Pemphigus in Korea: Clinical Manifestations and Treatment Protocol

A Global View of Pemphigus: Geographical Variations

Pemphigus, an autoimmune intraepidermal bullous disease group with roughly eight distinct forms, includes pemphigus vulgaris (PV) and pemphigus foliaceus (PF) as its predominant global forms. Despite the increased utilization of global health records and reporting systems, epidemiological data remain limited and poorly categorized. Therefore, this study aimed to conduct a review to track, identify, and characterize cases of PV and PF published and categorized worldwide. A research question was formulated; studies were selected based on the inclusion criteria; and data from these publications were systematically collected, summarized, and presented using narrative descriptions. The search strategy yielded 3,212 articles, of which 95 underwent critical analysis and data extraction. Studies from 52 countries contributed to the dataset, covering various pemphigus variants. Notably, only two countries, Iran (18.87%) and South Korea (11.43%), accounted for approximately a third of the reported PV cases, while Brazil contributed 40.25% of the foliaceus variants cases documented in the literature. These findings offer valuable insights into the global distribution of pemphigus and inform future research and healthcare efforts.

Prevalence of oral mucosal lesions in patients with pemphigus vulgaris: A systematic review and meta-analysis

OBJECTIVE

To assess the prevalence of oral mucosal lesions in patients with Pemphigus Vulgaris.

METHODS

Observational studies reporting the prevalence of oral lesions in pemphigus vulgaris patients, without restriction to language and year of publication, were selected in a two-phase process. Search strategies were applied to PubMed, Scopus, Livivo, Web of Science, LILACS, Google Scholar, and OpenGrey databases. Articles assessing the prevalence of oral lesions in patients with conditions other than pemphigus vulgaris were excluded. Risk of bias analysis was performed using the Joanna Briggs Institute's Critical Appraisal Checklist for Studies Reporting Prevalence Data. Synthesis of results was calculated by the software R Statistics version 4.0.2 (The R Foundation). Confidence in cumulative evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

RESULTS

From 1957 studies identified, 40 were included in qualitative synthesis and 38 in meta-analyses. The pooled prevalence of patients with oral lesions solely or concurrent with other mucocutaneous lesions was 90.3%. The prevalence of patients with exclusive oral mucosal lesions was 50.8%. Risk of bias was considered low, and the certainty of evidence was very low.

CONCLUSION

Oral lesions were present in approximately nine out of 10 patients with pemphigus vulgaris. The oral mucosa was the most common site of disease onset. Further longitudinal studies are urged to assess the prevalence of oral lesions at different disease stages.

A survey of bullous diseases in a Turkish university hospital: clinicoepidemiological characteristics and follow-up

BACKGROUND/AIM

Autoimmune bullous diseases, if left untreated, are life-threatening conditions affecting primarily skin and mucous membranes. These blistering disorders are characterized by epidermal or subepidermal detachment. Autoimmunity plays a key role in pathogenesis; therefore, immunosuppressive agents are the treatment of choice. The aim of this study is to document relative frequencies of different autoimmune bullous diseases, patient characteristics, treatment options, and side effects in patients presenting to our bullous skin disease center at İstanbul University, Cerrahpaşa, Cerrahpaşa Medical Faculty.

MATERIALS AND METHODS

Medical files were examined retrospectively for all patients with autoimmune bullous diseases who were followed up between 2003 and 2019 at the Bullous Skin Disease Center at İstanbul University, Cerrahpaşa.

RESULTS

A total of 346 patient files were examined. Pemphigus vulgaris was the most frequent autoimmune bullous disease, followed by bullous pemphigoid and pemphigus foliaceus, according to our study. There is a general female predominancy for all autoimmune bullous diseases. The most commonly preferred treatment options were high-dose daily corticosteroids.

CONCLUSION

This retrospective study summarizes the patient characteristics, comorbidities, treatment choices, and side effects during 16 years of clinical practice.

Incidence and death rate of pemphigus vulgaris and pemphigus foliaceus in Korea: A nationwide, population-based study (2006-2015)

The epidemiology of pemphigus varies among racial populations worldwide. Trends in the incidence of pemphigus have not been investigated based on the Korean National Health Insurance database. This study investigated the incidence and death rate of pemphigus with age using nationwide population data in South Korea. A nationwide population-based cohort study was performed using the Korean National Health Insurance Claims Database from 2006 to 2015. The incidence of pemphigus vulgaris (PV) per 1 000 000 person-years was 2.059 (1.885 for males and 2.234 for females), and for pemphigus foliaceus (PF) 1.138 (1.205 males and 1.07 for females). The incidence of PV and PF increased with age. The incidence was not different between the habitat and household income. These incidence of PV and PF was significantly higher in subjects with comorbid metabolic conditions, such as diabetes mellitus, hypertension and dyslipidemia. The death rate per 1000 person-years in PV and PF patients increased with age after adjustment for the presence of comorbidities compared with standard death rate. This study showed that age is an important factor in PV and PF patients in Korea.

