitaria la Princesa (IIS-IP), Hospital Universitario la Princesa, Madrid, Spain
| | - Pedro Rodríguez-Jiménez
- Department of, Dermatology, Instituto de Investigación Sanitaria la Princesa (IIS-IP), Hospital Universitario la Princesa, Madrid, Spain
| | - Esperanza González-Rojano
- Department of, Clinical Pharmacology, Instituto de Investigación Sanitaria la Princesa (IIS-IP), Hospital Universitario la Princesa, Madrid, Spain
| | - Mar Llamas-Velasco
- Department of, Dermatology, Instituto de Investigación Sanitaria la Princesa (IIS-IP), Hospital Universitario la Princesa, Madrid, Spain
| | - Javier Fraga
- Department of, Pathology, Instituto de Investigación Sanitaria la Princesa (IIS-IP), Hospital Universitario la Princesa, Madrid, Spain
| | - Esteban Daudén
- Department of, Dermatology, Instituto de Investigación Sanitaria la Princesa (IIS-IP), Hospital Universitario la Princesa, Madrid, Spain
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39
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Sadik CD, Langan EA, Grätz V, Zillikens D, Terheyden P. Checkpoint Inhibition May Trigger the Rare Variant of Anti-LAD-1 IgG-Positive, Anti-BP180 NC16A IgG-Negative Bullous Pemphigoid. Front Immunol 2019; 10:1934. [PMID: 31474998 PMCID: PMC6703093 DOI: 10.3389/fimmu.2019.01934] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/30/2019] [Indexed: 01/10/2023] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering skin disease characterized by an autoimmune response to type XVII collagen (BP180). The generation of anti-BP180-NC16A IgG autoantibodies is considered to be central to the pathogenesis of BP, in part due to the close correlation between serum concentration and disease activity. However, ~60% of BP patients also generate IgG autoantibodies against LAD-1, the soluble 120 kDa ectodomain of BP180. Whilst the pathogenic significance of anti-LAD-1 IgG remains unclear, it may be sufficient to precipitate the development of BP, even in the absence of anti-BP180-NC16A IgG, based on several case reports in Japanese patients. There is increasing recognition that immune-checkpoint inhibitors may trigger and/or exacerbate BP as an immune-related adverse event (irAE). Until now, all of these cases have been associated with the induction of anti-BP180-NC16A IgG. Here, we report the case of a female Caucasian patient who developed BP during treatment with the programmed cell death protein 1 (PD-1) inhibitor nivolumab. Intriguingly, the patient exclusively generated anti-LAD-1 IgG, suggesting that anti-LAD-1 IgG was responsible for the development of her autoimmune blistering dermatosis. This is the first such case documented in a non-Japanese patient, thus, lending further support to the pathogenic relevance of anti-LAD-1 IgG in BP.
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Daniel B, Murrell D. Review of autoimmune blistering diseases: the Pemphigoid diseases. J Eur Acad Dermatol Venereol 2019; 33:1685-1694. [DOI: 10.1111/jdv.15679] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/03/2019] [Indexed: 12/30/2022]
Affiliation(s)
- B.S. Daniel
- St Vincent's Hospital Melbourne Australia
- St George Hospital Sydney Australia
- University of New South Wales Sydney Australia
| | - D.F. Murrell
- St George Hospital Sydney Australia
- University of New South Wales Sydney Australia
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Mahé A. [What's new in clinical dermatology?]. Ann Dermatol Venereol 2019; 145 Suppl 7:VIIS1-VIIS10. [PMID: 30583751 DOI: 10.1016/s0151-9638(18)31283-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In this article, we performed a review of all new data of clinical relevance for the dermatologists that were published in the medical literature between September, 2017 and September, 2018. Besides advances that will be useful in day-to-day dermatological practice, we intended to give a more general perspective to this review by taking into account certain international health issues that might in final concern each of us in a globalized world. Focus were more particularly done on the following topics: infectious diseases (including sexually transmitted infections), neglected tropical diseases, adverse effects of drugs, bullous diseases, allergology, wound healing, dermatology on black skin, and public health dermatology.
