Skip to main content
SpringerLink
Log in

Management of Autoimmune Skin Disorders in the Elderly

  • Therapy In Practice
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Senescence of the skin immunological system may explain why the elderly population has an increased susceptibility to certain autoimmune skin disorders. These disorders are characterised by the production of either antibodies that react with host tissue or immune effector T cells that are autoreactive.

Bullous pemphigoid is the most common autoimmune blistering disease in the elderly. Although oral corticosteroids are the best established therapy, high-potency topical corticosteroids are very useful as initial treatment and, in the elderly, should be used instead of oral prednisolone wherever possible. Pemphigus is a chronic blistering disease of which there are two main subtypes: vulgaris and foliaceous. Paraneoplastic pemphigus is a unique clinical, histological and immunologically distinct autoimmune mucocutaneous disease which tends to be relentlessly progressive.

Lichen sclerosus presents specific complications and a small but definite increased risk of squamous cell carcinoma in elderly patients. It is important to be aware of practical issues such as the difficulty in applying topical corticosteroids, the mainstay treatment of this condition.

Dermatomyositis is an autoimmune systemic disorder where the skin and muscles are the most commonly affected organs. Tumour-associated disease occurs more commonly in elderly patients and has a poorer prognosis. Management of the disease includes sunscreens, topical or systemic corticosteroids, antimalarials, oral immunosuppressants or intravenous immunoglobulins.

It is important to bear in mind that old age modifies the management of skin diseases because of physical and social circumstances as well as the unwanted adverse effects of medications. Polypharmacy results in an increased risk of drug interactions and, therefore, drug regimens need to be kept as simple as possible. Drug-induced autoimmune skin eruptions are common amongst the elderly and usually resolve when the offending drug is discontinued.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. Sunderkotter C, Kalden H, Luger TA. Aging and the skin immune system. Arch Dermatol 1997; 133(10): 1256–62

    Article  PubMed  CAS  Google Scholar 

  2. Gilchrest BA, Murphy GF, Soter NA. Effect of chronologic ageing and ultraviolet irradiation on Langerhan cells in human epidermis. J Invest Dermatol 1982; 79: 85–8

    Article  PubMed  CAS  Google Scholar 

  3. Report on the enquiry into skin diseases in elderly people: a report of the Associate Parliamentary Group on the Skin. London: Portcullis Research, 2000 Nov

  4. Bernard P, Vaillant L, Labeille B, et al. Incidence and distribution of subepidermal autoimmune bullous skin diseases in three French regions. Arch Dermatol 1995; 131: 48–52

    Article  PubMed  CAS  Google Scholar 

  5. Zillikens D, Wever S, Roth A, et al. Incidence of autoimmune subepidermal blistering dermatoses in a region of Central Germany. Arch Dermatol 1995; 131: 957–8

    Article  PubMed  CAS  Google Scholar 

  6. Anhalt G, Bahn C, Labib R, et al. Pathogenic effects of bullous pemphigoid autoantibodies on rabbit corneal epithelium. J Clin Invest 1981; 68: 1097–101

    Article  PubMed  CAS  Google Scholar 

  7. Liu Z, Diaz L, Troy J, et al. A passive transfer model of the organ-specific autoimmune disease, bullous pemphigoid, using antibodies generated against the hemidesmosomal antigen BP180. J Clin Invest 1993; 92: 2480–8

    Article  PubMed  CAS  Google Scholar 

  8. Diaz L, Weiss H, Calcanico N. Phylogenetic studies with pemphigus and pemphigoid antibodies. Acta Derm Venereol (Stockh) 1978; 58: 535–9

    Google Scholar 

  9. Westerhof W. Treatment of bullous pemphigoid with topical clobetasol propionate. J Am Acad Dermatol 1989; 20: 458–61

    Article  PubMed  CAS  Google Scholar 

  10. Joly P, Roujeau JC, Benichou J, etal. A comparison of oral and topical corticosteroids in patients with bullous pemphigoid. N Engl J Med 2002; 346(5): 321–7

    Article  PubMed  CAS  Google Scholar 

  11. Fivenson D, Breneman D, Rosen G, et al. Nicotinamide and tetracycline therapy of bullous pemphigoid. Arch Dermatol 1994; 130: 753–8

    Article  PubMed  CAS  Google Scholar 

  12. Kawahara Y, Hashimoto T, Ohata Y, et al. Eleven cases of bullous pemphigoid treated with a combination of minocycline and nicotinamide. Eur J Dermatol 1996; 6: 427–9

    CAS  Google Scholar 

  13. Fox BJ, Odom RB, Findlay RF. Erythromycin therapy in bullous pemphigoid: possible anti-inflammatory effects. J Am Acad Dermatol 1982; 7: 504–10

    Article  PubMed  CAS  Google Scholar 

  14. Burton JL, Harman RR, Peachy RD, et al. Azathioprine plus prednisolone in treatment of pemphigoid. BMJ 1978; 2: 1190–1

