Surgical management of gingival recessions in patients with refractory gingival pemphigus vulgaris: A multidisciplinary challenge

BACKGROUND

Mucogingival surgery for root coverage of gingival recessions (GRs) is usually performed in patients with unremarkable periodontal and systemic health. However, the predictable results of surgical procedures and increasingly high aesthetic expectations of patients necessitate optimal management of GR also in patients with systemic conditions that affect the oral cavity. In patients with pemphigus vulgaris (PV), mucosal fragility and complicated surgical management of inflamed soft tissues are major challenges.

METHODS AND RESULTS

A 36-year-old female patient with PV and deep GR on the mandibular incisors is presented. After initial unresponsiveness to steroids and immunosuppressants, complete clinical remission was achieved through repeated rituximab infusions and topical platelet-rich plasma. After > 1 year of stable clinical remission off therapy the patient successfully underwent surgical procedures for vertically coronally advanced flap with connective tissue graft.

CONCLUSIONS

To the best of our knowledge, no studies have described the surgical management of GR in PV patients. Although controlled studies are required to confirm present results, complete and stable clinical remission is necessary to avoid complications. Collaboration among dermatologists, oral medicine specialists, and periodontologists is essential to determine whether mucogingival surgery for root surface exposure is indicated for PV patients.

KEY POINTS

Why are these cases new information? This is the first report of root coverage in a patient with oral PV What are the keys to the successful management of these cases? The achievement of complete and stable clinical remission from oral PV Multidisciplinary collaboration among dermatologists, oral medicine specialists, and periodontologists What are the primary limitations to success in these cases? The refractoriness of gingival lesions induced by PV Poor mucogingival conditions of inflamed gingival tissues exacerbated by PV.

Paraneoplastic Pemphigus Associated with Pelvic Inflammatory Fibrosarcoma: A Case Report

A 36-year-old African-American woman presented with an extensive stomatitis and pigmented cutaneous macules on the neck, axillae and hands. Subsequently she developed violaceus papules on the dorsa of the hands, histologically consistent with an interface dermatitis. After 18 months of progressive disease, paraneoplastic pemphigus was suspected and a search for an underlying neoplasm was initiated. An exploratory laparotomy revealed a pelvic mass and the histologic examination showed an inflammatory fibrosarcoma. The evidence of acantholysis on new cutaneous lesions and the positivity of indirect immunofluorescence with rodent urinary bladder epithelium reinforced the diagnostic criteria for paraneoplastic pemphigus, which is confirmed by the identification of strong protein bands at 210, 190 and 170 kd by immunoprecipitation. Paraneoplastic pemphigus should be considered when investigating atypical mucocutaneous manifestations of pemphigus vulgaris and lichen planus. Diagnostic screening for paraneoplastic pemphigus and a search for an underlying tumor should be performed.

Pemphigus vulgaris treated with allogeneic hematopoietic stem cell transplantation following non-myeloablative conditioning

OBJECTIVES

Successful treatment of severe, refractory Pemphigus vulgaris (PV) is reported.

METHODS

Reduced intensity, non-myeloablative conditioning was employed, followed by allogeneic hematopoietic stem cell transplantation (HSCT) from a fully matched sibling.

RESULTS

Treatment of refractory PV with myeloablation and subsequent allogenic HSCT has been previously reported, and sustained remission with this approach has been achieved. Toxicity, however, related to condition regimens remains high.

CONCLUSION

Since no cytotoxic chemotherapy was used, it is hereby hypothesized that clinical improvement may result from regulatory action from the donor's marrow: a "graft modifying the disease" effect, which may prove useful in the management of autoimmune diseases.

Pemphigus vulgaris: a therapeutic option for disease control

Pemphigus vulgaris (PV) is an autoimmune intra-epithelial dermatologic disease that is characterized by epithelial blistering and affected cutaneous and/or mucosal surfaces. The disease is caused by circulating immunoglobulin G (IgG) antibodies directed against desmosomes. These antibodies interfere with keratinocyte adhesion, causing acantholysis, which results in blister formation. At present, death from pemphigus infection is unusual; however, morbidity and mortality from chronic corticosteroid use remain considerable, indicating a need for additional therapies. This article presents a case of PV in a female patient that was treated with conventional corticosteroid therapy and discusses recent adjuvant therapy.

[Pemphigus vulgaris and intraepithelial neoplasia localized to the vagina]

BACKGROUND

Involvement of the vaginal mucosa in pemphigus vulgaris is a rare occurrence. Here we report an original case that resulted in discovery of intra-epithelial neoplasia at the same site.

PATIENTS AND METHODS

A 63 year-old woman was followed for 18 years for pemphigus vulgaris treated with prednisone, initially in combination with azathioprine. An erosive lesion was discovered in the pouch of Douglas during routine gynecological examination and demonstrated the histological features of pemphigus, despite remission of the disease at other sites. In spite of resumption of azathioprine and prednisone, the vaginal lesion continued to spread. A further biopsy revealed intra-epithelial vaginal neoplasia together with images of suprabasal cleavage and acantholysis. Surgical removal was carried out.

DISCUSSION

Intra-epithelial carcinoma associated with pemphigus vulgaris has been described in rare cases in the cervix but never in the vagina.

Paraneoplastic pemphigus and bronchiolitis obliterans associated with a mediastinal mass: A rare case of Castleman's disease with respiratory failure requiring lung transplantation

Castleman's disease is an infrequent and usually benign lymphoproliferative disorder. Resection of the tumor usually is curative. The immunostimulatory nature of the tumor can, in rare instances, result in paraneoplastic manifestations. The authors present a case of a 14 year old with mucocutaneous ulcerations and progressive dyspnea that was found to have a large mediastinal mass and circulating autoantibodies that were responsible for his paraneoplastic pemphigus and bronchiolitis obliterans. In spite of aggressive immunotherapy to control the autoimmune mucocutaneous lesions, the pulmonary fibrosis was irreversible and progressed to pulmonary failure necessitating lung transplantation. J Pediatr Surg 36:E22.