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Affiliation(s)
- A Mahé
- Service de dermatologie, hôpital Louis-Pasteur, 68024 Colmar cedex, France.
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Tasanen K, Varpuluoma O, Nishie W. Dipeptidyl Peptidase-4 Inhibitor-Associated Bullous Pemphigoid. Front Immunol 2019; 10:1238. [PMID: 31275298 PMCID: PMC6593303 DOI: 10.3389/fimmu.2019.01238] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/16/2019] [Indexed: 12/18/2022] Open
Abstract
Bullous pemphigoid (BP) is an organ-specific autoantibody-mediated blistering skin disease that mainly affects the elderly. Typical clinical features include the widespread blisters, often preceded by and/or associated with itchy urticarial or eczema-like lesions. BP patients have circulating autoantibodies against BP180 and/or the plakin family protein BP230 both of which are components of hemidesmosomes in basal keratinocytes. Most BP autoantibodies particularly target the epitopes within the non-collagenous NC16A domain of BP180. Clinical findings and murine models of BP have provided evidence of a pathogenic role of anti-NC16A autoantibodies. However, it is largely unknown what triggers the breakage of immunotolerance against BP180 in elderly individuals. The incidence of BP has been increased over the past two decades in several countries. Aside from aging populations, the factors behind this phenomenon are still not fully understood. Neurodegenerative diseases such as multiple sclerosis, Parkinson's disease, and certain dementias are independent risk factors for BP. Recently several case reports have described BP in patients with diabetes mellitus (DM) patients who have been treated with dipeptidyl peptidase-4 inhibitors (DPP-4i or gliptins), which are a widely used class of anti-DM drugs. The association between the use of DPP-4is, particularly vildagliptin, and BP risk has been confirmed by several epidemiological studies. Evidence suggests that cases of gliptin-associated BP in Japan display certain features that set them apart from cases of “regular” BP. These include a “non-inflammatory” phenotype, targeting by antibodies of different immunodominant BP180 epitopes, and a specific association with the human leukocyte antigen (HLA) types. However, recent studies in European populations have found no major differences between the clinical and immunological characteristics of gliptin-associated BP and “regular” BP. The DPP-4 protein (also known as CD26) is ubiquitously expressed and has multiple functions in various cell types. The different effects of the inhibition of DPP-4/CD26 activity include, for example, tissue modeling and regulation of inflammatory cells such as T lymphocytes. Although the pathomechanism of gliptin-associated BP is currently largely unknown, investigation of the unique effect of gliptins in the induction of BP may provide a novel route to better understanding of how immunotolerance against BP180 breaks down in BP.
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Affiliation(s)
- Kaisa Tasanen
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Outi Varpuluoma
- PEDEGO Research Unit, Department of Dermatology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Mai Y, Nishie W, Izumi K, Shimizu H. Preferential Reactivity of Dipeptidyl Peptidase-IV Inhibitor-Associated Bullous Pemphigoid Autoantibodies to the Processed Extracellular Domains of BP180. Front Immunol 2019; 10:1224. [PMID: 31191560 PMCID: PMC6549357 DOI: 10.3389/fimmu.2019.01224] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/14/2019] [Indexed: 12/21/2022] Open
Abstract
