Review on Bullous Pemphigoid: Fixed Drug Eruption or Autoimmune Disorder

Published: November 20, 2024

Authors

Adarsh Keshari, Roshan Pandey, Sarita Jangra, Amit Sharma, Bhavesh Dharmani, Bisman, and Thakur Gurjeet Singh

Keywords
Bullous pemphigoid, Fixed drug eruption, Basement membrane zone (BMZ), Drug induced Bullous pemphigoid, Autoantibodies.

Abstract

Background: Bullous pemphigoid is a blistering disease of autoimmune nature predominantly affecting the geriatric population. It is characterized by blister formation at the subepidermal level, due to autoantibodies at the dermo-epidermal junction targeting proteins BP180XV11 and BP230. Mainly an autoimmune condition, diagnosis and treatment get complicated as it overlaps with drug-induced hypersensitivity reactions, including fixed drug eruption. Unlike Bullous Pemphigoid, it is a condition of localized hypersensitivity mediated by T cells.

Purpose: The review tries to establish Bullous Pemphigoid as an autoimmune condition separate from fixed drug eruption. It is centered on the causative role of medications, which include diuretics, antibiotics, and dipeptidyl peptidase-4 inhibitors, in drug-induced bullous pemphigoid. Besides, it examines genetic, immunological, and environmental etiologies of the disease and delineates clinical and diagnostic characteristics of Bullous Pemphigoid and fixed drug eruptions.

Method: A systematic analysis of current literature was performed, focusing on the pathophysiology, immunological mechanisms, and histopathological differences between Bullous Pemphigoid and fixed drug eruptions. The review also examines the role of medications, genetic predispositions such as specific human leukocyte antigen haplotypes, and the diagnostic utility of histopathological and immunological methods like direct immunofluorescence.

Results: Autoantibodies against BP180 and BP230 in bullous pemphigoid initiate inflammatory cascades, causing subepidermal blistering and eosinophilic infiltration. Fixed drug eruption involves basal cell necrosis and localized lymphocytic infiltration. Drugs like dipeptidyl peptidase-4 inhibitors exacerbate bullous pemphigoid through immune modulation and oxidative stress. Genetic susceptibility plays a significant role, and immunological tests such as direct immunofluorescence help distinguish the two conditions.

Conclusion: Bullous pemphigoid is a distinct autoimmune disease with unique immunopathological mechanisms compared to fixed drug eruption. Understanding its pathogenesis, drug interactions, and diagnostic methods enhances accurate diagnosis and management of both spontaneous and drug-induced bullous pemphigoid.