Remarkable differences in the epidemiology of pemphigus among two ethnic populations in the same geographic region

BACKGROUND

The epidemiology of pemphigus in different ethnic populations exposed to similar environments is unknown. Trends in the incidence of pemphigus based on an immunopathologically validated cohort have not been investigated.

OBJECTIVES

We sought to estimate the incidence of pemphigus in Israel and to investigate differences between the 2 major ethnic populations.

METHODS

Pemphigus incidence was retrospectively estimated from January 2000 to December 2015 in 2 Israeli regions with a total population of 1.56 million inhabitants.

RESULTS

One hundred eighty patients with pemphigus (mean age, 54.70 ± 16 years) were identified. The overall estimated incidence was 7.2 per million inhabitants per year (95% confidence interval, 6.2-8.3). The incidence in the Jewish population was threefold higher than that in Arabs (9.6 vs 3.2 cases per million per year, respectively; P < .0001) and higher among women than men (9 vs 5.3 cases per million per year, respectively; P < .0001). The incidence decreased from 8.4 cases per million per year in 2000 to 2005 to 7.0 and 6.0 (95% confidence interval, 4.5-7.9) in 2006 to 2010 and 2011 to 2015, respectively (P = .068).

LIMITATIONS

This study was limited by the retrospective design and the small population.

CONCLUSIONS

The incidence of pemphigus in Israel is among the highest reported worldwide and is significantly more frequent among Jews.

Autoimmune blistering diseases in females: a review

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

What is already known on this topic?

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

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

What does this article add to our knowledge?

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

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

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

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

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

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

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

Epidemiology of pemphigus vulgaris in the Northeast China: a 10-year retrospective study

The aim of the present study was to evaluate the incidence, epidemiological, clinical and therapeutic features of patients with pemphigus vulgaris in China. We retrospectively investigated a total of 221 patients with pemphigus vulgaris. The parameters including age at diagnosis/onset, sex, diagnostic methods, hospitalizations, side-effects with different treatments, pemphigus vulgaris-associated diseases, the therapeutic features and duration of follow up were evaluated. The male : female ratio was 1:1.40. The incidence rate was obviously higher in two age groups, 31-40 years and 41-50 years. The mean age at onset was 44.19 ± 21.45 years. The majority of patients (56.56%) presented the mucocutaneous type. In addition, we found that various doses of corticosteroids (including the mean initial dose, maximum control dose, total dose before reducing and hospitalized total dose) exhibited statistical differences between only corticosteroids and corticosteroids-immunosuppressant groups in mild, moderate and severe pemphigus vulgaris (P < 0.05). Our survey suggested that pemphigus vulgaris most frequently occurred in the 41-50-year age group in China and the majority of patients manifested mucocutaneous lesions. Importantly, the incidence rate in females was higher than in males. The patients who needed combined immunosuppressant treatment, usually needed higher doses of corticosteroids initially, to control the disease and over the total course of treatment.

Clinical and histological characterization of oral pemphigus lesions in patients with skin diseases: a cross sectional study from Sudan

Background

Pemphigus is a rare group of life-threatening mucocutaneous autoimmune blistering diseases. Frequently, oral lesions precede the cutaneous ones. This study aimed to describe clinical and histological features of oral pemphigus lesions in patients with skin disease has been canceled aged 18 years and above, attending outpatient’s facility of Khartoum Teaching Hospital - Dermatology Clinic, Sudan. In addition, the study aimed to assess the diagnostic significance of routine histolopathology along with immunohistochemical (IHC) examination of formalin-fixed, paraffin-embedded biopsy specimens in patients with oral pemphigus.

Methods

A cross-sectional hospital-based study was conducted from October 2008 to January 2009. A total of 588 patients with confirmed skin has been canceled disease diagnosis completed an oral examination and a personal interview. Clinical evaluations supported with histopathology were the methods of diagnosis. IHC was used to confirm the diagnosis. Location, size, and pain of oral lesions were used to measure the oral disease activity.

