Bullous pemphigoid-What do we know about the most recent therapies?

Introduction: Bullous pemphigoid (BP) is the most common subtype of autoimmune blistering diseases that primarily affects the elderly and is classically defined by the presence of IgG and/or complement C3 against the BP180 and BP230 hemidesmosome proteins. However, most recent studies have introduced the role of specific eosinophil receptors and chemokine mediators in the pathogenesis of BP which are helpful in identifying new targets for future treatments. Areas covered: This review will focus on the involvement of eosinophils in BP, including the processes that lead to their recruitment, activation, and regulation. Subsequently, covering new therapeutic options in relation to the role of eosinophils. Eotaxin enhances the recruitment of eosinophils in BP, with CCR3 chemoreceptor that is expressed on eosinophils being identified as a key binding site for eotaxin-1. The pathogenic role of IgE and IL-4 in BP is corroborated by successful treatments with Omalizumab and Dupilumab, respectively. IL-5, IL-17 and IL-23 inhibitors may be effective given their roles in promoting eosinophilia. Expert opinion: Further research into inhibitors of eotaxin, IL-4, IL-5, IL-17, IL-23, CCR3, and specific complement factors are warranted as preliminary studies have largely identified success in treating BP with these agents. Learning from novel treatments for other IgG-mediated autoimmune diseases may be beneficial.

Side effects of steroid-sparing agents in patients with bullous pemphigoid and pemphigus: A systematic review.

Background: Systemic glucocorticoids are first-line treatment options for autoimmune blistering diseases; however, their long-term use is associated with significant toxicities. Objective: To evaluate the side effects of steroid-sparing agents and compare them with those of steroids. Methods: We searched Cochrane Reviews, Embase, MEDLINE, and Scopus between October 1978 and May 2020 using the keywords "bullous pemphigoid," "pemphigus," "autoimmune blistering diseases," and "side effects." A total of 31 randomized controlled trials and retrospective case series were critically appraised. Results: This review includes a total of 1685 patients with autoimmune blistering diseases, of whom 781 had bullous pemphigoid and 904 had either pemphigus vulgaris or pemphigus foliaceous. Limitations: A major limitation is that because adjuvants are generally used in combination with steroids, only 12 of the studies reviewed included a "steroid-only" arm to allow for a direct comparison of side effects. Additionally, there is inadequate literature and lack of standardized grade reporting of specific side effects of each steroid-sparing agent. Conclusion: In the future, researchers should consider implementing the Common Terminology Criteria for Adverse Events, version 5.0, for reporting of all side effects to allow for consistency and standardization. It would be useful to have an index similar to the Glucocorticoid Toxicity Index to quantify these side effects.

Evaluation of the toxicity of glucocorticoids in patients with autoimmune blistering disease using the Glucocorticoid Toxicity Index: A cohort study.

BACKGROUND: Glucocorticoids are the mainstay of treatment for autoimmune blistering diseases (AIBDs). The Glucocorticoid Toxicity Index (GTI) is a novel, outcome-based glucocorticoid-induced adverse effects monitoring instrument. OBJECTIVE: To investigate whether the GTI score was able to accurately quantify the glucocorticoid-induced toxicity in patients with AIBDs. METHODS: The prospective cohort study included patients with confirmed diagnoses of AIBDs (group1, currently receiving glucocorticoids; and group 2, had glucocorticoids ceased earlier). Data were collected minimally at baseline (V1) and 3 months (V2). Further data from patients who were able to complete the follow-up visits at 6 months (V3) and 12 months (V4) amid the COVID-19 pandemic were also included. GTI scores were calculated after data collection. RESULTS: Analysis of data from V1 and V2 found a linear correlation between GTI score and prednisone doses (P < .05) and a significant difference in GTI scores between group1 and group 2 (P < .05). Data from V3 and V4 suggested that GTI scores continued to rise progressively alongside increasing cumulative prednisone dose. LIMITATIONS: Small sample size, further exacerbated by the COVID-19 pandemic. Single-center study. CONCLUSION: The GTI sensitively and specifically captured the changes in glucocorticoids toxicity over time among patients with AIBDs. The GTI could be a feasible tool that can be used in future clinical trials as a glucocorticoid-induced toxicity outcome measure.

