Archives of Dermatological Research

, Volume 302, Issue 4, pp 241–253 | Cite as

Immunoadsorption in dermatology

Mini Review

Abstract

Immunoadsorption (IA), also termed immunoapheresis, has been established as effective and specific tool advantageous to plasmapheresis to remove immunoglobulin and immune complexes and in cytapheresis, immune cells from the circulation. IA was successfully used in various autoantibody-mediated diseases, e.g. acquired hemophilia, myasthenia gravis, dilated cardiomyopathy, and Guillain–Barré syndrome. In dermatology, IA has been applied as an effective adjuvant treatment for autoimmune bullous diseases. Autoimmune blistering disorders are a heterogeneous group of diseases that are associated with autoantibodies to desmosomal (pemphigus group) and basal membrane zone proteins (pemphigoid group, epidermolysis bullosa acquisita). Because the pathogenic relevance of autoantibodies was clearly demonstrated in the majority of these disorders, removal of autoantibodies, therefore, appears to be a rational therapeutic approach for these patients. IA has been shown to effectively lower the autoantibody levels and leads to rapid clinical responses in patients with immunobullous disorders. Here, clinical effects and adverse events of IA in more than 50 reported patients with autoimmune blistering disorders are reviewed. In addition, an overview of the available IA systems and treatment protocols is provided and guidelines of a recent consensus of German, Austrian, and Swiss experts for the use of IA in autoimmune bullous diseases are summarized.

Keywords

Autoantibody Pemphigoid Immunoapheresis Pemphigus Treatment 

Notes

Acknowledgment

This work was supported by the Schleswig–Holstein Cluster of Excellence in Inflammation Research (DFG EXC 306/1).