Bullous pemphigoid (BP) is a common autoimmune blistering disease in which autoantibodies target the hemidesmosomal components BP180 and/or BP230 in basal keratinocytes. In BP, 80 to 90% of autoantibodies target the juxtamembranous extracellular non-collagenous 16th A (NC16A) domain of BP180. Recently, the administration of dipeptidyl peptidase-IV inhibitors (DPP4i), which are widely used as antihyperglycemic drugs, has been recognized to be a causative factor for BP. DPP4i-associated BP (DPP4i-BP) autoantibodies tend to target epitopes on non-NC16A regions of BP180, and the pathomechanism for the development of the unique autoantibodies remains unknown. To address the characteristics of DPP4i-BP autoantibodies in detail, we performed epitope analysis of 18 DPP4i-BP autoantibodies targeting the non-NC16A domains of BP180 using various domain-specific as well as plasmin-digested polypeptides derived from recombinant BP180. Firstly, Western blotting showed that only one DPP4i-BP serum reacted with the epitopes on the intracellular domain of BP180, and no sera reacted with the C-terminal domain of the molecule. In addition, only 2 DPP4i-BP sera reacted with BP230 as determined by enzyme-linked immunosorbent assay. Thus, DPP4i-BP autoantibodies were found to mainly target the non-NC16A mid-portion of the extracellular domain of BP. Interestingly, Western blotting using plasmin-digested BP180 as a substrate revealed that all of the DPP4i-BP sera reacted more intensively with the 97-kDa processed extracellular domain of BP180, which is known as the LABD97 autoantigen, than full-length BP180 did. All of the DPP4i-BP autoantibodies targeting the LABD97 autoantigen were IgG1, and IgG4 was observed to react with the molecule in only 7 cases (38.9%). In summary, the present study suggests that IgG1-class autoantibodies targeting epitopes on the processed extracellular domain of BP180, i.e., LABD97, are the major autoantibodies in DPP4i-BP.
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Affiliation(s)
| | - Wataru Nishie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Nishie W. Dipeptidyl peptidase IV inhibitor-associated bullous pemphigoid: a recently recognized autoimmune blistering disease with unique clinical, immunological and genetic characteristics. Immunol Med 2019; 42:22-28. [PMID: 31169082 DOI: 10.1080/25785826.2019.1619233] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/12/2019] [Indexed: 01/08/2023] Open
Abstract
Bullous pemphigoid (BP) is an organ-specific autoantibody-mediated autoimmune blistering skin disorder that tends to affect the elderly. Tense blister formation associated with itchy urticarial erythema is clinically observed in BP, and subepidermal blister formation with eosinophilic infiltration is a histopathological characteristic. BP autoantibodies target two hemidesmosomal components in basal keratinocytes: BP180 and BP230. Anti-BP180 autoantibodies play major roles in blister formation. Although the autoantibody-mediated pathomechanism of blister formation has been extensively studied, little is known about how and why immune tolerance to BP180 may be broken in certain elderly individuals. Recently, BP has been increasingly reported in diabetes mellites (DM) patients receiving dipeptidyl peptidase-IV inhibitors (DPP4is), which are widely used anti-DM drugs. Pharmacovigilance and cohort studies have revealed that DPP4is, especially vildagliptin, teneligliptin, and linagliptin, are a potential risk factor for BP onset. Interestingly, it has been revealed that Japanese DPP4i-BP tends to show a non-inflammatory phenotype, with less erythema than normal BP, and that DPP4i-BP autoantibodies target distinct epitopes on BP180. In addition, human leukocyte antigen-DQB1*03:01 was identified as the major haplotype in Japanese DPP4i-BP. This review summarizes the latest understanding of the pathogenesis of BP, with a special focus on the recently recognized DPP4i-BP.
