Intractable epidermolysis bullosa acquisita: efficacy of cyclosporin A

Canadian consensus statement on the use of intravenous immunoglobulin therapy in dermatology

BACKGROUND

As a safe, well-tolerated, and potentially beneficial therapy, intravenous immunoglobulin (IVIG) has been increasingly used by dermatologists to treat immune-mediated skin disease. However, practical and comprehensive guidelines for the use of IVIG have yet to be established.

OBJECTIVE

To develop the first Canadian consensus statement on the use of IVIG therapy in skin disease.

METHODS

A group of Canadian dermatologists convened to discuss current issues in IVIG therapy. The participants reviewed and evaluated the literature and shared clinical experience. Using a modified Delphi process, a consensus statement was developed.

RESULTS

Herein we provide a brief overview of pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, Stevens-Johnson syndrome, and toxic epidermal necrolysis. Recommendations for the management of these diseases are detailed, and therapeutic algorithms for the treatment of various autoimmune mucocutaneous blistering diseases are presented. The appropriate use of IVIG therapy is placed in context for each disease.

CONCLUSION

Although preliminary data suggest that IVIG is a safe and effective therapy for many skin disorders, uncontrolled clinical trials, case series, and anecdotal case reports dominate the literature. Collaborative randomized controlled trials are required to firmly establish the role of IVIG in dermatology.

Therapy of autoimmune bullous diseases

Autoimmune bullous diseases result from an immune response to molecular components of the desmosome or basement membrane. Bullous diseases are associated with a high degree of morbidity and occasional mortality. Therapy of bullous diseases consists of suppressing the immune system, controlling inflammation and improving healing of erosions. The therapeutic agents used in the treatment of bullous diseases may be associated with high morbidity and occasional mortality. Successful treatment requires understanding of the pathophysiology of the disease process and the pharmacology of the drugs being used.

Management of autoimmune bullous diseases: Pharmacology and therapeutics

Bullous diseases are associated with high morbidity and mortality. They result from autoimmune response to one or more components of the basement membrane or desmosomes. Management consists of treating the immunologic basis of the disease, treating the inflammatory process involved in lesion formation, and providing supportive care both locally and systemically. Therapeutic agents are chosen based on their known pharmacologic properties and evidence of effectiveness derived from observations and studies. Learning objectives At the completion of this learning activity, participants should be able to understand the pharmacology of drugs used in the treatment of bullous diseases, the principles of therapy for various such diseases, and a practical approach to the management of these diseases.

Emerging treatment for epidermolysis bullosa acquisita

Epidermolysis bullosa acquisita (EBA) is a rare, chronic, subepidermal, mucocutaneous blistering disease characterized by skin fragility and spontaneous as well as trauma-induced blisters that heal with scar formation and milia. Treatment is often frustrating because conventional therapy with corticosteroids and immunosuppressive agents frequently does not result in significant clinical improvement. We review the conventional treatment of EBA and critically analyze the literature on various adjuvants and therapeutic modalities that have recently been used. These include cyclosporine, colchicine, plasmapheresis, extracorporeal photochemotherapy, and intravenous gammaglobulins. Although the data are preliminary, they suggest that intravenous immunoglobulins may be a promising treatment modality for resistant, nonresponsive, or refractory EBA. The use of intravenous immunoglobulins results in significant improvement of skin and mucosal lesions, and it is quite safe, with minimal side effects.

Ocular involvement in IgA-epidermolysis bullosa acquisita

Epidermolysis bullosa acquisita (EBA) is an autoimmune bullous disease with frequent ocular involvement, but visual loss is rare. In contrast, EBA patients with predominant IgA autoantibodies more frequently develop severe ocular involvement, which tends to be refractory to therapy. We report two patients with 'IgA-EBA' with ocular involvement. Both initially presented with a generalized bullous disease, and direct immunofluorescence microscopy demonstrated IgA in the basement membrane zone of the skin, and in the conjunctiva and cornea of patient 1. On salt-split patient skin, IgA was found predominantly on the dermal side of the artificial split in both patients. Direct immunoelectron microscopy demonstrated IgA below the lamina densa in close association with the anchoring fibrils in both patients. In patient 1, who had a prolonged course of the disease, the skin disorder responded well to treatment with cyclosporin, but the ocular involvement ended in bilateral blindness despite repeated surgical treatment. In patient 2, the blister formation and scarring conjunctivitis was stopped by a combination of prednisolone and colchicine. These patients show that in subepithelial blistering diseases, early delineation of disease nosology is critical to detect subtypes with severe ocular involvement such as 'IgA-EBA'. In addition, colchicine may be a valuable alternative in the treatment of EBA with ocular involvement.