References

  1. 1.
    Amagai M, Hashimoto T, Shimizu N, Nishikawa T (1994) Absorption of pathogenic autoantibodies by the extracellular domain of pemphigus vulgaris antigen (Dsg3) produced by baculovirus. J Clin Invest 94(1):59–67CrossRefPubMedGoogle Scholar
  2. 2.
    Amagai M, Hashimoto T, Green KJ, Shimizu N, Nishikawa T (1995) Antigen-specific immunoadsorption of pathogenic autoantibodies in pemphigus foliaceus. J Invest Dermatol 104(6):895–901CrossRefPubMedGoogle Scholar
  3. 3.
    Amagai M, Ikeda S, Shimizu H, Iizuka H, Hanada K, Aiba S, Kaneko F, Izaki S, Tamaki K, Ikezawa Z, Takigawa M, Seishima M, Tanaka T, Miyachi Y, Katayama I, Horiguchi Y, Miyagawa S, Furukawa F, Iwatsuki K, Hide M, Tokura Y, Furue M, Hashimoto T, Ihn H, Fujiwara S, Nishikawa T, Ogawa H, Kitajima Y, Hashimoto K (2009) A randomized double-blind trial of intravenous immunoglobulin for pemphigus. J Am Acad Dermatol 60(4):595–603CrossRefPubMedGoogle Scholar
  4. 4.
    Anhalt GJ, Labib RS, Voorhees JJ, Beals TF, Diaz LA (1982) Induction of pemphigus in neonatal mice by passive transfer of IgG from patients with the disease. N Engl J Med 306(20):1189–1196PubMedGoogle Scholar
  5. 5.
    Anhalt GJ (2004) Paraneoplastic pemphigus. J Investig Dermatol Symp Proc 9(1):29–33CrossRefPubMedGoogle Scholar
  6. 6.
    Bertram F, Brocker EB, Zillikens D, Schmidt E (2009) Prospective analysis of the incidence of autoimmune bullous disorders in Lower Franconia, Germany. J Dtsch Dermatol Ges 7(5):434–440PubMedGoogle Scholar
  7. 7.
    Braun N, Bosch T (2000) Immunoadsorption, current status and future developments. Expert Opin Investig Drugs 9(9):2017–2038CrossRefPubMedGoogle Scholar
  8. 8.
    Bystryn JC, Steinman NM (1996) The adjuvant therapy of pemphigus: an update. Arch Dermatol 132(2):203–212CrossRefPubMedGoogle Scholar
  9. 9.
    Chams-Davatchi C, Valikhani M, Daneshpazhooh M, Esmaili N, Balighi K, Hallaji Z, Barzegari M, Akhiani M, Ghodsi Z, Mortazavi H, Naraghi Z (2005) Pemphigus: analysis of 1209 cases. Int J Dermatol 44(6):470–476CrossRefPubMedGoogle Scholar
  10. 10.
    Cotterill JA, Barker DJ, Millard LG (1978) Plasma exchange in the treatment of pemphigus vulgaris. Br J Dermatol 98(2):243CrossRefPubMedGoogle Scholar
  11. 11.
    Eming R, Rech J, Barth S, Kalden JR, Schuler G, Harrer T, Hertl M (2006) Prolonged clinical remission of patients with severe pemphigus upon rapid removal of desmoglein-reactive autoantibodies by immunoadsorption. Dermatology 212(2):177–187CrossRefPubMedGoogle Scholar
  12. 12.
    Felix SB, Staudt A (2008) Immunoadsorption as treatment option in dilated cardiomyopathy. Autoimmunity 41(6):484–489CrossRefPubMedGoogle Scholar
  13. 13.
    Freedman J, Garvey MB (2004) Immunoadsorption of factor VIII inhibitors. Curr Opin Hematol 11(5):327–333CrossRefPubMedGoogle Scholar
  14. 14.
    Frost N, Messer G, Fierlbeck G, Risler T, Lytton SD (2005) Treatment of pemphigus vulgaris with protein A immunoadsorption: case report of long-term history showing favorable outcome. Ann N Y Acad Sci 1051:591–596CrossRefPubMedGoogle Scholar
  15. 15.
    Gaubitz M, Schneider KM (2003) Immunoadsorption in systemic lupus erythematosus: different techniques and their current role in medical therapy. Ther Apher Dial 7(2):183–188CrossRefPubMedGoogle Scholar
  16. 16.
    Genberg H, Kumlien G, Wennberg L, Tyden G (2007) Long-term results of ABO-incompatible kidney transplantation with antigen-specific immunoadsorption and rituximab. Transplantation 84(12 Suppl):S44–S47CrossRefPubMedGoogle Scholar
  17. 17.
    Genberg H, Kumlien G, Wennberg L, Berg U, Tyden G (2008) ABO-incompatible kidney transplantation using antigen-specific immunoadsorption and rituximab: a 3-year follow-up. Transplantation 85(12):1745–1754CrossRefPubMedGoogle Scholar
  18. 18.