State-of-the-art review of human autoimmune blistering diseases (AIBD).

Autoimmune blistering diseases (AIBDs) are a heterogenous group of skin conditions, broadly classified into two categories depending on the location of blister formation: intraepidermal blistering in the pemphigus group and subepidermal blistering in the pemphigoid group. Although AIBDs occur in both humans and animals, the arsenal of data for human AIBDs far exceeds those of their animal counterpart. Therefore, the main purpose of this review is to highlight existing knowledge, and recent advances in the diagnosis and management of AIBDs in humans - to serve as a road map for veterinary dermatologists. AREAS COVERED: Recent findings include complement-independent pathways in the pathogenesis of bullous pemphigoid, as well as the role of desmoglein and desmocollin autoantibodies in inducing acantholysis. Systemic glucocorticoids are the mainstay of treatment for AIBDs in humans, yet their long-term use is associated with severe adverse effects and complications, thereby limiting their use. Therefore, researchers have been exploring new and safer alternative therapeutic options for human AIBDs such as anti-CD20 monoclonal antibodies (Rituximab), Bruton's tyrosine kinase inhibitors (BTKi) and neonatal Fc receptor (FcRn) blockers. EXPERT OPINION: Randomised controlled trial (RCT) level evidence show that Rituximab and short-course GC regimes are more effective and safer than traditional GC treatment for human AIBDs. FcRn blockers such as SYNT001 have shown positive results in preliminary phase 2 clinical trials for treatment of human pemphigus; further trials are required. Rilzabrutinib (PRN1008), an orally administered BTKi, has recently completed phase 2 trials in pemphigus and is in a phase 3 RCT in humans.

Les maladies auto-immunes de clivage (AIBDs) est un groupe hétérogène de maladies cutanées, classifiées en deux catégories dépendantes de la localisation du clivage : intra-épidermique dans le groupe pemphigus et sous-épidermique dans le groupe pemphigoïde. Bien que les AIBDs existent chez l'homme et chez l'animal, l'arsenal de données pour les AIBDs de l'homme est bine plus développé que pour l'animal. Ainsi, le principal objectif de cette revue et de mettre en lumière les connaissances existantes et les avancées récentes du diagnostic et de la gestions des AIBDs de l'homme- afin de servir de carte de route pour les vétérinaires dermatologues. ZONES COUVERTES: Des données récentes comprennent les voies indépendantes du complément dans la pathogénie de la pemphigoïde bulleuse, ainsi que le rôle de la desmogléine et desmocolline dans la formation de l'acantholyse. Les corticoïdes (GC) systémiques sont le principal traitement des AIBDs de l'homme, bien que leur utilisation au long court avec effets secondaires sévères et complications, limitent leur utilisation. Ainsi, les chercheurs ont explorés de nouvelles options thérapeutiques alternatives plus sures pour les AIBDs de l'homme tels que les anticorps monoclonaux anti-CD20 (Ritumimab), les inhibiteurs de tyrosine kinase de Bruton (BTKi) et des bloqueurs de récepteur Fc néonataux (FcRn). POSITION DES EXPERTS: Les niveaux de preuves des essais contrôlés randomisés (RCT) montrent que le Ritumimab et les traitements de corticoïdes de courte durée sont plus efficaces et plus surs que les traitements traditionnels de GC pour les AIBDs de l'homme. Les bloqueurs FcRn tels que SYNT001 ont montré des résultats positifs dans les essais préliminaires cliniques de phase 2 pour le traitement du pemphigus de l'homme ; d'autres études sont nécessaires. Le Rilzabrutinib (PRN1008), un BTKi oral, a récemment fini un essai de phase 2 dans le pemphigus et une étude de phase 3 RCT chez l'homme.