Cyclosporine consensus conference: with emphasis on the treatment of psoriasis

Cyclosporine has been in worldwide use for 15 years for patients who have undergone transplantation operations and is now being used to control inflammatory reactions in other organs (eg, joints, bowel, and skin). Neoral, a more consistently absorbed form of cyclosporine, has recently been approved by the Food and Drug Administration for the treatment of psoriasis. This report outlines the indications, contraindications, dosage recommendations, monitoring requirements, adverse events, drug interactions, interactions with other psoriasis treatments, and suggestions for cyclosporine's use in rotational therapy.

Intravenous immunoglobulin treatment in therapy-resistant epidermolysis bullosa acquisita

Epidermolysis bullosa acquisita is an uncommon autoimmune bullous disease of the skin and mucous membranes. It is chronic, disabling, and difficult to treat. We describe a case of severe epidermolysis bullosa acquisita of 7 years' duration that had been treated with azathioprine, corticosteroids, chlorambucil, plasma exchanges, cyclophosphamide, cyclosporine, and colchicine without any lasting effect. Seven cycles of treatment were administered with immunoglobulin given intravenously at a low dose, 40 mg/kg body weight daily for 5 days. The patient was free of disease for 10 months after the initiation of therapy. We suggest that low-dose regimens of immunoglobulins may be as effective in this disease as the high-dose regimens suggested in the literature, and at much lower cost.

Cyclosporine in the treatment of dermatologic disease: an update

Treatment with cyclosporine is beneficial for many dermatologic diseases such as psoriasis, lichen planus, Behçet disease, atopic dermatitis, pyoderma gangrenosum, and epidermolysis bullosa acquisita. The selective action of cyclosporine on helper T cells and its rapid therapeutic action and weak myelotoxicity are the key advantages in the treatment of many dermatologic diseases. Nevertheless, drug toxicity, especially nephrotoxicity, high rates of relapse after treatment cessation, and high cost have limited its use to those diseases refractory to other therapies. Herein we discuss the use of cyclosporine for dermatologic diseases relative to efficacy, dosage, safety profile, and monitoring. In addition, we review the formulations and metabolism of cyclosporine; discuss its mechanism of action, clinical indications in dermatology, and side effects; and provide usage guidelines for this drug. Cyclosporine can be safely administered when potential toxicities, dosing, and monitoring guidelines are known.

Successful treatment of epidermolysis bullosa acquisita using intravenous immunoglobulins

We report a 55-year-old man with severe inflammatory epidermolysis bullosa acquisita. The skin lesions did not respond to various immunosuppressive treatments. The combined administration of prednisone, azathioprine, dapsone and colchicine resulted only in a transient and incomplete resolution of the lesions. The bullae and increased skin fragility were successfully controlled by the addition of high-dose intravenous immunoglobulin therapy.

Epidermolysis bullosa acquisita--a case with upper airways obstruction requiring tracheostomy and responding to cyclosporin

The case is reported of a 56-year-old man with epidermolysis bullosa acquisita (EBA) who developed such severe involvement of the upper respiratory tract that a tracheostomy had to be performed. Control of his disease was ultimately obtained with cyclosporin and the use of this drug in EBA is reviewed.

Epidermolysis bullosa acquisita: efficacy of high-dose intravenous immunoglobulins

A 16-year-old boy had a 6-year history of a generalized bullous eruption that was resistant to multiple therapies. Findings of immunofluorescent split-skin studies and electron microscopy were consistent with a diagnosis of epidermolysis bullosa acquisita. Treatment with cyclosporine and prednisolone decreased new blister formation. Additional therapy with high-dose intravenous immunoglobulins was successful in controlling the patient's disease.