Download Free Medical Cutaneous Autoimmune Blistering Disease PowerPoint Presentation

Cutaneous Autoimmune Blistering Disease PowerPoint Presentation

DOWNLOAD MEDICAL POWERPOINT PRESENTATION

About This Presentation

Description : Check out this medical presentation on Blisters, which is titled "Cutaneous Autoimmune Blistering Disease", to know about cutaneous blister.

Tags : Blisters, Cutaneous Autoimmune, Blistering Disease

Published on : Jul 05, 2021 | Views : 1930 | Downloads : 1

Shareable Url :

Embed Code :

Comment

Transcript

Slide 1-

Immunobullous disorders Dr Amrita Upadhyaya AP Dermatology 21st july 2017
Slide 2-

Blister: fluid filled cavity formed within or beneath the epidermis Vesicle: blister < 0.5cm Bullae: >0.5cm
Slide 3-

ppt slide no 3 content not found
Slide 4-

1. spongiosis: extracellular fluid in epidermis Eg eczema, miliaria crystallina 2. Acantholysis: loss of keratinocyte cell to cell contact…….. Rounded keratinocytes…… condensed cytoplasm…large nuclei…. Peripheral condensation of chromatin and prominent nucleoli Eg: pemphigus, hailey hailey ds, darriers dis Mechanism of blister formation:
Slide 5-

Tzanck smear
Slide 6-

Reticular degeneration – ballooning degeneration (intracellular oedema) eg: viral infections Cytolysis- friction and heat Basement membrane zone destruction – primary structural deficiency immunologically mediated damage- BP, linear Ig A disease, DH
Slide 7-

ppt slide no 7 content not found
Slide 8-

Intraepidermal- A. subcorneal- miliaria crystallina, SSSS, P. foliaceous, Bullous impetigo, SCPD B. Spinous- Eczema, Hailey Hailey, Miliaria Rubra C. Suprabasal- Pemphigus vulgaris, Paraneoplastic pemphigus, Darriers Disease Based upon plane of separation
Slide 9-

Subepidermal: Bullous Pemphigoid DH Linear Ig A disease Porphyria cutanea tarda
Slide 10-

Classification
Slide 11-

The immunobullous diseases are characterized by pathogenic autoantibodies directed at target antigens whose function is either cell-to-cell adhesion within the epidermis or adhesion of stratified squamous epithelium to dermis or mesenchyme. These diseases are often associated with significant morbidity and some can even cause mortality, if left untreated. Immunobullous disorders Introduction
Slide 12-

Adhesion between keratinocytes: Desmosomes (transmembrane glycoproteins) 1. desmogleins- 1,2,3 desmoglein 3 – in basal and suprabasal layers and mucosae 2. desmocollins
Slide 13-

Others: non glycosylated proteins Plakoglobin; desmoplakin 1 and 2; plakophilin
Slide 14-

Intraepidermal immunobullous disorders
Slide 15-

ppt slide no 15 content not found
Slide 16-

ppt slide no 16 content not found
Slide 17-

The term pemphigus stems from the Greek ‘pemphix’ meaning blister or bubble. Pemphigus is a group of autoimmune blistering disease of skin & mucous membranes characterized by: Histologically, intraepidermal blisters due to loss of cell-cell adhesion of keratinocytes. Immunopathologically, the finding of in vivo bound & circulating IgG autoantibodies directed against the cell surface of the keratinocytes. Pemphigus vulgaris
Slide 18-

All patients develop painful oral erosions. More than half of patients also have flaccid blisters and widespread cutaneous erosions. Mucosa: painful erosions over buccal & palatine mucosa. Intact blisters are rare. Esophagus, conjunctiva, & nasal mucosa may develop these lesions. Skin lesions: primary lesions are flaccid, thin walled easily ruptured blisters. Blisters are fragile and soon rupture to form painful erosions. Erosions often become large and partially covered with crusts. Some lesions on healing leave hyperpigmentation but no scarring. Pemphigus vulgaris
Slide 19-

ppt slide no 19 content not found
Slide 20-

ppt slide no 20 content not found
Slide 21-

Skin lesions Oral mucosal lesions PEMPHIGUS VULGARIS
Slide 22-

ppt slide no 22 content not found
Slide 23-

Nikolsky sign : positive Tzanck smear: Acantholytic cells
Slide 24-

Rare vegetative variant of pemphigus vulgaris. Flaccid blisters that become erosions and then form papillomatous projections especially in intertriginous areas and on scalp or face. Two subtypes: Neumann type: severe Hallopeau type: mild Pemphigus vegetans Figure: pemphigus vegetans. Extensive vegetating papillomatous lesions
Slide 25-

ppt slide no 25 content not found
Slide 26-

Patients develop scaly, crusted cutaneous erosions, often on an erythematous base. Lesions are well demarcated and have a seborrhoeic distribution, i.e. they favor the face, scalp and upper trunk No clinically apparent mucosal involvement. Patients are not severely ill. Disease may remain localized for years or it may rapidly progress, in some cases to erythrodermic exfoliative dermatitis. Pemphigus foliaceus
Slide 27-

ppt slide no 27 content not found
Slide 28-

ppt slide no 28 content not found
Slide 29-

Early disease: Scaly crusted erosions on the back Progressive disease: Lesions have become confluent PEMPHIGUS FOLIACEUS
Slide 30-