    Guillaume JC, Roujeau JC, Morel P, Doutre MS, Guillot B, Lambert D, Lauret P, Lorette G, Prigent F, Triller R et al (1988) Controlled study of plasma exchange in pemphigus. Arch Dermatol 124(11):1659–1663CrossRefPubMedGoogle Scholar
  19. 19.
    Gunther C, Laske J, Frind A, Julius U, Pfeiffer C (2008) Successful therapy of pemphigus vulgaris with immunoadsorption using the TheraSorbtrade mark adsorber. J Dtsch Dermatol GesGoogle Scholar
  20. 20.
    Herrero-Gonzalez JE, Sitaru C, Klinker E, Brocker EB, Zillikens D (2005) Successful adjuvant treatment of severe bullous pemphigoid by tryptophan immunoadsorption. Clin Exp Dermatol 30(5):519–522CrossRefPubMedGoogle Scholar
  21. 21.
    Hiepe F, Pfuller B, Wolbart K, Bruns A, Leinenbach HP, Hepper M, Schossler W, Otto V (1999) C1q: a multifunctional ligand for a new immunoadsorption treatment. Ther Apher 3(3):246–251PubMedGoogle Scholar
  22. 22.
    Ino N, Kamata N, Matsuura C, Shinkai H, Odaka M (1997) Immunoadsorption for the treatment of bullous pemphigoid. Ther Apher 1(4):372–376CrossRefPubMedGoogle Scholar
  23. 23.
    Iwata H, Kamio N, Aoyama Y, Yamamoto Y, Hirako Y, Owaribe K, Kitajima Y (2009) IgG from patients with bullous pemphigoid depletes cultured keratinocytes of the 180-kDa bullous pemphigoid antigen (type XVII collagen) and weakens cell attachment. J Invest Dermatol 129(4):919–926CrossRefPubMedGoogle Scholar
  24. 24.
    Kaczmarek I, Deutsch MA, Sadoni S, Brenner P, Schmauss D, Daebritz SH, Weiss M, Meiser BM, Reichart B (2007) Successful management of antibody-mediated cardiac allograft rejection with combined immunoadsorption and anti-CD20 monoclonal antibody treatment: case report and literature review. J Heart Lung Transplant 26(5):511–515CrossRefPubMedGoogle Scholar
  25. 25.
    Kadar JG, Borberg H (1990) Biocompatibility of extracorporeal immunoadsorption systems. Transfus Sci 11(2):223–239CrossRefPubMedGoogle Scholar
  26. 26.
    Kasperkiewicz M, Hoppe U, Zillikens D, Schmidt E (2009) Relapse-associated autoantibodies to BP180 in a patient with anti-p200 pemphigoid. Clin Exp Dermatol (in press)Google Scholar
  27. 27.
    Kasperkiewicz M, Schmidt E, Rose C, Frambach, Anemüller W, Grabbe J, Ludwig R, Zillikens D (2009) Immunadsorption bei Patienten mit schwerster atopischer Dermatitis und exzessiv erhöhten peripheren Serum-IgE-Spiegeln. 82. Jahrestagung der Norddeutschen Dermatologischen Gesellschaft. 02.04.09.2009, Halle (Saale) (abstract)Google Scholar
  28. 28.
    Knobl P, Derfler K (1999) Extracorporeal immunoadsorption for the treatment of haemophilic patients with inhibitors to factor VIII or IX. Vox Sang 77(Suppl 1):57–64PubMedGoogle Scholar
  29. 29.
    Kumlien G, Ullstrom L, Losvall A, Persson LG, Tyden G (2006) Clinical experience with a new apheresis filter that specifically depletes ABO blood group antibodies. Transfusion 46(9):1568–1575CrossRefPubMedGoogle Scholar
  30. 30.
    Langan SM, Smeeth L, Hubbard R, Fleming KM, Smith CJ, West J (2008) Bullous pemphigoid and pemphigus vulgaris–incidence and mortality in the UK: population based cohort study. BMJ 337:a180Google Scholar
  31. 31.
    Lazarova Z, Yee C, Darling T, Briggaman RA, Yancey KB (1996) Passive transfer of anti-laminin 5 antibodies induces subepidermal blisters in neonatal mice. J Clin Invest 98(7):1509–1518CrossRefPubMedGoogle Scholar
  32. 32.
    Liu Z, Diaz LA, Troy JL, Taylor AF, Emery DJ, Fairley JA, Giudice GJ (1993) A passive transfer model of the organ-specific autoimmune disease, bullous pemphigoid, using antibodies generated against the hemidesmosomal antigen, BP180. J Clin Invest 92(5):2480–2488CrossRefPubMedGoogle Scholar
  33. 33.
    Liu Z, Diaz LA, Swartz SJ, Troy JL, Fairley JA, Giudice GJ (1995) Molecular mapping of a pathogenically relevant BP180 epitope associated with experimentally induced murine bullous pemphigoid. J Immunol 155(11):5449–5454PubMedGoogle Scholar
  34. 34.
