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Application of Direct Immunofluorescence for Skin and Mucosal Biopsies: A Practical Review

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Handbook of Practical Immunohistochemistry

Abstract

This is a practical overview of the use of the application of direct immunofluorescence, written in telegraphic style, based on the author’s personal experience and supplemented by a recommended reference reading list, conceptual diagrams, and illustrative examples.

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References

  1. Bean SF. Proper biopsy technique for immunofluorescence tests on skin. J Dermatol Surg. 1976;2(2):148–50.

    Article  CAS  PubMed  Google Scholar 

  2. Elston DM, Stratman EJ, Miller SJ. Skin biopsy: biopsy issues in specific diseases. J Am Acad Dermatol. 2016;74(1):1–16; quiz 7–8 [Correction. J Am Acad Dermatol. 2016;75(4):854].

    Google Scholar 

  3. Jonkman MF, Diercks GFH. How to take a biopsy. In: Jonkman MF, editor. Autoimmune bullous diseases. Cham: Springer International Publishing; 2016. p. 33–7.

    Chapter  Google Scholar 

  4. Vodegel RM, de Jong MC, Meijer HJ, Weytingh MB, Pas HH, Jonkman MF. Enhanced diagnostic immunofluorescence using biopsies transported in saline. BMC Dermatol. 2004;4:10.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  5. Michel B, Milner Y, David K. Preservation of tissue-fixed immunoglobulins in skin biopsies of patients with lupus erythematosus and bullous diseases--preliminary report. J Invest Dermatol. 1972;59(6):449–52.

    Article  CAS  PubMed  Google Scholar 

  6. Grimwood RE, Proffer LH. Long-term preservation of direct immunofluorescence staining in slides stored at room temperature. J Cutan Pathol. 2000;27(5):224–7.

    Article  CAS  PubMed  Google Scholar 

  7. Lazarova Z, Yancey KB. Reactivity of autoantibodies from patients with defined subepidermal bullous diseases against 1 mol/L salt-split skin. Specificity, sensitivity, and practical considerations. J Am Acad Dermatol. 1996;35(3 Pt 1):398–403.

    Article  CAS  PubMed  Google Scholar 

  8. Vodegel RM, Jonkman MF, Pas HH, de Jong MC. U-serrated immunodeposition pattern differentiates type VII collagen targeting bullous diseases from other subepidermal bullous autoimmune diseases. Br J Dermatol. 2004;151(1):112–8.

    Article  CAS  PubMed  Google Scholar 

  9. Chan LS, Ahmed AR, Anhalt GJ, Bernauer W, Cooper KD, Elder MJ, et al. The first international consensus on mucous membrane pemphigoid: definition, diagnostic criteria, pathogenic factors, medical treatment, and prognostic indicators. Arch Dermatol. 2002;138(3):370–9.

    Article  PubMed  Google Scholar 

  10. Chan LS. Human skin basement membrane in health and in autoimmune diseases. Front Biosci. 1997;2:d343–52.

    Article  CAS  PubMed  Google Scholar 

  11. Zillikens D. Diagnosis of autoimmune bullous skin diseases. Clin Lab. 2008;54(11–12):491–503.

    CAS  PubMed  Google Scholar 

  12. Rose C, Weyers W, Denisjuk N, Hillen U, Zillikens D, Shimanovich I. Histopathology of anti-p200 pemphigoid. Am J Dermatopathol. 2007;29(2):119–24.

    Article  PubMed  Google Scholar 

  13. Terra JB, Meijer JM. Mucous membrane pemphigoid. In: Jonkman MF, editor. Autoimmune bullous diseases. Cham: Springer International Publishing; 2016. p. 141.

    Google Scholar 

  14. Witte M, Zillikens D, Schmidt E. Diagnosis of autoimmune blistering diseases. Front Med (Lausanne). 2018;5:296.

    Article  Google Scholar 

  15. Terra JB, Pas HH, Hertl M, Dikkers FG, Kamminga N, Jonkman MF. Immunofluorescence serration pattern analysis as a diagnostic criterion in antilaminin-332 mucous membrane pemphigoid: immunopathological findings and clinical experience in 10 Dutch patients. Br J Dermatol. 2011;165(4):815–22.

    Article  CAS  PubMed  Google Scholar 

  16. Meijer JM, Diercks GF, Schmidt E, Pas HH, Jonkman MF. Laboratory diagnosis and clinical profile of anti-p200 pemphigoid. JAMA Dermatol. 2016;152(8):897–904.

    Article  PubMed  Google Scholar 

  17. Mutasim DF, Bilic M, Hawayek LH, Pipitone MA, Sluzevich JC. Immunobullous diseases. J Am Acad Dermatol. 2005;52(6):1029–43.