Localized variant of pemphigus foliaceus. Scaly and crusted lesions of pemphigus foliaceus appear in the malar region of face and in other ‘seborrheic’ areas. Immunologic features of both lupus erythematosus and pemphigus. In vivo IgG and C3 deposition on cell surface of keratinocytes as well as basement membrane zone, in addition to circulating antinuclear antibodies(ANA). Pemphigus erythematosus (Senear-Usher Syndrome)
Slide 31-

Associated with underlying neoplasms, both malignant and benign. Most commonly associated neoplasms are non-Hodgkin lymphoma(40%), chronic lymphocytic leukemia(30%), Castleman’s disease , thymomas, sarcomas In children and adolescents, Castleman’s disease is the most commonly associated tumor. Most constant clinical feature is intractable stomatitis. Cutaneous findings are pleomorphic and may present as macules, flaccid/tense blisters, Erythema Multiforme like lesions, lichenoid eruption. Paraneoplastic pemphigus
Slide 32-

Pemphigus erythematosus: scaly crusted erosions are seen on the nose and malar area. Paraneoplastic pemphigus: severe stomatitis extending onto vermilion lip
Slide 33-

Intraepidermal antikeratinocyte IgA vesicopustular Subcorneal pustular dermatosis (SCPD) type: Presents as flaccid vesicles or pustules on either erythematous or normal skin. Pustules tend to coalesce to form an annular or circinate pattern with crusts in the center of the lesion. Most commonly involved sites are axilla and groin. Mucus membrane involvement is rare. Pruritus is a significant symptom. IgA Pemphigus = intercellular Ig A dermatosis
Slide 34-

Intraepidermal neutrophilic (IEN) type: Presents as flaccid vesicles or pustules on either erythematous or normal skin. Pustules tend to coalesce to form an annular or circinate pattern with crusts in the center of the lesion Sunflower -like configuration of pustules is a characteristic sign of the IEN type. Most commonly involved sites are axilla and groin IgA Pemphigus
Slide 35-

Subcorneal pustular dermatosis(SCPD) type: pustules coalescing in annular or circinate pattern with central crusting. Intraepithelial neutrophilic (IEN) type: characteristic sunflower-like configuration of pustules is seen. IgA PEMPHIGUS
Slide 36-

ppt slide no 36 content not found
Slide 37-

Drugs: penicillamine captopril Radiotherapy Thermal burns Induced Pemphigus
Slide 38-

SUBEPIDERMAL IMMUNOBULLOUS DISEASES
Slide 39-

Bullous pemphigoid is an acquired non-scarring autoimmune blistering disease of the elderly age group characterized histologically by subepidermal bullae and immunopathologically by deposition of antibodies and complement along the epidermal basement membrane zone (BMZ). The median age of onset ranges from 60 to 75 years. BULLOUS PEMPHIGOID
Slide 40-

tense blisters, hemorrhagic or filled with thick fibrinous fluid, on normal appearing skin or on an erythematous base. The blisters range from vesicles to large bullae and may be seen all over the body, the commonest sites of involvement being the lower abdomen, inner thighs, groin and the flexor aspects of the limbs. The flexural and intertriginous areas are often affected. Vesicles may also develop on the palms and soles. Nikolsky’s sign is negative.
Slide 41-

For blisters that rupture, the resulting erosions and may become covered with a crust. The erosions heals without scarring, but transient pigmentary changes and milia formation can occur. Pruritus is generally present, but the degree is variable, ranging from none to intense. Mucosal lesions have been reported in 10%– 40% of patients They are often mild and transient.
Slide 42-

ppt slide no 42 content not found
Slide 43-

ppt slide no 43 content not found
Slide 44-

Mucous membrane pemphigoid (MMP) is a group of chronic inflammatory, autoimmune, subepithelial blistering diseases predominantly affecting mucous membranes and is characterized by linear deposition of IgG, IgA, or C3 along the epithelial basement membrane zone (BMZ). Scarring is the clinical hallmark, but is not always obvious, particularly in the oral mucosa. MUCOUS MEMBRANE PEMPHIGOID (SYN. CICATRICIAL PEMPHIGOID)
Slide 45-

