Pemphigus erythematosus

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Pemphigus erythematosus
Other namesSenear–Usher syndrome [1]
Pronunciation
  • /ˈpɛmfɪɡəs ˌɛrɪθɪməˈtoʊsəs/
Specialty Dermatology
Symptoms Flaccid bullae (blisters), crusted plaques, photosensitivity
Usual onset40 - 60 years of age
DurationLong term
CausesUnclear
Diagnostic method Based on symptoms, blood tests, and skin biopsy
Differential diagnosis Pemphigus foliaceus, systemic lupus erythematosus
TreatmentCorticosteroids, mycophenolate mofetil, and anti-CD20 antibodies

Pemphigus erythematosus (Senear-Usher Syndrome) is a rare form of pemphigus with features of pemphigus foliaceus and lupus erythematosus. [1] [2] It was first described by Francis Senear and Barney Usher at the University of Illinois College of Medicine in 1926. [3] Patients with pemphigus erythematosus typically present with flaccid scaling blisters on the face, scalp, and trunk in sun-exposed areas. [1] Patients may also have a butterfly-shaped malar rash similar to systemic lupus erythematosus. [2]

Contents

Pemphigus is an autoimmune disease that involves antibodies targeting a protein called desmoglein in the top layer of the skin that holds skin cells together. The proteins are destroyed or disabled by the immune system, leading to the separation of the skin layers, which causes the blisters. The separation itself is called acantholysis. [4]

Patients with pemphigus erythematosus have antibodies against desmoglein-1 primarily, similar to pemphigus foliaceus. [1] Pemphigus erythematosus and pemphigus foliaceus both exhibit superficial blistering of the skin with minimal involvement on the mucosa (eg. mouth). This is in contrast to pemphigus vulgaris, which has antibodies against desmoglein-3 primarily. [2] Patients with pemphigus erythematosus will have positive ANA serology, a common feature of lupus. [5]

Signs and symptoms

Superficial erosions of pemphigus erythematosus may look similar to Grover's disease (pictured) Grover's disease, advanced case.JPG
Superficial erosions of pemphigus erythematosus may look similar to Grover's disease (pictured)

Patients with pemphigus erythematosus typically present with superficially eroded lesions, or vesiculobullae, that may ooze and crust. [5] This is especially common in areas of the body that are exposed to the sun, like the back, upper chest, and face. [5] The lesions are initially flaccid bullae that progress to crusted or scaly erosions with a red/pink base. [5] The early appearance of the lesions may be confused with other acantholytic processes like Grover's Disease, or cutaneous lupus. [3]

The symptoms of pemphigus erythematosus usually appear slowly and progress slowly. The patient might not be aware that their condition is photosensitive, although the lesions frequently appear on sun-exposed areas and flare after prolonged exposure to the sun. [5]

Patient with lupus showing malar erythema without blisters Lupusfoto.jpg
Patient with lupus showing malar erythema without blisters

The facial rash in pemphigus erythematosus is unique to the disease, as it is not seen in pemphigus foliaceus. [1] The appearance of crusted blisters on the cheeks and under the eyes that avoid the mouth and nasolabial folds is highly specific for pemphigus erythematosus. [1] Although lupus patients may present with a rash in the same distribution, it does not present with blisters. [6]

Other forms of pemphigus present with oral blisters, which are often the first symptoms of the disease. Pemphigus erythematosus, however, does not produce oral ulcers, or any other mucosal lesions. [2] Pemphigus erythematosus targets desmoglein 1, which is primarily found in the skin. Desmoglein 3 is present in higher numbers in the mucosa. Pemphigus vulgaris targets desmoglein 3 and therefore produces mouth ulcers. [1]

Pathophysiology

Desmosomes between skin cells are the target of pemphigus antibodies. Desmosome cell junction en.svg
Desmosomes between skin cells are the target of pemphigus antibodies.

Pemphigus patients experience an autoimmune reaction that targets desmosomes, which are the structures that hold skin cells together. [7] Desmosomes are made of many different proteins, including proteins in the cadherin family like desmocollins and desmogleins. Patients with pemphigus have antibodies targeting their desmoglein proteins, triggering the immune system to destroy them. [1] Fewer numbers of functional desmoglein proteins lead to the separation of skin cells from one another. When a large number of skin cells separate in one area, this forms a blister. The blisters often appear wet or crusted, which is caused by serous fluid leaking through the compromised skin barrier. [5]

The photosensitivity of pemphigus erythematosus is thought to occur by a similar mechanism to that of lupus. [6] Exposure to the sun's UV rays damages skin cells, leading to apoptosis (controlled cell death) and necrosis (uncontrolled cell death). In turn, cellular proteins including desmogleins are released from the cell, becoming exposed to pemphigus antibodies, causing an inflammatory reaction. [6]

The cause of autoimmune pemphigus is generally unknown; however, certain medications have been linked to the development of pemphigus erythematosus. For example, pemphigus erythematosus flares have been linked to atorvastatin use. [8] There has been one report of a new case of pemphigus erythematosus following topical ingenol mebutate treatment. [9]

Diagnosis

Like other forms of pemphigus, pemphigus erythematosus is diagnosed by physical symptoms, skin biopsies, and blood tests. [1]

Treatment

Rituximab (Anti-CD20 antibody) has been used to treat pemphigus erythematosus. Rituximab ( MabTas ).jpg
Rituximab (Anti-CD20 antibody) has been used to treat pemphigus erythematosus.