Results

Twenty-one patients were diagnosed with pemphigus vulgaris (PV), 19 of them (mean age: 43.0; range: 20–72 yrs) presented with oral manifestations. Pemphigus foliaceus was diagnosed in one patient. In PV, female: male ratio was 1.1:1.0. Buccal mucosa was the most commonly affected site. Exclusive oral lesions were detected in 14.2% (3/21). In patients who experienced both skin and oral lesion during their life time, 50.0% (9/18) had oral mucosa as the initial site of involvement, 33.3% (6/18) had skin as the primary site, and simultaneous involvement of both skin and oral mucosa was reported by 5.5% (1/18). Two patients did not provide information regarding the initial site of involvement. Oral lesion activity score was higher in those who reported to live outside Khartoum state, were outdoor workers, had lower education and belonged to Central and Western tribes compared with their counterparts. Histologically, all tissues except one had suprabasal cleft and acantholytic cells. IHC revealed IgG and C3 intercellularly in the epithelium.

Conclusions

PV was the predominating subtype of pemphigus in this study. The majority of patients with PV presented with oral lesions. Clinical and histological pictures of oral PV are in good agreement with the literature. IHC confirmed all diagnoses of PV.

Epidemiology of pemphigus in the western region of Turkey: retrospective analysis of 87 patients

BACKGROUND

Pemphigus is a worldwide disease and varies in its clinical profile and epidemiology in different regions of the world. The disease is rare and few epidemiological data are available.

OBJECTIVE

The purpose of this study was to evaluate the epidemiologic, clinical, and therapeutic features of pemphigus in the western region of Turkey.

METHODS

We retrospectively investigated a total of 87 patients with pemphigus. The parameters including age at diagnosis, sex, diagnostic delay, diagnostic methods, hospitalizations, distribution of skin lesions, duration and dose of therapy, side effects, and duration of follow-up were evaluated.

RESULTS

The mean age at the onset was 48 years. The average annual incidence of the disease was seven new patients and estimated annual incidence rate was 0.18 per 100,000 inhabitants. The male-to-female ratio was 1/1.64. All patients were treated with systemic corticosteroids. The mean initial dose was 100 mg prednisolone equivalent. Thirty-three (37.9%) patients received azathioprine as adjuvant therapy. The mean time to control the disease activity was 23 days in our study group. Ten patients (11.5%) were in clinical remission without treatment, 41 patients (47.1%) were on low dose steroid (≤ 10 mg daily), and 28 (32.2%) were using > 10 mg/day corticosteroid at the end of the study period.

CONCLUSION

Pemphigus vulgaris (PV) is the most common clinical subtype in the western part of Turkey. The disease is more frequent in the fifth decade of life and has a female predominance in our region. The patients with both oral mucosa and skin involvement need higher corticosteroid dose, more time to control the disease activity and longer hospitalization time when compared with the patients with oral mucosa involvement alone.

Epidemiologic survey of pemphigus vulgaris with oral manifestations in northern Greece: retrospective study of 129 patients

OBJECTIVE

To evaluate the epidemiology of pemphigus vulgaris (PV) in a Greek population and to compare it with other countries.

MATERIALS AND METHODS

A retrospective study was conducted based on the records of 129 patients (41 males and 88 females) with PV who visited the Department of the Oral Medicine and Maxillofacial Pathology, Aristotle University of Thessaloniki, Greece and the State Hospital for Skin and Venereal Diseases of Thessaloniki, Greece, between 1985 and 2004. A group of 73 individuals was used as controls.

RESULTS

The average annual incidence was found to be eight patients per year. The male to female ratio was 1 : 2.25. The difference in the age of onset between the two genders was statistically significant in marginal levels (P = 0.05). In addition, 86.1% of the patients showed oral lesions only, 13.3% oral and skin lesions and 1.3% manifested oral, skin, and ocular lesions. Twenty-eight of the 88 females were in the premenopausal period-of-life. Additionally, 19 males were farmers who had daily contact with organophosphoric pesticides. Co-existing pathologic conditions were present in 75 of the 129 patients, and of these 75 patients six (8%) were diabetics, 15 (20%) presented with hypertension, two (2.6%) faced problems from their thyroid gland, and 10 (13.3%) of the patients complained of allergic reactions.

CONCLUSIONS

The results of this study demonstrated a relatively high incidence of PV in northern Greece compared with that in other countries. The disease most frequently occurred in the sixth decade-of-life and the majority of the patients manifested oral lesions. Further epidemiological studies are needed to elucidate whether this region is constituted from population groups with high susceptibility to PV.