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Affiliation(s)
- Wataru Nishie
- a Department of Dermatology , Hokkaido University Graduate School of Medicine , Sapporo , Japan
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Tanaka H, Ishii T. Analysis of patients with drug-induced pemphigoid using the Japanese Adverse Drug Event Report database. J Dermatol 2018; 46:240-244. [PMID: 30575097 DOI: 10.1111/1346-8138.14741] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 11/13/2018] [Indexed: 12/31/2022]
Abstract
To clarify the incidence of drug-induced pemphigoid in Japan, we conducted a database search and analysis using the Japanese Adverse Drug Event Report database (JADER). Among the cases recorded in JADER between April 2004 and November 2017, we targeted "pemphigoid" and analyzed the patients' backgrounds, drug involvement, time of pemphigoid onset, outcomes and year reported. For cases where three or more drugs were reportedly involved, the signal index was calculated using the reporting odds ratio (ROR) method. The total number of reported pemphigoid cases was 769. Males accounted for 58% (446 cases) and patients over the age of 60 years accounted for 82% (630 cases). The most frequently reported causative drug was vildagliptin (288 cases), followed in order by sitagliptin phosphate hydrate (102 cases), teneligliptin hydrobromide hydrate (86 cases), linagliptin (64 cases) and furosemide (46 cases). For the 27 causative drugs, the safety signal was detected by the ROR method. The median time to onset tended to be long for these drugs. For vildagliptin with the largest reported number, the value was 508 days (range, 2-1871). Analysis of outcomes demonstrated recovery or improvement in 66.3% of cases. Analysis of the years in which reports had been published revealed that the number of pemphigoid cases has increased rapidly in recent years. Our survey was able to reveal useful data on the incidence of drug-induced pemphigoid. We expect that these results will aid the early detection and treatment of this condition.
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Affiliation(s)
- Hiroyuki Tanaka
- Department of Practical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Funabashi, Japan
| | - Toshihiro Ishii
- Department of Practical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Funabashi, Japan
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Abstract
Pemphigus and pemphigoid are characterized as autoimmune blistering diseases in which immunoglobulin G autoantibodies cause blisters and erosions of the skin or mucosa or both. Recently, understanding of the pathophysiology of pemphigus and pemphigoid has been furthered by genetic analyses, characterization of autoantibodies and autoreactive B cells, and elucidation of cell–cell adhesion between keratinocytes. For the management of pemphigus and pemphigoid, the administration of systemic corticosteroids still represents the standard treatment strategy; however, evidence of the efficacy of therapies not involving corticosteroids, such as those employing anti-CD20 antibodies, is increasing. The goal should be to develop antigen-specific immune suppression-based treatments.
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Affiliation(s)
- Jun Yamagami
- Department of Dermatology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Amber KT, Valdebran M, Kridin K, Grando SA. The Role of Eosinophils in Bullous Pemphigoid: A Developing Model of Eosinophil Pathogenicity in Mucocutaneous Disease. Front Med (Lausanne) 2018; 5:201. [PMID: 30042946 PMCID: PMC6048777 DOI: 10.3389/fmed.2018.00201] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease which carries a significant mortality and morbidity. While historically BP has been characterized as an IgG driven disease mediated by anti-BP180 and BP230 IgG autoantibodies, developments in recent years have further elucidated the role of eosinophils and IgE autoantibodies. In fact, eosinophil infiltration and eosinophilic spongiosis are prominent features in BP. Several observations support a pathogenic role of eosinophils in BP: IL-5, eotaxin, and eosinophil-colony stimulating factor are present in blister fluid; eosinophils line the dermo-epidermal junction (DEJ) in the presence of BP serum, metalloprotease-9 is released by eosinophils at the site of blisters; eosinophil degranulation proteins are found on the affected basement membrane zone as well as in serum corresponding with clinical disease; eosinophil extracellular DNA traps directed against the basement membrane zone are present, IL-5 activated eosinophils cause separation of the DEJ in the presence of BP serum; and eosinophils are the necessary cell required to drive anti-BP180 IgE mediated skin blistering. Still, it is likely that eosinophils contribute to the pathogenesis of BP in numerous other ways that have yet to be explored based on the known biology of eosinophils. We herein will review the role of eosinophils in BP and provide a framework for understanding eosinophil pathogenic mechanisms in mucocutaneous disease.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of California, Irvine, Irvine, CA, United States
| | - Manuel Valdebran
- Department of Dermatology, University of California, Irvine, Irvine, CA, United States
| | - Khalaf Kridin
- Department of Dermatology, Rambam Healthcare Campus, Haifa, Israel
| | - Sergei A Grando
- Department of Dermatology, University of California, Irvine, Irvine, CA, United States.,Departments of Dermatology and Biological Chemistry, Institute for Immunology, University of California, Irvine, Irvine, CA, United States
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