    Article  PubMed  Google Scholar 

  18. Kasperkiewicz M, Zillikens D. The pathophysiology of bullous pemphigoid. Clin Rev Allergy Immunol. 2007;33(1–2):67–77.

    Article  CAS  PubMed  Google Scholar 

  19. Fleming TE, Korman NJ. Cicatricial pemphigoid. J Am Acad Dermatol. 2000;43(4):571–91; quiz 91-4.

    Article  CAS  PubMed  Google Scholar 

  20. Castro LA, Lundell RB, Krause PK, Gibson LE. Clinical experience in pemphigoid gestationis: report of 10 cases. J Am Acad Dermatol. 2006;55(5):823–8.

    Article  PubMed  Google Scholar 

  21. Jenkins RE, Hern S, Black MM. Clinical features and management of 87 patients with pemphigoid gestationis. Clin Exp Dermatol. 1999;24(4):255–9.

    Article  CAS  PubMed  Google Scholar 

  22. Chi CC, Wang SH, Charles-Holmes R, Ambros-Rudolph C, Powell J, Jenkins R, et al. Pemphigoid gestationis: early onset and blister formation are associated with adverse pregnancy outcomes. Br J Dermatol. 2009;160(6):1222–8.

    Article  PubMed  Google Scholar 

  23. Sitaru C, Dahnrich C, Probst C, Komorowski L, Blocker I, Schmidt E, et al. Enzyme-linked immunosorbent assay using multimers of the 16th non-collagenous domain of the BP180 antigen for sensitive and specific detection of pemphigoid autoantibodies. Exp Dermatol. 2007;16(9):770–7.

    Article  CAS  PubMed  Google Scholar 

  24. Kirtschig G, Marinkovich MP, Burgeson RE, Yancey KB. Anti-basement membrane autoantibodies in patients with anti-epiligrin cicatricial pemphigoid bind the alpha subunit of laminin 5. J Invest Dermatol. 1995;105(4):543–8.

    Article  CAS  PubMed  Google Scholar 

  25. Egan CA, Lazarova Z, Darling TN, Yee C, Yancey KB. Anti-epiligrin cicatricial pemphigoid: clinical findings, immunopathogenesis, and significant associations. Medicine (Baltimore). 2003;82(3):177–86.

    Google Scholar 

  26. Rose C, Schmidt E, Kerstan A, Thoma-Uszynski S, Wesselmann U, Kasbohrer U, et al. Histopathology of anti-laminin 5 mucous membrane pemphigoid. J Am Acad Dermatol. 2009;61(3):433–40.

    Article  CAS  PubMed  Google Scholar 

  27. Pas HH. Immunoblot assay in differential diagnosis of autoimmune blistering skin diseases. Clin Dermatol. 2001;19(5):622–30.

    Article  CAS  PubMed  Google Scholar 

  28. Mihai S, Sitaru C. Immunopathology and molecular diagnosis of autoimmune bullous diseases. J Cell Mol Med. 2007;11(3):462–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Remington J, Chen M, Burnett J, Woodley DT. Autoimmunity to type VII collagen: epidermolysis bullosa acquisita. Curr Dir Autoimmun. 2008;10:195–205.

    Article  CAS  PubMed  Google Scholar 

  30. Chen M, Chan LS, Cai X, O’Toole EA, Sample JC, Woodley DT. Development of an ELISA for rapid detection of anti-type VII collagen autoantibodies in epidermolysis bullosa acquisita. J Invest Dermatol. 1997;108(1):68–72.

    Article  CAS  PubMed  Google Scholar 

  31. Kasperkiewicz M, Meier M, Zillikens D, Schmidt E. Linear IgA disease: successful application of immunoadsorption and review of the literature. Dermatology. 2010;220(3):259–63.

    Article  CAS  PubMed  Google Scholar 

  32. Waldman MA, Black DR, Callen JP. Vancomycin-induced linear IgA bullous disease presenting as toxic epidermal necrolysis. Clin Exp Dermatol. 2004;29(6):633–6.

    Article  CAS  PubMed  Google Scholar 

  33. Gruschwitz M, Keller J, Hornstein OP. Deposits of immunoglobulins at the dermo-epidermal junction in chronic light-exposed skin: what is the value of the lupus band test? Clin Exp Dermatol. 1988;13(5):303–8.

    Article  CAS  PubMed  Google Scholar 

  34. Kontos AP, Jirsari M, Jacobsen G, Fivenson DP. Immunoglobulin M predominance in cutaneous lupus erythematosus. J Cutan Pathol. 2005;32(5):352–5.

    Article  PubMed  Google Scholar 

  35. Crowson AN, Magro C. The cutaneous pathology of lupus erythematosus: a review. J Cutan Pathol. 2001;28(1):1–23.

    Article  CAS  PubMed  Google Scholar 

  36. Gammon WR, Woodley DT, Dole KC, Briggaman RA. Evidence that anti-basement membrane zone antibodies in bullous eruption of systemic lupus erythematosus recognize epidermolysis bullosa acquisita autoantigen. J Invest Dermatol. 1985;84(6):472–6.