References

  • Agarwala, M., Mukhopadhyay, S., Sekhar, Mr., & Dincy Peter, C. (2016). Bullous fixed drug eruption probably induced by paracetamol. Indian Journal of Dermatology, 61(1), 121. https://doi.org/10.4103/0019-5154.174098
  • Alpsoy, E., Akman-Karakas, A., & Uzun, S. (2015). Geographic variations in epidemiology of two autoimmune bullous diseases: pemphigus and bullous pemphigoid. Archives of Dermatological Research, 307(4), 291–298. https://doi.org/10.1007/s00403-014-1531-1
  • Baican, A., Baican, C., Chiriac, G., Chiriac, M. T., Macovei, V., Zillikens, D., Ciuce, D., & Sitaru, C. (2010). Pemphigus vulgaris is the most common autoimmune bullous disease in Northwestern Romania. International Journal of Dermatology, 49(7), 768–774. https://doi.org/10.1111/j.1365-4632.2009.04345.x
  • Bernard, P., & Antonicelli, F. (2017). Bullous Pemphigoid: A Review of its Diagnosis, Associations and Treatment. American Journal of Clinical Dermatology, 18(4), 513–528. https://doi.org/10.1007/s40257-017-0264-2
  • Cozzani, E., Gasparini, G., Burlando, M., Drago, F., & Parodi, A. (2015). Atypical presentations of bullous pemphigoid: Clinical and immunopathological aspects. Autoimmunity Reviews, 14(5), 438–445. https://doi.org/10.1016/j.autrev.2015.01.006
  • Della Torre, R., Combescure, C., Cortés, B., Marazza, G., Beltraminelli, H., Naldi, L., & Borradori, L. (2012). Clinical presentation and diagnostic delay in bullous pemphigoid: a prospective nationwide cohort. British Journal of Dermatology, 167(5), 1111–1117. https://doi.org/10.1111/j.1365-2133.2012.11108.x
  • Hammers, C. M., & Stanley, J. R. (2016). Mechanisms of Disease: Pemphigus and Bullous Pemphigoid. Annual Review of Pathology: Mechanisms of Disease, 11(1), 175–197. https://doi.org/10.1146/annurev-pathol-012615-044313
  • Holgate, S., Smith, N., Massanari, M., & Jimenez, P. (2009). Effects of omalizumab on markers of inflammation in patients with allergic asthma. Allergy, 64(12), 1728–1736. https://doi.org/10.1111/j.1398-9995.2009.02201.x
  • Kanahara, S. M., & Agrawal, A. (2016). Drug-induced bullous pemphigoid. Journal of General Internal Medicine, 31(11), 1393–1394. https://doi.org/10.1007/s11606-016-3679-1
  • Kershenovich, R., Hodak, E., & Mimouni, D. (2014). Diagnosis and classification of pemphigus and bullous pemphigoid. Autoimmunity Reviews, 13(4–5), 477–481. https://doi.org/10.1016/j.autrev.2014.01.011
  • Langan, S. M., Smeeth, L., Hubbard, R., Fleming, K. M., Smith, C. J. P., & West, J. (2008). Bullous pemphigoid and pemphigus vulgaris–incidence and mortality in the UK: population based cohort study. BMJ, 337(jul09 1), a180–a180. https://doi.org/10.1136/bmj.a180
  • Lo Schiavo, A., Ruocco, E., Brancaccio, G., Caccavale, S., Ruocco, V., & Wolf, R. (2013). Bullous pemphigoid: Etiology, pathogenesis, and inducing factors: Facts and controversies. Clinics in Dermatology, 31(4), 391–399. https://doi.org/10.1016/j.clindermatol.2013.01.006
  • Marzano, A. V, Tedeschi, A., Berti, E., Fanoni, D., Crosti, C., & Cugno, M. (2011). Activation of coagulation in bullous pemphigoid and other eosinophil-related inflammatory skin diseases. Clinical and Experimental Immunology, 165(1), 44–50. https://doi.org/10.1111/j.1365-2249.2011.04391.x
  • Miyamoto, D., Santi, C. G., Aoki, V., & Maruta, C. W. (2019). Bullous pemphigoid. Anais Brasileiros de Dermatologia, 94(2), 133–146. https://doi.org/10.1590/abd1806-4841.20199007
  • Nanda, A., Dvorak, R., Al‐Saeed, K., Al‐Sabah, H., & Alsaleh, Q. A. (2004). Spectrum of autoimmune bullous diseases in Kuwait. International Journal of Dermatology, 43(12), 876–881. https://doi.org/10.1111/j.1365-4632.2004.02292.x
  • Nino, M., Francia, M. G., Costa, C., & Scalvenzi, M. (2009). Bullous Fixed Drug Eruption Induced by Paracetamol: Report of a Pediatric Case. Case Reports in Dermatology, 1(1), 56–59. https://doi.org/10.1159/000243728
  • Patel, S., John, A. M., Handler, M. Z., & Schwartz, R. A. (2020). Fixed Drug Eruptions: An Update, Emphasizing the Potentially Lethal Generalized Bullous Fixed Drug Eruption. American Journal of Clinical Dermatology, 21(3), 393–399. https://doi.org/10.1007/s40257-020-00505-3
  • Saniklidou, A. H., Tighe, P. J., Fairclough, L. C., & Todd, I. (2018). IgE autoantibodies and their association with the disease activity and phenotype in bullous pemphigoid: a systematic review. Archives of Dermatological Research, 310(1), 11–28. https://doi.org/10.1007/s00403-017-1789-1
  • Schmidt, E., & Zillikens, D. (2013). Pemphigoid diseases. The Lancet, 381(9863), 320–332. https://doi.org/10.1016/S0140-6736(12)61140-4
  • Sharma, A., Baldi, A., & Sharma, D. K. (2022). Levofloxacin induced bullous fixed drug eruption: a rare case report. European Journal of Hospital Pharmacy, 29(e1), e95–e96. https://doi.org/10.1136/ejhpharm-2020-002566
  • Stavropoulos, P. G., Soura, E., & Antoniou, C. (2014). Drug‐induced pemphigoid: a review of the literature. Journal of the European Academy of Dermatology and Venereology, 28(9), 1133–1140. https://doi.org/10.1111/jdv.12366
  • Taquin, H., Chiaverini, C., & Lacour, J. P. (2016). Spectrum of Clinical Responses to Therapies in Infantile Bullous Pemphigoid. Pediatric Dermatology, 33(2). https://doi.org/10.1111/pde.12779
  • Ujiie, H., Nishie, W., & Shimizu, H. (2011). Pathogenesis of Bullous Pemphigoid. Dermatologic Clinics, 29(3), 439–446. https://doi.org/10.1016/j.det.2011.03.008
  • Verheyden, M., Bilgic, A., & Murrell, D. (2020). A Systematic Review of Drug-Induced Pemphigoid. Acta Dermato Venereologica, 100(15), adv00224. https://doi.org/10.2340/00015555-3457
  • Vornicescu, C., Șenilă, S., Cosgarea, R., Candrea, E., Pop, A., & Ungureanu, L. (2018). Pemphigoid nodularis – rare presentation of bullous pemphigoid: A case report and literature review. Experimental and Therapeutic Medicine. https://doi.org/10.3892/etm.2018.7057
  • Yan, T., Xie, Y., Liu, Y., Shan, Y., Wu, X., Wang, J., Zuo, Y.G., & Zhang, Z. (2023). Dupilumab effectively and rapidly treats bullous pemphigoid by inhibiting the activities of multiple cell types. Frontiers in Immunology14, 1194088. https://doi.org/10.3389/fimmu.2023.1194088

How to Cite

Adarsh Keshari, Roshan Pandey, Sarita Jangra, Amit Sharma, Bhavesh Dharmani, Bisman, and Thakur Gurjeet Singh. Review on Bullous Pemphigoid: Fixed Drug Eruption or Autoimmune Disorder. J. Pharm. Technol. Res. Manag.. 2024, 12, 15-24
Review on Bullous Pemphigoid: Fixed Drug Eruption or Autoimmune Disorder

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