    Liumbruno GM, Centoni PE, Molfettini P, Ceretelli S, Ceccarini M, Bachini L, Pomponi A, Bagnoni G, Vitolo M, Eberle O, Biondi A, Sodini ML (2006) Lymphocytapheresis in the treatment of psoriasis vulgaris. J Clin Apher 21(3):158–164CrossRefPubMedGoogle Scholar
  35. 35.
    Luftl M, Stauber A, Mainka A, Klingel R, Schuler G, Hertl M (2003) Successful removal of pathogenic autoantibodies in pemphigus by immunoadsorption with a tryptophan-linked polyvinylalcohol adsorber. Br J Dermatol 149(3):598–605CrossRefPubMedGoogle Scholar
  36. 36.
    Marazza G, Pham HC, Scharer L, Pedrazzetti PP, Hunziker T, Trueb RM, Hohl D, Itin P, Lautenschlager S, Naldi L, Borradori L (2009) Incidence of bullous pemphigoid and pemphigus in Switzerland: a 2-year prospective study. Br J Dermatol 161(4):861–868CrossRefPubMedGoogle Scholar
  37. 37.
    Marn Pernat A, Buturovic-Ponikvar J, Svigelj V, Ponikvar R (2009) Guillain–Barre syndrome treated by membrane plasma exchange and/or immunoadsorption. Ther Apher Dial 13(4):310–313CrossRefPubMedGoogle Scholar
  38. 38.
    Matic G, Hofmann D, Winkler R, Tiess M, Michelsen A, Schneidewind JM, Hebestreit G, Keysser M, Muller W, Kinze EM, Ramlow W (2000) Removal of immunoglobulins by a protein A versus an antihuman immunoglobulin G-based system: evaluation of 602 sessions of extracorporeal immunoadsorption. Artif Organs 24(2):103–107CrossRefPubMedGoogle Scholar
  39. 39.
    Mitsuyama K, Sata M (2009) Therapeutic leukocytapheresis in inflammatory bowel disease: clinical efficacy and mechanisms of action. Cytotherapy 11(2):229–237CrossRefPubMedGoogle Scholar
  40. 40.
    Mulyowa GK, Jaeger G, Kabakyenga J, Brocker EB, Zillikens D, Schmidt E (2006) Autoimmune subepidermal blistering diseases in Uganda: correlation of autoantibody class with age of patients. Int J Dermatol 45(9):1047–1052CrossRefPubMedGoogle Scholar
  41. 41.
    Nagel A, Hertl M, Eming R (2009) B-cell-directed therapy for inflammatory skin diseases. J Invest Dermatol 129(2):289–301CrossRefPubMedGoogle Scholar
  42. 42.
    Naito K, Morioka S, Ogawa H (1982) The pathogenic mechanisms of blister formation in bullous pemphigoid. J Invest Dermatol 79(5):303–306CrossRefPubMedGoogle Scholar
  43. 43.
    Niedermeier A, Eming R, Pfutze M, Neumann CR, Happel C, Reich K, Hertl M (2007) Clinical response of severe mechanobullous epidermolysis bullosa acquisita to combined treatment with immunoadsorption and rituximab (anti-CD20 monoclonal antibodies). Arch Dermatol 143(2):192–198CrossRefPubMedGoogle Scholar
  44. 44.
    Norda R, Stegmayr BG (2003) Therapeutic apheresis in Sweden: update of epidemiology and adverse events. Transfus Apher Sci 29(2):159–166CrossRefPubMedGoogle Scholar
  45. 45.
    Ogata K, Yasuda K, Matsushita M, Kodama H (1999) Successful treatment of adolescent pemphigus vulgaris by immunoadsorption method. J Dermatol 26(4):236–239PubMedGoogle Scholar
  46. 46.
    Ohji S, Nomura K (2008) The indication of steroid pulse therapy and apheresis therapy for multiple sclerosis. Nippon Rinsho 66(6):1127–1132PubMedGoogle Scholar
  47. 47.
    Pfutze M, Eming R, Kneisel A, Kuhlmann U, Hoyer J, Hertl M (2009) Clinical and immunological follow-up of pemphigus patients on adjuvant treatment with immunoadsorption or rituximab. Dermatology 218(3):237–245CrossRefPubMedGoogle Scholar
  48. 48.
    Pisanti S, Sharav Y, Kaufman E, Posner LN (1974) Pemphigus vulgaris: incidence in Jews of different ethnic groups, according to age, sex, and initial lesion. Oral Surg Oral Med Oral Pathol 38(3):382–387CrossRefPubMedGoogle Scholar
  49. 49.
    Poullin P, Announ N, Mugnier B, Guis S, Roudier J, Lefevre P (2005) Protein A-immunoadsorption (Prosorba column) in the treatment of rheumatoid arthritis. Joint Bone Spine 72(2):101–103CrossRefPubMedGoogle Scholar
  50. 50.
