Pemphigus and the terminal hair follicle

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.

Plucked Hair as a Substrate for Indirect Immunofluorescence in Cases of Pemphigus Vulgaris

Introduction

Indirect immunofluorescence (IIF) is used to determine the circulating autoantibodies in cases of Pemphigus. For IIF in Pemphigus several substrates had been used. This study was done to determine whether plucked hair can be utilized as a substrate for IIF in cases of Pemphigus. Aim & Objectives: To determine the efficacy of utilizing the plucked hair as a substrate for indirect immunofluorescence among patients with Pemphigus vulgaris.

Methodology

Thirty two consecutive patients with active and fresh diagnosed cases of pemphigus vulgaris (PV) who did not undergo any treatment and those patients who had positive DIF findings of characteristic fish net or chicken wire pattern of intercellular IgG deposits in the epidermis of perilesional skin were included in the study. A total of 32 control subjects without any auto immune disorders were selected and the blood samples were taken from these patients for IIF analysis. Anagen hair were collected from the healthy volunteers without pemphigus in the same way as for trichogram. Telogen hair were obtained by combing the hair and collecting the loose strands of hair on the comb and further confirmed under microscope. Three hairs each of anagen and telogen stage were collected from each subject to be utilized as a substrate for IIF.

Results

Out of 32 samples 20 samples showed positive results for Ig G alone and 5 samples showed positivity for Ig G and C3. One sample showed positivity for C3alone. All these 26 samples were considered to have positive IIF test based on the intercellular pattern of deposit. Positive IIF results were observed in anagen hair samples and were negative in all the telogen hair samples. Six anagen hair samples did not show any positive findings in IIF for the study group. All the 32 control samples showed negative reports in IIF.

Conclusion

In conclusion, IIF microscopy on plucked hair as a substrate is a more sensitive immunoassay for the detection of circulating intercellular autoantibodies in PV and the lower negative predictive value of this substrate is a limitation. Further large scale studies might provide better information regarding the practical utility.

Scalp involvement in pemphigus: a prognostic marker

Introduction

Scalp involvement in the course of pemphigus is observed in 16–60% of patients.

Aim

To determine the prognostic significance of scalp involvement in pemphigus vulgaris and pemphigus foliaceus.

Material and methods

A total of 75 patients (46 with pemphigus vulgaris, 29 with pemphigus foliaceus) were included into this prospective study. The following clinical data were analyzed: Pemphigus Disease Area Index, time to complete clinical remission and duration of complete clinical remission. Indirect immunofluorescence and enzyme-linked immunosorbent assay were performed to monitor serum pemphigus antibodies.

Results

Scalp involvement was observed in 30/46 (65.2%) patients with pemphigus vulgaris and 28/29 (96.6%) patients with pemphigus foliaceus. A positive correlation was found between scalp involvement and general disease severity as measured by the Pemphigus Disease Area Index (r = 0.7, p < 0.05). The time required to achieve a complete clinical remission in patients with and without scalp involvement was 39.1 ±47.1 and 9.1 ±7.8 months, respectively. The duration of complete clinical remission was 14.1 ±17.4 and 105.7 ±108.8 months, respectively. The respective time required to achieve serological remission was 37.7 ±58.5 and 15.5 ±18.8 months, whereas the duration of serological remission was 9.2 ±18.8 and 39.1 ±60.1 months, respectively. The average concentration of anti-desmoglein 1 autoantibodies was significantly higher in patients with scalp involvement compared to patients without scalp involvement (109.9 ±68.0 U/ml and 21.3 ±39.4 U/ml).

Conclusions

Scalp involvement in pemphigus is associated with a higher disease severity, longer time required to achieve complete clinical and serological remission and may indicate the need for a more aggressive therapeutical approach.

Comparison of Direct Immunofluorescence of Plucked Hair and Skin for Evaluation of Immunological Remission in Pemphigus

BACKGROUND

Pemphigus is a chronic autoimmune bullous disorder characterized by autoantibodies directed against desmoglein 3 and/or 1. Demonstration of intercellular deposition of IgG on the cell surface of keratinocytes by direct immunofluorescence (DIF) of the skin is the gold standard in the diagnosis of pemphigus. Recently, DIF of plucked hair demonstrating intercellular deposition of IgG in the outer root sheath (ORS) has shown to be useful.

OBJECTIVE

To compare the DIF of plucked hair and skin for the evaluation of immunological remission in pemphigus vulgaris patients in clinical remission.

MATERIALS AND METHODS

A total of 30 patients with pemphigus vulgaris with positive DIF of the skin and hair at baseline were included, and DIF of skin and hair was repeated after 6 months or more of clinical remission (with no new/non-healing lesions). Presence of intercellular deposits of IgG and or C3 in skin and ORS of the hair was considered as positive.

RESULTS

Of the 30 patients, DIF of skin was positive in 10 patients and hair was positive 14 patients. The findings of hair and skin DIF correlated with each other in 22 patients. In 6 (20%) patients DIF of hair was positive even though the DIF of skin was negative. The sensitivity of hair DIF was 80% and specificity was 70%.

