[Ocular cicatricial pemphigoid. Bullous dermatitis with mucous synechiae and atrophy]

Drug-induced cicatricial pemphigoid affecting the conjunctiva. Light and electron microscopic features

Cicatricial pemphigoid (CP) is a chronic inflammatory disease which can affect the conjunctiva. It is a slowly progressive disorder of unknown but presumed autoimmune etiology. Pseudopemphigoid, or CP associated with ocular drug administration, has also been described. These cases, which appear clinically indistinguishable from unilateral idiopathic CP affecting the conjunctiva, have been related to the use of echothiophate iodide, pilocarpine, idoxuridine, and epinephrine. We report the histopathologic and ultrastructural characteristics of 22 biopsies from ten patients with iatrogenic CP following the use of various ocular drugs. All patients presented with clinically obvious, active CP affecting the conjunctiva. Light microscopy and electron microscopy revealed findings identical to those previously reported for idiopathic CP of the conjunctiva: squamous metaplasia, increased numbers of desmosomes, basal lamina modifications suggestive of damage and attempted repair, subepithelial inflammatory cell infiltration, and diminished intravascular space within the stroma. These patients responded to immunosuppressive therapy. The authors wonder if it is possible that these patients were destined to develop CP, but that with topical ocular drug use, a more rapid emergence of the chronic cicatrizing feature of CP developed.

Immunologic aspects of cicatricial pemphigoid

A 56-year-old woman presented with the typical findings of cicatricial pemphigoid: vesicular lesions of the mucous membranes and skin. Ocular involvement included symblepharon and dryness. A regimen of 80 mg of oral trimcinolone per day healed the lesions of the skin and mucous membrane. The patient received three injections of 0.5 ml of triamcinolone acetonide into the area of the symblepharon without apparent effect on the ocular disease. Direct immunofluorescent microscopy of the patient's conjunctiva revealed fluorescence of the basement membrane when incubated with fluorescein labeled anti-IgG. The finding of immunologlobulin fixed to be basement membrane in cicatricial pepmhigoid indicates some type of immune mechanism, and would seem to place this entity in the spectrum of the pemphigus-pemphigoid group.