    Rech J, Hueber AJ, Kallert S, Leipe J, Kalden JR, Beck M, Schett G, Schulze-Koops H (2008) Remission of demyelinating polyneuropathy with immunoadsorption, low dose corticosteroids and anti-CD20 monoclonal antibody. Ther Apher Dial 12(3):205–208CrossRefPubMedGoogle Scholar
  51. 51.
    Ronspeck W, Brinckmann R, Egner R, Gebauer F, Winkler D, Jekow P, Wallukat G, Muller J, Kunze R (2003) Peptide based adsorbers for therapeutic immunoadsorption. Ther Apher Dial 7(1):91–97CrossRefPubMedGoogle Scholar
  52. 52.
    Roujeau JC, Revuz J, Touraine R, Joneau-Fabre M, Mannoni P (1979) Cortico-resistant bullous pemphigoid: favorable results with plasmapheresis. Nouv Presse Med 8(41):3362PubMedGoogle Scholar
  53. 53.
    Roujeau JC, Andre C, Joneau Fabre M, Lauret P, Flechet ML, Kalis B, Revuz J, Touraine R (1983) Plasma exchange in pemphigus: uncontrolled study of ten patients. Arch Dermatol 119(3):215–221CrossRefPubMedGoogle Scholar
  54. 54.
    Sakai Y, Sakai S, Otsuka T, Ohno D, Murasawa T, Munakata K, Mizuno K (2009) Efficacy of high-throughput leukocytapheresis for rheumatoid arthritis with a reduced response to infliximab. Ther Apher Dial 13(3):179–185CrossRefPubMedGoogle Scholar
  55. 55.
    Sawada K, Muto T, Shimoyama T, Satomi M, Sawada T, Nagawa H, Hiwatashi N, Asakura H, Hibi T (2003) Multicenter randomized controlled trial for the treatment of ulcerative colitis with a leukocytapheresis column. Curr Pharm Des 9(4):307–321CrossRefPubMedGoogle Scholar
  56. 56.
    Schiltz JR, Michel B (1976) Production of epidermal acantholysis in normal human skin in vitro by the IgG fraction from pemphigus serum. J Invest Dermatol 67(2):254–260CrossRefPubMedGoogle Scholar
  57. 57.
    Schmidt E, Obe K, Brocker EB, Zillikens D (2000) Serum levels of autoantibodies to BP180 correlate with disease activity in patients with bullous pemphigoid. Arch Dermatol 136(2):174–178CrossRefPubMedGoogle Scholar
  58. 58.
    Schmidt E, Klinker E, Opitz A, Herzog S, Sitaru C, Goebeler M, Mansouri Taleghoni B, Brocker EB, Zillikens D (2003) Protein A immunoadsorption: a novel and effective adjuvant treatment of severe pemphigus. Br J Dermatol 148(6):1222–1229CrossRefPubMedGoogle Scholar
  59. 59.
    Schmidt E, Brocker EB, Goebeler M (2008) Rituximab in treatment-resistant autoimmune blistering skin disorders. Clin Rev Allergy Immunol 34(1):56–64CrossRefPubMedGoogle Scholar
  60. 60.
    Schmidt E, Goebeler M, Zillikens D (2009) Rituximab in severe pemphigus. Ann N Y Acad Sci 1173(9):683–691CrossRefPubMedGoogle Scholar
  61. 61.
    Schmidt E, Zillikens D (2009) Research in practice: diagnosis of subepidermal autoimmune bullous disorders. J Dtsch Dermatol Ges 7(4):296–300PubMedGoogle Scholar
  62. 62.
    Schoen H, Foedinger D, Derfler K, Amann G, Rappersberger K, Stingl G, Volc-Platzer B (1998) Immunoapheresis in paraneoplastic pemphigus. Arch Dermatol 134(6):706–710CrossRefPubMedGoogle Scholar
  63. 63.
    Shimanovich I, Herzog S, Schmidt E, Opitz A, Klinker E, Brocker EB, Goebeler M, Zillikens D (2006) Improved protocol for treatment of pemphigus vulgaris with protein A immunoadsorption. Clin Exp Dermatol 31(6):768–774CrossRefPubMedGoogle Scholar
  64. 64.
    Shimanovich I, Nitschke M, Rose C, Grabbe J, Zillikens D (2008) Treatment of severe pemphigus with protein A immunoadsorption, rituximab and intravenous immunoglobulins. Br J Dermatol 158(2):382–388PubMedCrossRefGoogle Scholar
  65. 65.
    Shimanovich I, Bohmke AK, Westermann L, Kramer J, Zillikens D, Schmidt E (2009) Successful treatment of severe pemphigus with the combination of immunoadsorption and rituximab. J Invest Dermatol 129:S97Google Scholar
  66. 66.
    Sitaru C, Kromminga A, Hashimoto T, Brocker EB, Zillikens D (2002) Autoantibodies to type VII collagen mediate Fcgamma-dependent neutrophil activation and induce dermal-epidermal separation in cryosections of human skin. Am J Pathol 161(1):301–311PubMedGoogle Scholar
  67. 67.