Mucous membrane pemphigoid is a rare disease that primarily affects the elderly (the peak incidence is between the age of 60 and 80 years). It affects twice as many women as men. The onset is usually insidious. The oral mucosa is most commonly involved (approximately 85% of patients), followed by the ocular, nasal, nasopharyngeal, anogenital, skin, laryngeal, and esophageal mucosa in descending order of involvement.
Slide 46-

In the oral cavity, the gingival and palatal mucosae and less commonly the labial, glossal, and buccal mucosae are affected. There may be swollen, bright, erythematous, focal or generalized, mildly painful erosions on the gingiva (termed ‘desquamative gingivitis’) The presentation may also be as fluid- or sometimes blood-filled blisters. The lips are rarely involved.
Slide 47-

The eyes are affected in about two-thirds of patients, most often by a unilateral chronic cicatricial conjunctivitis with symptoms of burning, irritation and excessive lacrimation. Genital involvement has been observed in about 20% of cases, as blisters and erosions on the glans and prepuce or the labia. Skin lesions occur in 10%–30% of patients, and are of two types: scarring and nonscarring. Flaccid blisters develop on erythematous plaques on the head, neck and upper trunk, and heal with atrophic scars. This eruption tends to be localized and recurrent.
Slide 48-

ppt slide no 48 content not found
Slide 49-

ppt slide no 49 content not found
Slide 50-

ppt slide no 50 content not found
Slide 51-

Pemphigoid gestationis (PG), also known as herpes gestationis, is a rare autoimmune pruritic polymorphic dermatosis of pregnancy and puerperium. pemphigoid gestationis is undoubtedly under hormonal influence since it occurs only with pregnancy, menstruation, oral contraceptive ingestion, hydatidiform mole or choriocarcinoma. The PG antigen is the 180 kDa BP antigen (BP180 or BPAG2),that is present in the hemidesmosomes of the basement membrane. PEMPHIGOID GESTATIONIS
Slide 52-

PG may occur in the first or any subsequent pregnancy. It usually begins in the second or third trimester, though it can begin at any time between the first trimester and the immediate postpartum period. Intense pruritus usually accompanies but occasionally precedes a polymorphic eruption of erythematous urticarial papules and plaques, vesicles or bullae arising on inflamed or normal skin. Classically, there are erythematous urticarial plaques rimmed by blisters, and crusts that enlarge peripherally to form annular or polycyclic patterns.
Slide 53-

The eruption usually begins on the abdomen, especially around the umbilicus, or on the extremities and then spreads to the rest of the trunk, palms and soles. Facial and mucosal lesions are rare.
Slide 54-

ppt slide no 54 content not found
Slide 55-

ppt slide no 55 content not found
Slide 56-

Dermatitis herpetiformis is a rare chronic blistering skin disease characterized clinically by intensely pruritic grouped vesicles arising on an erythematous base, by granular IgA deposits in the dermal papillae on direct immunofluorescence, and associated with gluten-sensitivity and a mostly asymptomatic enteropathy. It presents most often in the second or third decades, but the disease can occasionally occur in children also. A slight male predominance has been reported. DERMATITIS HERPETIFORMIS
Slide 57-

Onset may be acute or gradual. The eruption is characteristically polymorphous, although at a given time any one type of lesion (e.g. papular, urticarial, vesicular or bullous) may predominate. The primary lesion is classically, a small vesicle on an erythematous, edematous base, or an erythematous papule, or an urticarial plaque. The vesicles may be grouped in a herpetiform manner on an erythematous plaque. Intense itching or a burning or stinging sensation is a common
Slide 58-

If the rash is chronic, there are often lichenified plaques at the sites of involvement. The areas of predilection are the elbows, knees, buttocks, sacrum, shoulders, posterior hairline and scalp. The lesions are symmetrically distributed over the extensor surfaces of the limbs. The face is occasionally affected, but the mucous membranes, only rarely.
Slide 59-

ppt slide no 59 content not found
Slide 60-

Linear IgA disease can be clinically categorized into two disorders with two distinct presentations: CBDC, which begins in childhood, and adult LAD, which begins in adult life. In children, the disease usually starts below the age of 5. The onset is usually abrupt, with large tense bullae filled with clear or hemorrhagic fluid on or near the genitalia. They gradually involve other areas such as the buttocks, scalp and face, especially the perioral and periocular areas. LINEAR IgA DISEASE
Slide 61-