Thymoma with pemphigus foliaceus

A 75-year-old Japanese woman was referred to us because of an anterior mediastinal mass. Crusts and shallow erosions developed 10 months earlier on her upper chest, back, and scalp. Pemphigus foliaceus was diagnosed based on histological examination of skin biopsy specimens and positivity for serum anti-desmoglein 1 antibody by enzyme-linked immunosorbent assay. Neurological examination and electromyography ruled out myasthenia gravis. Total thymectomy was performed, and the postoperative pathology studies showed mixed lymphoepithelial thymoma. One year after the resection, the eruption and alopecia improved and the serum anti-desmoglein 1 antibody titer decreased, suggesting a beneficial effect of thymectomy on thymoma-related pemphigus.

Carbon dioxide laser vaporization of recalcitrant symptomatic plaques of Hailey-Hailey disease and Darier's disease

Carbon dioxide laser vaporization of localized, recalcitrant intertriginous plaques was done in two patients with Hailey-Hailey disease and two patients with Darier's disease. After treatment, only one patient had recurrence in one treatment site. All patients had significant clinical and symptomatic improvement. Destructive treatment must include the follicular infundibulum in Darier's disease, because histologically this was the focus of recurrent disease at one treated site. We suggest carbon dioxide laser vaporization for the treatment of chronic, localized, symptomatic plaques of Hailey-Hailey or Darier's disease, if medical therapy has been ineffective.

Wide excision of perineal Hailey-Hailey disease with healing by secondary intention

In this paper we advocate secondary healing for closure of large perineal wounds following full thickness skin excision for the treatment of Hailey-Hailey disease.

Carbon dioxide laserabrasion: a new approach to management of familial benign chronic pemphigus (Hailey-Hailey disease)

Familial benign chronic pemphigus (FBCP), or Hailey-Hailey disease, can be a debilitating condition. Treatment is palliative and only excision of lesional skin followed by split-thickness grafting may be curative. The success of surgery is attributed to the removal of adnexal structures and a decrease in sweating and maceration. This is the first report of successful carbon dioxide (CO2) laserabrasion of a patient with FBCP. The procedure spared the underlying adnexae which contributed to the reepithelialization of the epidermis. The selective destructive property of the CO2 laser may contribute to understanding the pathophysiology of FBCP.

Surgical control of Hailey-Hailey disease

Hailey-Hailey disease is a benign, chronic genodermatosis manifested by recurrent lesions with a predilection for the intertriginous areas. The malodorous, weeping sores are a source of great discomfort to the patient. Medical therapy controls most lesions adequately; however, some are refractory. Experience with excision of skin involved with Hailey-Hailey disease is reported. The best results were obtained in those patients whose wounds were resurfaced with split skin grafts. Primary suture was associated with recurrent disease and residual morbidity. The findings of other isolated reports in the literature are also summarised. The results show that surgical control of Hailey-Hailey disease is indicated in recalcitrant cases.

Surgical approach to the treatment of refractory lesions of pemphigus vulgaris

A patient with pemphigus vulgaris had lesions on the lip that proved to be refractory to intralesional corticosteroid therapy and to treatment with azathioprine and later to daily administration of 250 mg of prednisone. The patient developed marked cushingoid features and deep vein thrombosis, rendering the continuation of the prednisone therapy unadvisable . Total vermilionectomy of the affected lip was performed and the prednisone was gradually tapered, taking care that oral lesions remained under control. Eighteen months after the operation, the patient is receiving a single alternate-daily dose of 20 mg prednisone, and both the lip and oral lesions are in remission.

Surgical management of familial benign chronic pemphigus by excision and primary closure

A case describing primary closure after full-thickness excision of long-standing familial benign chronic pemphigus (Hailey-Hailey disease) in a 54-year-old man is presented. The involved axillary, inguinoscrotal, and perineal skin was excised and closed primarily without difficulty. Eradication of the disease in the excised areas was accomplished with minimal hospitalization and morbidity. Familial benign chronic pemphigus and its differential diagnosis are discussed and the literature on surgical management of this rare disease is reviewed.

Hailey-Hailey disease. Report of a case treated surgically

A 51-year-old man with Hailey-Hailey disease was treated with a split thickness skin graft of the left axilla. The dramatic improvement in the grafted area is contrasted with the continued disease activity in the untreated axilla and other intertriginous areas. Local excision and grafting, with a resultant decrease in sweating and maceration, is an effective form of therapy for Hailey-Hailey disease.

Surgical treatment of familial benign chronic pemphigus

Familial benign chronic pemphigus (Hailey and Hailey disease) is a rare, recalcitrant, often disabling genodermatosis that may not respond to conservative dermatologic therapy. We describe herein five patients with intertriginous familial benign chronic pemphigus who underwent excision and split-thickness skin grafting. All were men whose duration of disease ranged from one to 38 years. Follow-up evaluations ranging from ten months to nine years revealed no recurrence in graft sites in three patients, mild recurrence in one patient after eight years, and one death from pulmonary embolus in the postoperative period. The occurrence of familial benign chronic pemphigus around graft edges was a universal, but relatively minor, problem. Surgical excision provided definite relief from an otherwise disabling disease in four of our patients and a satisfactory improvement in life-style.

Surgical management of Hailey-Hailey disease: report of a case

An intractable and disabling case of Hailey-Hailey disease largely in the groins is reported. Conservative treatment was ineffective, but surgical excision and grafting had good results.