LIMITATIONS

Small sample size.

CONCLUSION

DIF of hair is a simple, non-invasive, and cost effective procedure and can be used as an additional procedure for the assessment of immunological remission in patients with pemphigus vulgaris.

A retrospective study of antihypertensives in pemphigus: a still unchartered odyssey particularly between thiols, amides and phenols

INTRODUCTION

Autoimmune pemphigus diseases comprise several entities with serious prognoses, including the pemphigus vulgaris (PV) group and pemphigus foliaceus (PF) group. Antihypertensives are suspected to be one of the factors triggering/sustaining pemphigus. Here, the data of pemphigus patients regarding arterial hypertension (AH) and taking potentially noxious drugs were statistically analyzed in a setting of a Polish university dermatology department.

MATERIAL AND METHODS

Medical histories of pemphigus patients (40 admissions of 24 female patients - 13 PV, 11 PF; and 102 admissions of 38 male patients - 24 PV, 14 PF), diagnosed at both immunopathological and biochemical-molecular levels, were studied.

RESULTS

Ten of 16 (62.50%) AH-positive PV patients received known PV triggers/sustainers 11 times (1-3 per patient). Fourteen of 15 (93.33%) AH-positive PF patients received known PF triggers/sustainers 21 times (1-3 per patient). No differences in numbers of patients taking potentially culprit drugs were shown between PV and PF (Fisher's exact test: p = 0.0829; Yates' χ(2) test: p = 0.1048). The most frequently used culprit drugs were ramipril in PV and enalapril in PF. On average, each PV/PF AH-positive patient received 3.161 different antihypertensives in his/her history of admissions (2.155 antihypertensives per admission).

CONCLUSIONS

Drug triggering should be suspected in every case of newly diagnosed or exacerbated pemphigus, as eliminating possible PV/PF triggers/sustainers may alleviate the clinical symptoms and enable the decrease of dose/range of immunosuppressants regardless of pemphigus form. Eliminating possible drug PV/PF triggers/sustainers may alleviate the clinical symptoms and enable the decrease of dose/range of immunosuppressants regardless of pemphigus form.

Direct immunofluorescence on hair follicles--present and future perspectives

Direct immunofluorescence (DIF) is an important tool for evaluating bullous autoimmune and connective tissue disorders. We report 21 cases of pemphigus vulgaris, bullous pemphigoid and lupus erythematosus that were investigated by performing DIF on scalp hair follicles. The study was done using a simplified technique of preparing the hairs for DIF testing. The anagen hairs tested positive in pemphigus vulgaris patients while the telogen hairs were negative. In bullous pemphigoid and lupus erythematosus cases hair DIF presented negative results.Hair DIF has the potential of taking the place of skin or mucosal DIF in pemphigus patients if performed on anagen hair follicles. The technique used to perform hair DIF is important in obtaining reliable results and eliminating the possibility of generating false-negative testing. Larger studies are needed in order to validate this method.

Alopecia as a rare but distinct manifestation of pemphigus vulgaris

BACKGROUND

Pemphigus vulgaris (PV) patients may develop scalp erosions, however, the development of alopecia has been reported to be extremely rare.

OBJECTIVE

To delineate the clinicopathological features of alopecia in PV and provide insight into the pathogenesis of this rarely observed manifestation.

METHODS

A retrospective case note review was performed on five PV patients presenting with progressive hair loss and alopecic patches. Data were collected on demographics and clinical findings. Results for hair pull tests, direct immunofluorescence study of plucked hairs, established laboratory tests to detect anti-desmoglein 1 and 3 autoantibodies and scalp swab culture were recorded. A combination of vertical and horizontal sectioning technique enabled detailed histopathological analysis of alopecic patches. Clinical course was monitored.

RESULTS

Anagen hair follicles with the outer root sheath structure were easily pulled from perilesional scalp, with intercellular IgG deposition on the outer root sheath keratinocytes. Acantholysis between outer root sheath keratinocytes extending from the infundibulum to suprabalbar level was evident in anagen hair follicles of affected lesions. Perifollicular cell infiltration was observed in the lesions where scalp swabs detected micro-organisms. The bulge stem cell area was mostly intact. Alopecia was non-scarring and following 4 weeks of therapy hair re-growth was seen in all patients.

CONCLUSION

In PV, the combination of anti-desmoglein autoantibody-mediated acantholysis in conjunction with secondary factors, such as inflammatory changes due to infection, may cause weakening of hair follicle anchorage resulting in hair loss and alopecic patches. This unusual clinical phenotype should alert physicians to PV as a potential diagnosis.

Immunofluorescence of the outer root sheath: an aid to diagnosis in pemphigus

BACKGROUND

The direct immunofluorescence (DIF) pattern of the outer root sheath (ORS) of the hair follicle in patients with pemphigus resembles that of perilesional skin. We performed DIF on anagen and telogen hair ORS from patients with pemphigus and compared the findings with those of perilesional skin.

AIM

To assess the sensitivity of DIF in the ORS of anagen and telogen hair in patients with pemphigus with positive DIF results in perilesional skin.