Immunosuppressant medication is the most common treatment for pemphigus erythematosus. [1] Corticosteroids such as oral prednisone pills are an established long-term therapy for pemphigus. However, their extensive side-effect profile may limit their use. [5] Alternative steroid-sparing therapies include methotrexate, azathioprine, mycophenolate mofetil, cyclophosphamide, and intravenous immunoglobulin. These may be used in combination with corticosteroids to manage disease symptoms. [2]

Rituximab is a monoclonal antibody therapy targeting CD20 that has been used to treat different forms of pemphigus reliably. In 2018, the FDA approved rituximab for the treatment of pemphigus vulgaris. [10] It has been shown effective in treating cases of pemphigus vulgaris that did not respond to corticosteroids. [11] Several recent case reports have shown its effectiveness in treating pemphigus erythematosus. Other anti-CD20 monoclonal antibodies such as ocrelizumab, veltuzumab, and ofatumumab have been suggested for the management of pemphigus. [12]

Immunoadsorption and plasmapheresis have also been shown to be useful treatments for pemphigus erythematosus. [13] [14]

See also

Related Research Articles

<span class="mw-page-title-main">Desmosome</span> Cell junction involved in cell-to-cell adhesion

A desmosome, also known as a macula adherens, is a cell structure specialized for cell-to-cell adhesion. A type of junctional complex, they are localized spot-like adhesions randomly arranged on the lateral sides of plasma membranes. Desmosomes are one of the stronger cell-to-cell adhesion types and are found in tissue that experience intense mechanical stress, such as cardiac muscle tissue, bladder tissue, gastrointestinal mucosa, and epithelia.

<span class="mw-page-title-main">Pemphigus</span> Blistering autoimmune diseases

Pemphigus is a rare group of blistering autoimmune diseases that affect the skin and mucous membranes. The name is derived from the Greek root pemphix, meaning "blister".

<span class="mw-page-title-main">Polymorphous light eruption</span> Medical condition

Polymorphous light eruption (PLE) presents with itchy red small bumps on sun-exposed skin, particularly face, neck, forearms and legs. It generally appears 30 minutes to a few hours after sun exposure and may last between one and 14 days. The bumps may become small blisters or plaques and may appear bloody,often healing with minimal scarring.

Nikolsky's sign is a clinical dermatological sign, named after Pyotr Nikolsky (1858–1940), a Russian physician who trained and worked in the Russian Empire. The sign is present when slight rubbing of the skin results in exfoliation of the outermost layer. A typical test would be to place the eraser of a pencil on the roof of a lesion and spin the pencil in a rolling motion between the thumb and forefinger. If the lesion is opened, then the Nikolsky's sign is present/positive.

Discoid lupus erythematosus (DLE) is an uncommon autoimmune disease of the basal cell layer of the skin. It occurs in humans and cats, more frequently occurring in dogs. It was first described in dogs by Griffin and colleagues in 1979. DLE is one form of cutaneous lupus erythematosus (CLE). DLE occurs in dogs in two forms: a classical facial predominant form or generalized with other areas of the body affected. Other non-discoid variants of CLE include vesicular CLE, exfoliative CLE and mucocutaneous CLE. It does not progress to systemic lupus erythematosus (SLE) in dogs. SLE can also have skin symptoms, but it appears that the two are either separate diseases. DLE in dogs differs from SLE in humans in that plasma cells predominate histologically instead of T lymphocytes. Because worsening of symptoms occurs with increased ultraviolet light exposure, sun exposure most likely plays a role in DLE, although certain breeds (see below) are predisposed. After pemphigus foliaceus, DLE is the second most common autoimmune skin disease in dogs.

<span class="mw-page-title-main">Pemphigus vulgaris</span> Chronic blistering skin disease

Pemphigus vulgaris is a rare chronic blistering skin disease and the most common form of pemphigus. Pemphigus was derived from the Greek word pemphix, meaning blister. It is classified as a type II hypersensitivity reaction in which antibodies are formed against desmosomes, components of the skin that function to keep certain layers of skin bound to each other. As desmosomes are attacked, the layers of skin separate and the clinical picture resembles a blister. These blisters are due to acantholysis, or breaking apart of intercellular connections through an autoantibody-mediated response. Over time the condition inevitably progresses without treatment: lesions increase in size and distribution throughout the body, behaving physiologically like a severe burn.

