Abstract
Purpose of Review
In this review, we seek to discuss the pathogenesis, clinical manifestations, treatments, and latest research developments for autoimmune blistering disorders including pemphigus vulgaris (PV) and bullous pemphigoid (BP). We also offer our clinical observations and personal experiences with these conditions as they relate to geriatric patients.
Recent Findings
Recent studies have uncovered important disease associations and new information regarding the pathophysiology of disease. Novel treatments aimed at disease-specific targets hold therapeutic promise.
Summary
Autoimmune blistering disorders are common in the geriatric population and can have a significant impact on overall health and quality of life. Early and accurate diagnosis is critical. Treatment can be challenging given the frequent number of comorbidities in this patient population, but is necessary to reduce morbidity and mortality.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
•• Pollmann R, Schmidt T, Eming R, Hertl M. Pemphigus: a comprehensive review on pathogenesis, clinical presentation and novel therapeutic approaches. Clin Rev Allergy Immunol. 2018;54(1):1–25 This review provides a comprehensive overview of pemphigus vulgaris.
Zhao CY, Murrell DF. Pemphigus vulgaris: an evidence-based treatment update. Drugs. 2015;75(3):271–84.
Marazza G, Pham HC, Schärer L, Pedrazzetti PP, Hunziker T, Trüeb RM, et al. Incidence of bullous pemphigoid and pemphigus in Switzerland: a 2-year prospective study. Br J Dermatol. 2009;161(4):861–8.
Lara-Corrales I, Pope E. Autoimmune blistering diseases in children. Semin Cutan Med Surg. 2010;29(2):85–91.
Langan SM, Smeeth L, Hubbard R, Fleming KM, Smith CJP, West J. Bullous pemphigoid and pemphigus vulgaris—incidence and mortality in the UK: population based cohort study. BMJ. 2008;337:a180.
Bertram F, Bröcker EB, Zillikens D, Schmidt E. Prospective analysis of the incidence of autoimmune bullous disorders in Lower Franconia, Germany. J Dtsch Dermatol Ges. 2009;7(5):434–40.
•• Amber KT, Murrell DF, Schmidt E, Joly P, Borradori L. Autoimmune subepidermal bullous diseases of the skin and mucosae: clinical features, diagnosis, and management. Clin Rev Allergy Immunol. 2018;54(1):26–51 This review highlights important concepts in the diagnosis and treatment of bullous pemphigoid.
Sun C, Chang B, Gu H. Non-bullous lesions as the first manifestation of bullous pemphigoid: a retrospective analysis of 24 cases. J Dermatolog Treat. 2009;20(4):233–7.
Stavropoulos PG, Soura E, Antoniou C. Drug-induced pemphigoid: a review of the literature. J Eur Acad Dermatol Venereol. 2014;28(9):1133–40.
Hayashida MZ, Pinheiro JRS, Enokihara MMSS, Vasconcellos MRA. Biologic therapy-induced pemphigus. An Bras Dermatol. 2017;92(4):591–3.
Bastuji-Garin S, Joly P, Lemordant P, Sparsa A, Bedane C, Delaporte E, et al. Risk factors for bullous pemphigoid in the elderly: a prospective case-control study. J Invest Dermatol. 2011;131(3):637–43.
Smith EP, et al. Antigen identification in drug-induced bullous pemphigoid. J Am Acad Dermatol. 1993;29(5 Pt 2):879–82.
Kashihara M, Danno K, Miyachi Y, Horiguchi Y, Imamura S. Bullous pemphigoid-like lesions induced by phenacetin. Report of a case and an immunopathologic study. Arch Dermatol. 1984;120(9):1196–9.
Hofmann M, Audring H, Sterry W, Trefzer U. Interleukin-2-associated bullous drug dermatosis. Dermatology. 2005;210(1):74–5.
Ruocco V, Sacerdoti G. Pemphigus and bullous pemphigoid due to drugs. Int J Dermatol. 1991;30(5):307–12.
Lee JJ, Downham TF 2nd. Furosemide-induced bullous pemphigoid: case report and review of literature. J Drugs Dermatol. 2006;5(6):562–4.
Lloyd-Lavery A, Chi CC, Wojnarowska F, Taghipour K. The associations between bullous pemphigoid and drug use: a UK case-control study. JAMA Dermatol. 2013;149(1):58–62.