Blisters may also appear in a generalized but asymmetric distribution. Typical features include herpetiform clustering of blisters, formation of bizarre, irregularly shaped bullae as they enlarge and coalesce, and ‘rosettes’ or ‘clusters of jewels’ which represent the annular arrangements of new, small, tense blisters around a crusted healing erythematous plaque (the ‘string of pearls’ sign) . Pruritus is variable in intensity. In adults, the onset may be insidious or abrupt, with symptoms varying from mild pruritus to severe pruritus and burning.
Slide 62-

There may be flexural and truncal involvement with scattered vesicles and tense blisters similar to BP. The bullae may be somewhat linear, sausage- shaped and hemorrhagic. A few patients of LAD may present with a DH like itchy eruption with grouped papulovesicles involving the extensor surfaces. Perineal and perioral involvement is less common than in children. Approximately 80% of adults and children with LAD have mucosal lesions
Slide 63-

ppt slide no 63 content not found
Slide 64-

Management includes- Investigations Treatment Treatment of Immunobullous disorders
Slide 65-

1-Routine Full blood count and differential Fasting blood sugar Liver function tests Renal function tests Chest x-ray Urinalysis INVESTIGATIONS
Slide 66-

2-Specific –for diagnosis Tzanck smear Histopathological examination DIF IIF Immunoblotting Immunoelectron microscopy ELISA
Slide 67-

The treatment of immunobullous diseases consists of three phases: control, consolidation, and maintenance. control phase- intense therapy is given to suppress disease activity until no new lesions appear. consolidation phase during which drugs and doses are maintained until complete clearance of lesions. Finally, medications can be gradually tapered in the maintenance phase, aiming for the lowest dose that prevents new lesions from appearing . TREATMENT
Slide 68-

Aim of therapy is to prevent the appearance of new lesions & produce healing of existing lesions. The choice of therapy Severity of the disease at presentation. Patient-related age general health associated medical illnesses Drug-related onset of action efficacy adverse effects cost
Slide 69-

GENERAL THERAPY PHARMACOLOGICAL THERAPY- TOPICAL SYSTEMIC TREATMENT PHASES
Slide 70-

It includes- General nursing care- Proper and regular dressing of the raw area is done until re-epithelization takes place. This is performed with sterile petroleum gauze or gauge impregnated with topical antibiotics. 2.Adequate Nutrition – Oral supplementation with protein and high calorie fluids. Soft easily chewable diet in case of oral lesions General measures
Slide 71-

3. control of secondary infection-antibiotics should be given preferably following culture and sensitivity report. 4. restoring fluid and electrolyte equilibrium
Slide 72-

Is indicated in more local oral lesion with less aggressive behaviour. Skin lesions- clobetasol propionate .05% may reduces the requirement of oral steroid. Potassium permanganate and antiseptics to reduce the risk of secondary infection. Topical therapy
Slide 73-

Oral lesions- soft diets, soft toothbrushes help to minimize local trauma. Topical analgesics or anaesthetics - benzydamine hydrochloride 0.15% (Oral Rinse) are useful in alleviating oral pain, particularly prior to eating or tooth brushing. Tooth brushing should be encouraged and antiseptic mouthwashes may be used such as - chlorhexidine gluconate 0.2% - hexetidine 0.1% -01:4 hydrogen peroxide solutions.
Slide 74-

Patients are susceptible to oral candidiasis which should be treated. Topical Corticostreoid therapy may help to reduce the requirement for systemic agents. It include application of clobetasol gel .05% Clobetasol gel may be used with occlusive vehicle mainly in desquamative gingivitis
Slide 75-

Soluble betamethasone sodium phosphate 0.5 mg tablet dissolved in 10 mL water may be used up to four times daily, holding the solution in the mouth for about 5 minutes. Isolated oral erosions could be treated with application of triamcinolone acetonide 0.1% in adhesive paste 2.5 mg hydrocortisone lozenges or sprayed directly with an asthma aerosol inhaler, for example beclomethasone dipropionate 50-200 micrograms or budesonide 50-200 micrograms.
Slide 76-

Topical ciclosporin (100 mg/mL) in oral pemphigus has been described and may be of some benefit but is expensive Tetracyclines are successful in pemphigus vulgaris and cicatricial pemphigoid Tacrolimus is indicated in oral resistant cicatricial pemphigoid
Slide 77-

Corticosteroids: Oral Pulse IV Adjuvant drugs Azathioprine Oral cyclophosphamide Pulsed cyclophosphamide and dexamethasone MMF Gold Methotrexate Ciclosporin Tetracyclin and nicotinamide Dapsone Chlorambucil SYSTEMIC THERAPY
Slide 78-

Newer treatment modalities IVIG Cholinomimetic drugs Plasma exchange Extracorporeal photophoresis Biologicals Immunoadsorption
Slide 79-

THANKS