Clinical variants of pemphigoid

Immunological features and factors associated with mucocutaneous bullous pemphigoid - a retrospective cohort study

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.

Assessment of the Prevalence of Mucosal Involvement in Bullous Pemphigoid

Importance

The prevalence of mucosal involvement in bullous pemphigoid (BP) is inconsistent. Nonoral mucosal involvement was reported anecdotally in few patients with BP.

Objective

To evaluate the prevalence of mucosal involvement in patients with BP, and to characterize the subgroup of patients with mucosal lesions.

Design, Setting, and Participants

A retrospective cohort study was performed including 328 consecutive patients diagnosed with immunopathologically validated BP at a tertiary care referral center for autoimmune bullous diseases in northern Israel between January 1, 2000, and December 31, 2017.

Main Outcome and Measures

The study was conducted to estimate the prevalence and distribution of mucosal involvement among patients with BP. Patients with mucosal involvement were compared with the remaining BP patients regarding clinical and immunological features, laboratory analyses, and treatments.

Results

The study cohort included 139 (42.4%) male and 189 (57.6%) female patients, with a mean (SD) age of 78.0 (11.8) years at presentation. Fifty-six patients (17.1%) presented with mucosal lesions. The oral mucosa was the most frequently affected mucosal surface (n = 44; 13.7%), followed by the laryngeal (n = 16; 4.9%) and the genital (n = 10; 3.0%) mucosae. Among patients with oral lesions, the most involved oral structures were the buccal mucosa (n = 25; 55.6%) and the soft palate (n = 24; 53.3%). Compared with other patients with BP, patients with mucosal involvement were younger (71.8 [14.4] years vs 79.3 [10.8] years; P < .001), presented more frequently with extensive disease (55.4% vs 39.7%; P = .002), had less peripheral eosinophilia (17.8% vs 41.9%; P < .001), and were treated with higher doses of corticosteroids (prednisone >1 mg/kg: 67.9% vs 51.8%; P = .03).

Conclusions and Relevance

Mucosal lesions are present in a notable subgroup of patients with BP and are associated with disease severity. Laryngeal involvement is more common than previously appreciated.