Patsatsi A, Vyzantiadis TA, Chrysomallis F, Devliotou-Panagiotidou D, Sotiriadis D. Medication history of a series of patients with bullous pemphigoid from northern Greece—observations and discussion. Int J Dermatol. 2009;48(2):132–5.
Pasmatzi E, Monastirli A, Habeos J, Georgiou S, Tsambaos D. Dipeptidyl peptidase-4 inhibitors cause bullous pemphigoid in diabetic patients: report of two cases. Diabetes Care. 2011;34(8):e133.
Skandalis K, Spirova M, Gaitanis G, Tsartsarakis A, Bassukas ID. Drug-induced bullous pemphigoid in diabetes mellitus patients receiving dipeptidyl peptidase-IV inhibitors plus metformin. J Eur Acad Dermatol Venereol. 2012;26(2):249–53.
Varpuluoma O, Försti AK, Jokelainen J, Turpeinen M, Timonen M, Huilaja L, et al. Vildagliptin significantly increases the risk of bullous pemphigoid: a Finnish Nationwide Registry study. J Invest Dermatol. 2018;138(7):1659–61.
Varpuluoma, O., Försti AK, Jokelainen J, Turpeinen M, Timonen M, Tasanen K,et al Oral diabetes medications other than dipeptidyl peptidase-4 inhibitors are not associated with bullous pemphigoid: a Finnish nationwide case control study. J Am Acad Dermatol, 2018.
Kasperkiewicz M, Zillikens D. The pathophysiology of bullous pemphigoid. Clin Rev Allergy Immunol. 2007;33(1–2):67–77.
Ameglio F, D’Auria L, Cordiali-Fei P, Mussi A, Valenzano L, D'Agosto G, et al. Bullous pemphigoid and pemphigus vulgaris: correlated behaviour of serum VEGF, sE-selectin and TNF-alpha levels. J Biol Regul Homeost Agents. 1997;11(4):148–53.
Rhodes LE, Hashim IA, McLaughlin P, Friedmann PS. Blister fluid cytokines in cutaneous inflammatory bullous disorders. Acta Derm Venereol. 1999;79(4):288–90.
Yamauchi PS, Lowe NJ, Gindi V. Treatment of coexisting bullous pemphigoid and psoriasis with the tumor necrosis factor antagonist etanercept. J Am Acad Dermatol. 2006;54(3 Suppl 2):S121–2.
Nin M, Tokunaga D, Ishii N, Komai A, Hashimoto T, Katoh N. Case of coexisting psoriatic arthritis and bullous pemphigoid improved by etanercept. J Dermatol. 2013;40(1):55–6.
Saraceno R, Citarella L, Spallone G, Chimenti S. A biological approach in a patient with psoriasis and bullous pemphigoid associated with losartan therapy. Clin Exp Dermatol. 2008;33(2):154–5.
Monnier-Murina K, du Thanh A, Merlet-Albran S, Guillot B, Dereure O. Bullous pemphigoid occurring during efalizumab treatment for psoriasis: a paradoxical auto-immune reaction? Dermatology. 2009;219(1):89–90.
Boussemart L, Jacobelli S, Batteux F, Goulvestre C, Grange P, Carlotti A, et al. Autoimmune bullous skin diseases occurring under anti-tumor necrosis factor therapy: two case reports. Dermatology. 2010;221(3):201–5.
Bordignon M, Belloni-Fortina A, Pigozzi B, Tarantello M, Alaibac M. Bullous pemphigoid during long-term TNF-alpha blocker therapy. Dermatology. 2009;219(4):357–8.
Lopez AT, Khanna T, Antonov N, Audrey-Bayan C, Geskin L. A review of bullous pemphigoid associated with PD-1 and PD-L1 inhibitors. Int J Dermatol. 2018;57(6):664–9.
Langan SM, Groves RW, West J. The relationship between neurological disease and bullous pemphigoid: a population-based case-control study. J Invest Dermatol. 2011;131(3):631–6.
Jedlickova H, Hlubinka M, Pavlik T, Semradova V, Budinska E, Vlasin Z. Bullous pemphigoid and internal diseases—a case-control study. Eur J Dermatol. 2010;20(1):96–101.
Li L, Chen J, Wang B, Yao Y, Zuo Y. Sera from patients with bullous pemphigoid (BP) associated with neurological diseases recognized BP antigen 1 in the skin and brain. Br J Dermatol. 2009;160(6):1343–5.
Kridin K, Zelber-Sagi S, Comaneshter D, Cohen AD. Association between pemphigus and neurologic diseases. JAMA Dermatol. 2018;154(3):281–5.