    Article  PubMed  CAS  Google Scholar 

  15. Guillaume JC, Vaillant L, Bernard P, et al. Controlled trial of azathioprine and plasma exchange in addition to prednisolone in the treatment of bullous pemphigoid. Arch Dermatol 1993; 129: 49–53

    Article  PubMed  CAS  Google Scholar 

  16. Bouscarat F, Chosidow O, Picard-Dahan C, et al. Treatment of bullous pemphigoid with dapsone: retrospective study of thirty-six cases. J Am Acad Dermatol 1996; 34: 683–4

    Article  PubMed  CAS  Google Scholar 

  17. Itoh T, Hosokawa H, Shirai Y, et al. Successful treatment of bullous pemphigoid with pulsed intravenous cyclophosphamide. Br J Dermatol 1996; 134: 931–3

    Article  PubMed  CAS  Google Scholar 

  18. Heilborn JD, Stahle-Backdahl M, Albertioni F, et al. Low dose oral pulse methotrexate as monotherapy in elderly patients with bullous pemphigoid. J Am Acad Dermatol 1999; 40: 741–9

    Article  PubMed  CAS  Google Scholar 

  19. Barthelemy H, Thivolet J, Cambazard F, et al. Cyclosporine in the treatment of bullous pemphigoid: preliminary study. Ann Dermatol Venereol 1986; 113: 309–13

    PubMed  CAS  Google Scholar 

  20. Harman KE, Black MM. High dose intravenous immune globulin for the treatment of autoimmune blistering diseases: an evaluation of its use in 14 cases. Br J Dermatol 1999; 140: 865–74

    Article  PubMed  CAS  Google Scholar 

  21. Egan CA, Meadows KP, Zone JJ. Plasmapheresis as a steroid saving procedure in bullous pemphigoid. Int J Dermatol 2000; 39: 230–5

    Article  PubMed  CAS  Google Scholar 

  22. Jan V, Callens A, Machet MC, et al. D-penicillamine-induced pemphigus, polymyositis and myasthenia. Ann Dermatol Venereol 1999; 126(2): 153–6

    PubMed  CAS  Google Scholar 

  23. Wojnarowska F, Eady RAJ, Burge S. Bullous eruptions. In: Champion RH, Burton JL, Ebling FJG, editors. Textbook of dermatology. 6th ed. Vol. 3. Oxford: Blackwell Scientific Publications, 1998: 1817–98

    Google Scholar 

  24. Fitzpatrick RE, Newcomer VD. The correlation of disease activity and antibody titres in pemphigus. Arch Dermatol 1980; 116: 285–90

    Article  PubMed  CAS  Google Scholar 

  25. Iwatsuki K, Takigawa M, Jin F, et al. Ultrastructural binding site of pemphigus foliaceous autoantibodies: comparison with pemphigus vulgaris. J Cutan Pathol 1991; 18: 160–3

    Article  PubMed  CAS  Google Scholar 

  26. Rosenberg FR, Sanders S, Nelson CT. Pemphigus: a 20 year review of 107 patients treated with corticosteroids. Arch Dermatol 1976; 112: 962–70

    Article  PubMed  CAS  Google Scholar 

  27. Aberer W, Wolff-Schreiner EC, Stingl G, et al. Azathioprine in the treatment of pemphigus vulgaris: a long term follow-up. J Am Acad Dermatol 1987; 16: 527–33

    Article  PubMed  CAS  Google Scholar 

  28. Tavadia SM, Mydlarski PR, Reis MD, et al. Screening for azathioprine toxicity: a pharmacoeconomic analysis based on a target case. J Am Acad Dermatol 2000; 42(4): 628–32

    PubMed  CAS  Google Scholar 

  29. Enk AH, Knop J. Mycophenolate mofetil is effective in the treatment of pemphigus vulgaris. Arch Dermatol 1999; 135: 54–6

    Article  PubMed  CAS  Google Scholar 

  30. Pasricha JS, Khaitan BK, Raman RS, et al. Dexamethasone-cyclophosphamide pulse therapy for pemphigus. Int J Dermatol 1995; 34: 875–82

    Article  PubMed  CAS  Google Scholar 

  31. Roujeau JC, Andre C, Fabre MJ, et al. Plasma exchange in pemphigus. Arch Dermatol 1983; 119: 215–21

    Article  PubMed  CAS  Google Scholar 

  32. Huilgol SC, Black MM. Management of the immunobullous disorders: II. Pemphigus. Clin Exp Dermatol 1995; 20: 283–93

    Article  PubMed  CAS  Google Scholar 

  33. Callen JP. Internal disorders associated with bullous disease of the skin: a critical review. J Am Acad Dermatol 1980; 3(2): 107–19