    Sitaru C, Schmidt E, Petermann S, Munteanu LS, Brocker EB, Zillikens D (2002) Autoantibodies to bullous pemphigoid antigen 180 induce dermal–epidermal separation in cryosections of human skin. J Invest Dermatol 118(4):664–671CrossRefPubMedGoogle Scholar
  68. 68.
    Sitaru C, Mihai S, Otto C, Chiriac MT, Hausser I, Dotterweich B, Saito H, Rose C, Ishiko A, Zillikens D (2005) Induction of dermal-epidermal separation in mice by passive transfer of antibodies specific to type VII collagen. J Clin Invest 115(4):870–878PubMedGoogle Scholar
  69. 69.
    Sitaru C, Chiriac MT, Mihai S, Buning J, Gebert A, Ishiko A, Zillikens D (2006) Induction of complement-fixing autoantibodies against type VII collagen results in subepidermal blistering in mice. J Immunol 177(5):3461–3468PubMedGoogle Scholar
  70. 70.
    Soerensen H, Schneidewind-Mueller JM, Lange D, Kashiwagi N, Franz M, Yokoyama T, Ramlow W (2006) Pilot clinical study of Adacolumn cytapheresis in patients with systemic lupus erythematosus. Rheumatol Int 26(5):409–415CrossRefPubMedGoogle Scholar
  71. 71.
    Sondergaard K, Carstens J, Jorgensen J, Zachariae H (1995) The steroid-sparing effect of long-term plasmapheresis in pemphigus. Acta Derm Venereol 75(2):150–152PubMedGoogle Scholar
  72. 72.
    Tan-Lim R, Bystryn JC (1990) Effect of plasmapheresis therapy on circulating levels of pemphigus antibodies. J Am Acad Dermatol 22(1):35–40CrossRefPubMedGoogle Scholar
  73. 73.
    Turner MS, Sutton D, Sauder DN (2000) The use of plasmapheresis and immunosuppression in the treatment of pemphigus vulgaris. J Am Acad Dermatol 43(6):1058–1064CrossRefPubMedGoogle Scholar
  74. 74.
    Wallukat G, Muller J, Hetzer R (2002) Specific removal of beta1-adrenergic autoantibodies from patients with idiopathic dilated cardiomyopathy. N Engl J Med 347(22):1806CrossRefPubMedGoogle Scholar
  75. 75.
    Waschke J (2008) The desmosome and pemphigus. Histochem Cell Biol 130(1):21–54CrossRefPubMedGoogle Scholar
  76. 76.
    Wohrl S, Geusau A, Karlhofer F, Derfler K, Stingl G, Zillikens D (2003) Pemphigoid gestationis: treatment with immunoapheresis. J Dtsch Dermatol Ges 1(2):126–130PubMedGoogle Scholar
  77. 77.
    Woodley DT, Ram R, Doostan A, Bandyopadhyay P, Huang Y, Remington J, Hou Y, Keene DR, Liu Z, Chen M (2006) Induction of epidermolysis bullosa acquisita in mice by passive transfer of autoantibodies from patients. J Invest Dermatol 126(6):1323–1330CrossRefPubMedGoogle Scholar
  78. 78.
    Zillikens D, Derfler K, Eming R, Fierlbeck G, Goebeler M, Hertl M, Hofmann SC, Karlhofer F, Kautz O, Nitschke M, Opitz A, Quist S, Rose C, Schanz S, Schmidt E, Shimanovich I, Michael M, Ziller F (2007) Recommendations for the use of immunoapheresis in the treatment of autoimmune bullous diseases. J Dtsch Dermatol Ges 5(10):881–887CrossRefPubMedGoogle Scholar

[Related articles recently published in the Archives of Dermatological Research (selected by the journal’s editorial staff)]

  1. 79.
    Abreu-Velez AM, Howard MS, Hashimoto K, Hashimoto T (2009) Autoantibodies to sweat glands detected by different methods in serum and in tissue from patients affected by a new variant of endemic pemphigus foliaceus. Arch Dermatol Res 301:711–718CrossRefPubMedGoogle Scholar
  2. 80.
    Gaines E, Werth VP (2008) Development of outcome measures for autoimmune dermatoses. Arch Dermatol Res 300:3–9CrossRefPubMedGoogle Scholar
  3. 81.
    Leighty L, Li N, Diaz LA, Liu Z (2007) Experimental models for the autoimmune and inflammatory blistering disease: bullous pemphigoid. Arch Dermatol Res 299:417–422CrossRefPubMedGoogle Scholar
  4. 82.
    Nancy AL, Yehuda S (2009) Prediction and prevention of autoimmune skin disorders. Arch Dermatol Res 301:57–64CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  1. 1.Department of DermatologyUniversity of LübeckLübeckGermany

Personalised recommendations