Hsu, D.Y., et al., Association of pemphigus and systemic corticosteroid use with comorbid health disorders: a case-control study. Dermatol Online J, 2017. 23(12).
Beissert S, Mimouni D, Kanwar AJ, Solomons N, Kalia V, Anhalt GJ. Treating pemphigus vulgaris with prednisone and mycophenolate mofetil: a multicenter, randomized, placebo-controlled trial. J Invest Dermatol. 2010;130(8):2041–8.
Chams-Davatchi C, Esmaili N, Daneshpazhooh M, Valikhani M, Balighi K, Hallaji Z, et al. Randomized controlled open-label trial of four treatment regimens for pemphigus vulgaris. J Am Acad Dermatol. 2007;57(4):622–8.
Werth VP, Fivenson D, Pandya AG, Chen D, Rico MJ, Albrecht J, et al. Multicenter randomized, double-blind, placebo-controlled, clinical trial of dapsone as a glucocorticoid-sparing agent in maintenance-phase pemphigus vulgaris. Arch Dermatol. 2008;144(1):25–32.
Hall RP 3rd, Fairley J, Woodley D, Werth VP, Hannah D, Streilein RD, et al. A multicentre randomized trial of the treatment of patients with pemphigus vulgaris with infliximab and prednisone compared with prednisone alone. Br J Dermatol. 2015;172(3):760–8.
Kjellman P, Eriksson H, Berg P. A retrospective analysis of patients with bullous pemphigoid treated with methotrexate. Arch Dermatol. 2008;144(5):612–6.
Du-Thanh A, Merlet S, Maillard H, Bernard P, Joly P, Estève E, et al. Combined treatment with low-dose methotrexate and initial short-term superpotent topical steroids in bullous pemphigoid: an open, multicentre, retrospective study. Br J Dermatol. 2011;165(6):1337–43.
Heilborn JD, Ståhle-Bäckdahl M, Albertioni F, Vassilaki I, Peterson C, Stephansson E. Low-dose oral pulse methotrexate as monotherapy in elderly patients with bullous pemphigoid. J Am Acad Dermatol. 1999;40(5 Pt 1):741–9.
Arnold DF, Burton J, Shine B, Wojnarowska F, Misbah SA. An ‘n-of-1’ placebo-controlled crossover trial of intravenous immunoglobulin as adjuvant therapy in refractory pemphigus vulgaris. Br J Dermatol. 2009;160(5):1098–102.
• Joly P, Maho-Vaillant M, Prost-Squarcioni C, Hebert V, Houivet E, Calbo S, et al. First-line rituximab combined with short-term prednisone versus prednisone alone for the treatment of pemphigus (Ritux 3): a prospective, multicentre, parallel-group, open-label randomised trial. Lancet. 2017;389(10083):2031–40 This landmark study provides rationale for the first-line use of rituximab in the treatment of pemphigus vulgaris.
Lunardon L, Tsai KJ, Propert KJ, Fett N, Stanley JR, Werth VP, et al. Adjuvant rituximab therapy of pemphigus: a single-center experience with 31 patients. Arch Dermatol. 2012;148(9):1031–6.
Brown, A.E., K. Motaparthi, and S. Hsu, Rituximab and intravenous immunoglobulin as alternatives to long-term systemic corticosteroids in the treatment of pemphigus: a single center case series of 63 patients. Dermatol Online J, 2018. 23(12).
Mentink LF, Mackenzie MW, Tóth GG, Laseur M, Lambert FP, Veeger NJ, et al. Randomized controlled trial of adjuvant oral dexamethasone pulse therapy in pemphigus vulgaris: PEMPULS trial. Arch Dermatol. 2006;142(5):570–6.
Cho YT, Chu CY, Wang LF. First-line combination therapy with rituximab and corticosteroids provides a high complete remission rate in moderate-to-severe bullous pemphigoid. Br J Dermatol. 2015;173(1):302–4.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Donna Culton is the primary investigator on a clinical trial for pemphigus, which is not mentioned in the manuscript, and reports receiving personal fees for serving on the board for Genetech, which makes rituximab. Matthew Overton declares no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Dermatology and Wound Care
Rights and permissions
About this article
Cite this article
Overton, M., Culton, D. Autoimmune Blistering Disorders in the Geriatric Population. Curr Geri Rep 7, 243–249 (2018). https://doi.org/10.1007/s13670-018-0265-x
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13670-018-0265-x