    Article  PubMed  CAS  Google Scholar 

  34. Nousari HC, Anhalt GJ. Pemphigus. In: Lebwohl M, Heymann WR, Berth-Jones J, et al., editors. Treatment of skin disease. 1st ed. London: Harcourt Publishers Limited, 2002: 452–3

    Google Scholar 

  35. Horn TD, Anhalt GJ. Histologic features of paraneoplastic pemphigus. Arch Dermatol 1992; 128(8): 1091–5

    Article  PubMed  CAS  Google Scholar 

  36. Farrell AM, Marren P, Dean D, et al. Lichen sclerosus: evidence that immunological changes occur at all levels of the skin. Br J Dermatol 1999; 140: 1087–92

    Article  PubMed  CAS  Google Scholar 

  37. Oyama N, Chan I, Neill S, et al. Autoantibodies to extracellular matrix protein 1 in lichen sclerosus. Lancet 2003; 362: 118–23

    Article  PubMed  CAS  Google Scholar 

  38. Derrick EK, Ridley CM, Kobza-Black A, et al. A clinical study of 23 cases of female anogenital carcinoma. Br J Dermatol 2000; 143: 1217–23

    Article  PubMed  CAS  Google Scholar 

  39. Leibowitch M, Neill S, Pelisse M, et al. The epithelial changes associated with squamous cell carcinoma of the vulva: a review of the clinical, histologic and viral findings in 78 women. Br J Obstet Gynaecol 1990; 97: 1135–9

    Article  PubMed  CAS  Google Scholar 

  40. Dalziel K, Millard PR, Wojnarowska F. The treatment of vulval lichen sclerosus with a very potent topical corticosteroid (clobetasol propionate 0.05%) cream. Br J Dermatol 1991; 124: 461–4

    Article  PubMed  CAS  Google Scholar 

  41. Rowell NR, Goodfield MJD. The connective tissue diseases. In: Champion RH, Burton JL, Ebling FJG, editors. Textbook of dermatology. 6th ed. Vol. 3. Oxford: Blackwell Scientific Publications, 1998: 2437–575

    Google Scholar 

  42. Sullivan DB. Detmatomyositis. In: Cassidy JT, editor. Textbook of paediatric rheumatology. 1st ed. New York: Wiley, 1983: 407

    Google Scholar 

  43. Hill CL, Zhang Y, Sigurgeirsson B, et al. Frequency of specific cancer types in dermatomyositis and polymyositis: a population-based study. Lancet 2001; 357(9250): 96–100

    Article  PubMed  CAS  Google Scholar 

  44. Wakata N, Kurihara T, Saito E, et al. Polymyositis and dermatomyositis associated with malignancy: a 30 year retrospective study. Int J Dermatol 2002; 41: 729–34

    Article  PubMed  Google Scholar 

  45. Sparsa A, Liozon E, Herrmann F, et al. Routine vs extensive malignancy search for adult dermatomyositis and polymyositis. Arch Dermatol 2002; 138: 885–90

    Article  PubMed  Google Scholar 

  46. Callen J. Dermatomyositis. In: Lebwohl M, Heymann WR, Berth-Jones J, et al., editors. Treatment of skin disease. 1st ed. London: Harcourt Publishers Limited, 2002: 157–60

    Google Scholar 

  47. Stein M, Bell MJ, Ang LC. Hydroxychloroquine neuromyotoxicity. J Rheumatol 2000; 27: 2927–31

    PubMed  CAS  Google Scholar 

  48. Russell GI, Bing RF, Jones JA, et al. Hydralazine sensitivity: clinical features, autoantibody changes and HLA-DR pheno-type. Q J Med 1987; 65(246): 845–52

    PubMed  CAS  Google Scholar 

  49. Matzner Y, Erlich HA, Brautbar C, et al. Identical HLA class II alleles predispose to drug-triggered and idiopathic pemphigus vulgaris. Acta Derm Venereol 1995; 75(1) 12–4

    PubMed  CAS  Google Scholar 

  50. Brion PH, Mittal-Henkle A, Kalunian KC. Autoimmune skin rashes associated with Etanercept for rheumatoid arthritis [letter]. Ann Intern Med 1999; 131(8): 634

    PubMed  CAS  Google Scholar 

Download references

Acknowledgements

No sources of funding were used to assist in the preparation of this manuscript. The authors have no conflicts of interest that are directly relevant to the content of this review.

Author information

Authors and Affiliations

  1. Department of Dermatology, Addenbrooke’s NHS Trust, Hills Road, Cambridge, CB2 2QQ, UK

    Wei Jing Loo & Nigel P. Burrows

Authors
  1. Wei Jing Loo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nigel P. Burrows
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Wei Jing Loo.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Loo, W.J., Burrows, N.P. Management of Autoimmune Skin Disorders in the Elderly. Drugs Aging 21, 767–777 (2004). https://doi.org/10.2165/00002512-200421120-00002

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00002512-200421120-00002

Keywords

Search

Navigation