METHODS

In total, 50 patients with active pemphigus and positive DIF findings in perilesional skin were selected for the study. Anagen hair was obtained from the scalp by the same method used for a trichogram, and telogen hair was selected by combing the hair and collecting the loose strands of hair from the comb. The hair type was further confirmed by microscopy. Hair samples were transported in Michel medium and prepared for DIF by mounting on a slide without sectioning. Anagen and telogen hair samples were also collected from 50 controls.

RESULTS

Immunological deposits characteristic of pemphigus were found in the ORS of anagen and telogen hairs in all 50 patients, but in none of the 50 controls. Positive DIF findings were seen in scalp hair irrespective of the presence of scalp lesions. Of the 50 patients with pemphigus, 46 were diagnosed with pemphigus vulgaris, 2 with pemphigus vegetans, and 1 each with pemphigus foliaceus and pemphigus erythematosus, based on the clinical, histopathological and DIF findings. All the pemphigus variants had positive DIF findings in the ORS.

CONCLUSIONS

Using DIF on telogen hair ORS promises to be a useful tool for diagnosis and follow-up in cases of pemphigus.

Demonstration of pemphigus-specific immunofluorescence pattern by direct immunofluorescence of plucked hair

BACKGROUND

Direct immunofluorescence (DIF) of perilesional skin is the gold standard in the diagnosis of pemphigus. Since the outer root sheath (ORS) of anagen hair is structurally analogous to epidermal keratinocytes, pemphigus specific immunofluorescence pattern may be present in the ORS.

METHODS

Twenty consecutive patients of pemphigus were enrolled in the study, irrespective of any other inclusion or exclusion criteria. Hairs were plucked in a similar fashion to that of trichogram. Approximately 5 anagen hairs were selected processed and stained with fluorescein isothiocyanate (FITC) conjugates. DIF of perilesional skin and indirect immunofluorescence (IIF) were carried out simultaneously. DIF of hair was also done in equal numbers of controls with other dermatoses.

RESULTS

Intercellular deposition of IgG was seen in the ORS of anagen hair in 85% of patients (n = 17). The test was positive in all patients who had scalp lesions (n = 10); however, it was also positive in 7 patients (77.7%) who did not have scalp lesions. The test was negative in 3 patients; two of whom were elderly and had sparse scalp hair. The other patient only had mucosal lesion. The test was negative in the control group.

CONCLUSION

DIF of hair is a simple, non-invasive test. In future, it may alleviate the need for skin biopsies, in patients with pemphigus.

Immunofluoresence of the outer root sheath in anagen and telogen hair: an aid to diagnosis in pemphigus

Desmoglein 1 and 3 are distributed in the outer root sheath (ORS) of the hair follicle. Direct immunofluoresence (DIF) pattern of ORS in cases of pemphigus resembles the DIF pattern of the perilesional skin. We performed a DIF of the anagen and telogen hair ORS in a case of pemphigus and correlated it with the DIF findings of perilesional skin. Telogen hair ORS promises to be a useful tool in performing DIF for the purpose of diagnosis and follow-up in cases of pemphigus

A study on plucked hair as a substrate for direct immunofluorescence in pemphigus vulgaris

BACKGROUND

It has recently been demonstrated in a study on 15 patients that plucked hair can be used as a substrate for direct immunofluorescence (DIF) in pemphigus.

OBJECTIVE

Our aim was to assess the sensitivity of DIF on plucked hairs in pemphigus vulgaris (PV) patients with positive DIF of oral mucosa.

METHODS

One hundred and ten new PV patients were enrolled in the study. They all showed the typical clinical and histological findings as well as positive DIF of the oral mucosa, diagnostic for PV. Approximately 30 hairs were obtained in the same way as for the trichogram. The hairs with their outer root sheaths (ORS) were processed for DIF in order to detect immunoglobulin G and C3.

RESULTS

Immunodeposits favouring PV were demonstrated in the ORS of 100 cases showing a sensitivity of 91%.

CONCLUSION

Regarding the relatively high sensitivity of DIF on plucked hair in PV patients with positive oral mucosal DIF in our study, it seems that hair plucking is a suitable alternative to the more invasive techniques of skin or mucosal biopsy for obtaining specimens for DIF in PV.

Follicular Acantholysis: A Subtle Clue to the Early Diagnosis of Pemphigus Vulgaris

The histologic hallmark of fully established pemphigus vulgaris (PV), a chronic autoimmune disease of the skin and mucosa, is the presence of acantholysis induced at the suprabasal level. This case report of acantholysis restricted to the follicular epithelium as a subtle histologic manifestation of the disease, draws attention to the pitfalls encountered in the histologic diagnosis of early cases of pemphigus vulgaris.

Cicatricial pemphigoid rarely involves the scalp

We present a case of cicatricial pemphigoid with significant scarring alopecia as a major manifestation and review our series of cicatricial pemphigoid patients in Oxford (UK). Only four of 54 patients had scarring alopecia of the scalp. While rare, this manifestation poses a difficult management problem; patients find this cosmetically distressing and there are no successful treatments available to date.