Las enfermedades autoinmunes ampulosas (AIBDs, por sus siglas en inglés) son un grupo heterogéneo de afecciones cutáneas, que se clasifican ampliamente en dos categorías según la ubicación de la formación de ampollas: ampollas intraepidérmicas en el grupo de pénfigo y ampollas subepidérmicas en el grupo de penfigoides. Aunque los AIBD ocurren tanto en humanos como en animales, el arsenal de datos para los AIBD humanos supera con creces a los de sus homólogos animales. Por lo tanto, el propósito principal de esta revisión es resaltar el conocimiento existente y los avances recientes en el diagnóstico y manejo de los AIBD en humanos, para que sirva como una hoja de ruta para los dermatólogos veterinarios. ÁREAS CUBIERTAS: los hallazgos recientes incluyen vías independientes del complemento en la patogenia del penfigoide ampuloso, así como el papel de los autoanticuerpos de desmogleína y desmocolina en la inducción de acantólisis. Los glucocorticoides sistémicos son el pilar del tratamiento para los AIBD en humanos, sin embargo, su uso a largo plazo se asocia con efectos adversos graves y complicaciones, lo que limita su uso. Por lo tanto, los investigadores han estado explorando opciones terapéuticas alternativas nuevas y más seguras para las AIBDs humanas, como los anticuerpos monoclonales anti-CD20 (Rituximab), los inhibidores de la tirosina quinasa de Bruton (BTKi) y los bloqueadores del receptor de Fc neonatal (FcRn). OPINIÓN DE EXPERTOS: la evidencia a nivel de ensayos controlados aleatorios (RCT) muestra que los regímenes de Rituximab y GC de ciclo corto son más efectivos y más seguros que el tratamiento GC tradicional para los AIBD humanos. Los bloqueadores de FcRn como SYNT001 han mostrado resultados positivos en ensayos clínicos preliminares de fase 2 para el tratamiento del pénfigo humano; se requieren más pruebas. Rilzabrutinib (PRN1008), un BTKi administrado por vía oral, ha completado recientemente ensayos de fase 2 en pénfigo y se encuentra en un RCT de fase 3 en humanos.

As doenças autoimunes bolhosas (DAIBs) são um grupo heterógeno de dermatopatias, amplamente classificadas em duas categorias, dependendo da localização da formação das bolhas: bolhas intraepidermais no grupo do pênfigo e bolhas subepidermais no grupo penfigoide. Apesar das DAIBs ocorrerem tanto nos humanos quanto nos animais, o arsenal de dados sobre as DAIBs humanas é muito maior que o existente para animais. Desta forma, o principal propósito desta revisão é destacar o conhecimento existente, e os recentes avanços no diagnóstico e manejo das DAIBs em humanos - para servir como um roteiro para os dermatologistas veterinários. ÁREAS ABORDADAS: Os achados recentes incluem vias independentes do complemento na patogênese do penfigoide bolhoso, bem como a função dos autoanticorpos anti-desmogleína e anti-desmocolina induzindo acantólise. Glicocorticoides sistêmicos são a base do tratamento das DAIBs em humanos, apesar de seu uso prolongado ser associado a reações adversas e complicações graves,9R limitando assim o seu uso. Desta forma, os pesquisadores têm explorado novas alternativas terapêuticas mais seguras para as DAIBs humanas, tais como os anticorpos monoclonais anti-CD20 (Rituximab), inibidores de tirosina quinase de Bruton (BRKi) e bloqueadores de receptores Fc neonatais (FcRn). OPINIÃO DO ESPECIALISTA: Evidências de ensaios clínicos randomizados e controlados (RCT) demonstram que o Rituximab e terapias de curta duração com GC são mais eficazes e seguros que a terapia tradicional com GC para DAIBs humanas. Os bloqueadores de FcRn, como SYNT001, demostraram resultados positivos em ensaios clínicos preliminares de fase 2 para o tratamento de pênfigo humano; mais ensaios são necessários. Ensaios de fase 2 em pênfigo com o Rilzabrutinib (PRN1008), um BTKi administrado por via oral, foram concluídos e estão conduzindo os ensaios RCT de fase 3 em humanos.