<span class="mw-page-title-main">Hailey–Hailey disease</span> Medical condition

Hailey–Hailey disease (HHD), or familial benign chronic pemphigus or familial benign pemphigus, was originally described by the Hailey brothers in 1939. It is a genetic disorder that causes blisters to form on the skin.

The desmogleins are a family of desmosomal cadherins consisting of proteins DSG1, DSG2, DSG3, and DSG4. They play a role in the formation of desmosomes that join cells to one another.

<span class="mw-page-title-main">Desmoglein-1</span> Protein found in humans

Desmoglein-1 is a protein that in humans is encoded by the DSG1 gene. Desmoglein-1 is expressed everywhere in the skin epidermis, but mainly it is expressed in the superficial upper layers of the skin epidermis.

<span class="mw-page-title-main">Desmoglein-3</span> Protein found in humans

Desmoglein-3 is a protein that in humans is encoded by the DSG3 gene. In the skin epidermis Desmoglein-3 is expressed in the basal lower layers of the epidermis, and dominates in terms of expression on mucosal surfaces compared to Desmoglein-1.

<span class="mw-page-title-main">Pemphigoid</span> Autoimmune blistering diseases

Pemphigoid is a group of rare autoimmune blistering diseases of the skin and mucous membranes. As its name indicates, pemphigoid is similar in general appearance to pemphigus, however unlike pemphigus, pemphigoid does not feature acantholysis, a loss of connections between skin cells.

<span class="mw-page-title-main">Discoid lupus erythematosus</span> Autoimmune skin condition

Discoid lupus erythematosus is the most common type of chronic cutaneous lupus (CCLE), an autoimmune skin condition on the lupus erythematosus spectrum of illnesses. It presents with red, painful, inflamed and coin-shaped patches of skin with a scaly and crusty appearance, most often on the scalp, cheeks, and ears. Hair loss may occur if the lesions are on the scalp. The lesions can then develop severe scarring, and the centre areas may appear lighter in color with a rim darker than the normal skin. These lesions can last for years without treatment.

<span class="mw-page-title-main">Lupus erythematosus</span> Collection of human autoimmune diseases

Lupus erythematosus is a collection of autoimmune diseases in which the human immune system becomes hyperactive and attacks healthy tissues. Symptoms of these diseases can affect many different body systems, including joints, skin, kidneys, blood cells, heart, and lungs. The most common and most severe form is systemic lupus erythematosus.

<span class="mw-page-title-main">Dermatitis herpetiformis</span> Chronic autoimmune disorder leading to blistering skin

Dermatitis herpetiformis (DH) is a chronic autoimmune blistering skin condition, characterised by intensely itchy blisters filled with a watery fluid. DH is a cutaneous manifestation of coeliac disease, although the exact causal mechanism is not known. DH is neither related to nor caused by herpes virus; the name means that it is a skin inflammation having an appearance similar to herpes.

Pemphigus foliaceus is an autoimmune blistering disease of the skin. Pemphigus foliaceus causes a characteristic inflammatory attack at the subcorneal layer of epidermis, which results in skin lesions that are scaly or crusted erosions with an erythematous (red) base. Mucosal involvement is absent even with widespread disease.

Paraneoplastic pemphigus (PNP) is an autoimmune disorder stemming from an underlying tumor. It is hypothesized that antigens associated with the tumor trigger an immune response resulting in blistering of the skin and mucous membranes.

Tumid lupus erythematosus is a rare, but distinctive entity in which patients present with edematous erythematous plaque.

Subacute cutaneous lupus erythematosus is a clinically distinct subset of cases of lupus erythematosus that is most often present in white women aged 15 to 40, consisting of skin lesions that are scaly and evolve as poly-cyclic annular lesions or plaques similar to those of plaque psoriasis.

Lupus erythematosus panniculitis presents with subcutaneous nodules that are commonly firm, sharply defined and nontender.

Autoimmune skin diseases occur when the immune system of an infected animal attacks its own skin. In dogs, autoimmune skin diseases are usually not detected until visible symptoms appear, which differs from detection in humans who are able to verbally express their concerns. Genetics, nutrition, and external environmental factors all collectively contribute to increasing the probability an autoimmune skin disease occurring. The severity of symptoms varies based on the specific disease present and how far it has progressed. Diagnosis often requires the onset of visible symptoms and for a biopsy to be performed. For many diseases, the condition itself cannot be cured, but a veterinarian can prescribe medications and other forms of treatment to help manage the symptoms of the dog.

References

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Further reading