    Article  CAS  PubMed  Google Scholar 

  37. David-Bajar KM, Bennion SD, DeSpain JD, Golitz LE, Lee LA. Clinical, histologic, and immunofluorescent distinctions between subacute cutaneous lupus erythematosus and discoid lupus erythematosus. J Invest Dermatol. 1992;99(3):251–7.

    Article  CAS  PubMed  Google Scholar 

  38. Sarkany RP. The management of porphyria cutanea tarda. Clin Exp Dermatol. 2001;26(3):225–32.

    Article  CAS  PubMed  Google Scholar 

  39. Egbert BM, LeBoit PE, McCalmont T, Hu CH, Austin C. Caterpillar bodies: distinctive, basement membrane-containing structures in blisters of porphyria. Am J Dermatopathol. 1993;15(3):199–202.

    Article  CAS  PubMed  Google Scholar 

  40. Green JJ, Manders SM. Pseudoporphyria. J Am Acad Dermatol. 2001;44(1):100–8.

    Article  CAS  PubMed  Google Scholar 

  41. Ko CJ, McNiff JM. Punctate pemphigus: an underreported direct immunofluorescence pattern. J Cutan Pathol. 2014;41(3):293–6.

    Article  PubMed  Google Scholar 

  42. Diercks GF, Jonkman MF, Pas HH. Punctate pemphigus: an underreported direct immunofluorescence pattern. J Cutan Pathol. 2014;41(9):756–7.

    Article  PubMed  Google Scholar 

  43. Groves RW. Pemphigus: a brief review. Clin Med (Lond). 2009;9(4):371–5.

    Article  Google Scholar 

  44. Ishii K, Amagai M, Hall RP, Hashimoto T, Takayanagi A, Gamou S, et al. Characterization of autoantibodies in pemphigus using antigen-specific enzyme-linked immunosorbent assays with baculovirus-expressed recombinant desmogleins. J Immunol. 1997;159(4):2010–7.

    CAS  PubMed  Google Scholar 

  45. Amagai M, Komai A, Hashimoto T, Shirakata Y, Hashimoto K, Yamada T, et al. Usefulness of enzyme-linked immunosorbent assay using recombinant desmogleins 1 and 3 for serodiagnosis of pemphigus. Br J Dermatol. 1999;140(2):351–7.

    Article  CAS  PubMed  Google Scholar 

  46. Dasher D, Rubenstein D, Diaz L. Pemphigus foliaceus. Curr Dir Autoimmun. 2008;10:182–94.

    Article  CAS  PubMed  Google Scholar 

  47. Amerian ML, Ahmed AR, Pemphigus erythematosus. Presentation of four cases and review of literature. J Am Acad Dermatol. 1984;10(2 Pt 1):215–22.

    Article  CAS  PubMed  Google Scholar 

  48. Roh EK, Vleugels RA, Hoang MP. Case records of the Massachusetts General Hospital. Case 39-2013. A 57-year-old woman with painful bullous skin lesions. N Engl J Med. 2013;369(25):2438–49.

    Article  CAS  PubMed  Google Scholar 

  49. Oktarina DA, Poot AM, Kramer D, Diercks GF, Jonkman MF, Pas HH. The IgG “lupus-band” deposition pattern of pemphigus erythematosus: association with the desmoglein 1 ectodomain as revealed by 3 cases. Arch Dermatol. 2012;148(10):1173–8.

    Article  PubMed  Google Scholar 

  50. Robinson ND, Hashimoto T, Amagai M, Chan LS. The new pemphigus variants. J Am Acad Dermatol. 1999;40(5 Pt 1):649–71; quiz 72-3.

    Article  CAS  PubMed  Google Scholar 

  51. Duker I, Schaller J, Rose C, Zillikens D, Hashimoto T, Kunze J. Subcorneal pustular dermatosis-type IgA pemphigus with autoantibodies to desmocollins 1, 2, and 3. Arch Dermatol. 2009;145(10):1159–62.

    Article  PubMed  Google Scholar 

  52. Ishii N, Ishida-Yamamoto A, Hashimoto T. Immunolocalization of target autoantigens in IgA pemphigus. Clin Exp Dermatol. 2004;29(1):62–6.

    Article  CAS  PubMed  Google Scholar 

  53. Anhalt GJ. Paraneoplastic pemphigus. J Investig Dermatol Symp Proc. 2004;9(1):29–33.

    Article  PubMed  Google Scholar 

  54. Kaplan I, Hodak E, Ackerman L, Mimouni D, Anhalt GJ, Calderon S. Neoplasms associated with paraneoplastic pemphigus: a review with emphasis on non-hematologic malignancy and oral mucosal manifestations. Oral Oncol. 2004;40(6):553–62.

    Article  PubMed  Google Scholar 

  55. Probst C, Schlumberger W, Stocker W, Recke A, Schmidt E, Hashimoto T, et al. Development of ELISA for the specific determination of autoantibodies against envoplakin and periplakin in paraneoplastic pemphigus. Clin Chim Acta. 2009;410(1–2):13–8.

    Article  CAS  PubMed  Google Scholar 

  56. Madan V, August PJ. Exophytic plaques, blisters, and mouth ulcers. Pemphigus vegetans (PV), Neumann type. Arch Dermatol. 2009;145(6):715–20.

    Article  PubMed  Google Scholar 

  57. Ma DL, Fang K. Hallopeau type of pemphigus vegetans confined to the right foot: case report. Chin Med J. 2009;122(5):588–90.

    PubMed  Google Scholar 

  58. Helander SD, Rogers RS 3rd. The sensitivity and specificity of direct immunofluorescence testing in disorders of mucous membranes. J Am Acad Dermatol. 1994;30(1):65–75.

    Article  CAS  PubMed  Google Scholar 

  59. Raghu AR, Nirmala NR, Sreekumaran N. Direct immunofluorescence in oral lichen planus and oral lichenoid reactions. Quintessence Int. 2002;33(3):234–9.

    PubMed  Google Scholar 

  60. Zillikens D, Caux F, Mascaro JM, Wesselmann U, Schmidt E, Prost C, et al. Autoantibodies in lichen planus pemphigoides react with a novel epitope within the C-terminal NC16A domain of BP180. J Invest Dermatol. 1999;113(1):117–21.

    Article  CAS  PubMed  Google Scholar 

  61. Cohen DM, Ben-Amitai D, Feinmesser M, Zvulunov A. Childhood lichen planus pemphigoides: a case report and review of the literature. Pediatr Dermatol. 2009;26(5):569–74.

    Article  PubMed  Google Scholar 

  62. Magro CM, Crowson AN. A clinical and histologic study of 37 cases of immunoglobulin A-associated vasculitis. Am J Dermatopathol. 1999;21(3):234–40.

    Article  CAS  PubMed  Google Scholar 

  63. Crowson AN, Mihm MC Jr, Magro CM. Cutaneous vasculitis: a review. J Cutan Pathol. 2003;30(3):161–73.

    Article  PubMed  Google Scholar 

  64. Magro CM, Crowson AN. The immunofluorescent profile of dermatomyositis: a comparative study with lupus erythematosus. J Cutan Pathol. 1997;24(9):543–52.

    Article  CAS  PubMed  Google Scholar 

  65. Zaenglein AL, Hafer L, Helm KF. Diagnosis of dermatitis herpetiformis by an avidin-biotin-peroxidase method. Arch Dermatol. 1995;131(5):571–3.

    Article  CAS  PubMed  Google Scholar 

  66. Chandler W, Zone J, Florell S. C4d immunohistochemical stain is a sensitive method to confirm immunoreactant deposition in formalin-fixed paraffin-embedded tissue in bullous pemphigoid. J Cutan Pathol. 2009;36(6):655–9.

    Article  PubMed  Google Scholar 

  67. Magro CM, Dyrsen ME. The use of C3d and C4d immunohistochemistry on formalin-fixed tissue as a diagnostic adjunct in the assessment of inflammatory skin disease. J Am Acad Dermatol. 2008;59(5):822–33.

    Article  PubMed  Google Scholar 

  68. Valencia-Guerrero A, Deng A, Dresser K, Bouliane G, Cornejo KM. The value of direct immunofluorescence on proteinase-digested formalin-fixed paraffin-embedded skin biopsies. Am J Dermatopathol. 2018;40(2):111–7.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Dermatopathology Section, Department of Laboratory Medicine, Geisinger Medical Center, Danville, PA, USA

    William B. Tyler

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  1. William B. Tyler
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Editors and Affiliations

  1. Department of Laboratory Medicine, Geisinger Medical Center, Danville, PA, USA

    Fan Lin

  2. Department of Laboratory Medicine, Geisinger Medical Center, Danville, PA, USA

    Jeffrey W. Prichard

  3. Department of Laboratory Medicine, Geisinger Medical Center, Danville, PA, USA

    Haiyan Liu

  4. Department of Laboratory Medicine, Geisinger Medical Center, Danville, PA, USA

    Myra L. Wilkerson

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Tyler, W.B. (2022). Application of Direct Immunofluorescence for Skin and Mucosal Biopsies: A Practical Review. In: Lin, F., Prichard, J.W., Liu, H., Wilkerson, M.L. (eds) Handbook of Practical Immunohistochemistry. Springer, Cham. https://doi.org/10.1007/978-3-030-83328-2_36

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