Otoimmun Büllöz Hastalıkların Oral Mukoza Tutulumu
Özet
Otoimmün büllöz hastalıklar (OBH), deri ve/veya mukoz membranlarda otoantikor aracılı vezikül ve bül oluşumu ile karakterizedir. Bu hastalıklar ayrışmanın düzeyine göre subepitelyal bül oluşumu ile karakterize olan pemfigoid grubu hastalıklar ve intraepitelyal bül oluşumu ile karakterize olan pemfigus grubu hastalıklar olarak kabaca ikiye ayrılır. Pemfigus vulgariste oral mukoza, vakaların %70'e varan kısmında ilk etkilenen bölgedir. Özellikle friksiyon şeklindeki travmalara maruz kalan bölgelerde çok sayıda kronik ülser görülür. Paraneoplastik pemfigusun en belirgin klinik bulgusu, ağrılı stomatit, gingivit, hemorajik keilit, eritem, vezikülasyon ve erozyonlarla seyreden oral mukoza tutulumudur.
Mukoz membran pemfigoidi vakalarının %84-96'sında oral mukoza etkilenir. Hastalar mukozadaki deskuamasyona bağlı ağrı ve yutma güçlüğü şikayetiyle başvururlar. Lezyonlar başlangıçta seröz ve/veya hemorajik gergin veziküller şeklinde görünür. Büllöz pemfigoidde mukozal tutulum sıklığı, PV ve MMP gibi diğer hastalıklarla karşılaştırıldığında düşüktür. Oral büllöz lezyonlar genellikle asemptomatiktir ve geçici ülserasyonlar şeklindedir. Tanıda standart deri biyopsisi ile birlikte alınan perilezyonel biyopsinin direkt immünfloresan (DIF) mikroskopi ile analizi altın standarttır.
Tedavi zordur ve multidisipliner bir yaklaşım gerektirir. Oral mukoza hijyenine dikkat edilmesi, sigaranın bıraktırılması, acı ve baharatlı yiyeceklerden kaçınılması ve antiseptik gargaraların kullanılması gerekir. Klinik şiddetine göre topikal ve sistemik kortikosteroidler ana tedavidir. Daha şiddetli vakalarda çeşitli immünosüpresif ajanlardan da faydalanılır.
Autoimmune bullous diseases (OBD) are characterized by autoantibody-mediated vesiculation and blistering. Pemphigoids are characterized by subepithelial blistering and pemphigus group are characterized by intraepithelial blister formation. In pemphigus vulgaris, the oral mucosa is the first site affected in up to 70% of cases. Chronic ulcers are especially seen in areas exposed to friction. The most prominent clinical finding of paraneoplastic pemphigus is oral mucosal involvement with painful stomatitis, gingivitis, hemorrhagic cheilitis, erythema, vesiculation and erosions.
The oral mucosa is affected in 84-96% of mucous membrane pemphigoid cases. Patients complain of pain and difficulty swallowing. Lesions initially appear as tense serous or hemorrhagic vesicles. The frequency of mucosal involvement in bullous pemphigoid is low compared to PV and MMP. Oral lesions are usually appear as temporary ulcerations. Histopathological analysis of skin biopsy and direct immunofluorescence (DIF) microscopy is the gold standard in diagnosis.
Treatment is difficult and requires a multidisciplinary approach. It is necessary to pay attention to oral hygiene, quit smoking, avoid hot and spicy foods and use antiseptic mouthwashes. Depending on clinical severity, topical and systemic corticosteroids are the main treatment. In more severe cases, various immunosuppressive agents are also used.
Referanslar
Rashid H., Lamberts A., Diercks GF., Pas HH., Meijer JM., Bolling MC., Horváth B. Oral Lesions in Autoimmune Bullous Diseases: An Overview Of Clinical Characteristics And Diagnostic Algorithm. American Journal Of Clinical Dermatology, 2019;20:847-861.
Mustafa M B., Porter SR., Smoller BR., Sitaru C. Oral Mucosal Manifestations Of Autoimmune Skin Diseases. Autoimmunity Reviews, 2015; 14(10): 930-951.
Casiglia J., Woo SB., Ahmed AR. Oral İnvolvement İn Autoimmune Blistering Diseases. Clinics İn Dermatology,2001; 19(6):737-741.
Kasperkiewicz M, Ellebrecht CT, Takahashi H Et Al. Pemphigus. Nat Rev Dis Primers 2017; 3: 17026.
Van Beek N, Zillikens D, Schmidt E. Diagnosis Of Autoimmune Bullous Diseases. J Dtsch Dermatol Ges. 2018;16(9):1077-1091.
Schmidt E, Zillikens D. Pemphigoid Diseases. Lancet 2013; 381:320–2.
Goletz S, Zillikens D, Schmidt E. Structural Proteins Of The Dermal-Epidermal Junction Targeted By Autoantibodies in Pemphigoid Diseases. Exp Dermatol 2017;26: 1154–62.
Pollmann R., Schmidt T., Eming R., Hertl, M. Pemphigus:A Comprehensive Review On Pathogenesis, Clinical Presentation And Novel Therapeutic Approaches. Clinical Reviews İn Allergy & İmmunology 2018;54:1-25.
Ahmed AR., Blose DA. Pemphigus vegetans. Neumann type and Hallopeau type. International journal of dermatology, 1984;23(2), 135-141.
Fernández S, España A, Navedo M, Barona L. Study of oral, ear, nose and throat involvement in pemphigus vulgaris by endoscopic examination. Br J Dermatol 2012;167:1011–6.
Scully C, Paes De Almeida O, Porter SR, Gilkes JJ. Pemphigus vulgaris: the manifestations and long-term management of 55 patients with oral lesions. Br J Dermatol 1999;140:84–9.
Mignogna MD, LoMuzio L, Bucci E. Clinical features of gingival pemphigus vulgaris. J Clin Periodontol 2001;28:489–93.
Kavala M, Altıntaş S, Kocatürk E, Zindancı I, Can B, Ruhi C, et al. Ear, nose and throat involvement in patients with pemphigus vulgaris: correlation with severity, phenotype and disease activity. J Eur Acad Dermatol Venereol 2011;25:1324–7.
Sindhuja T., De D., Handa S., Goel S., Mahajan R., Kishore K. Pemphigus oral lesions intensity score (POLIS): A novel scoring system for assessment of severity of oral lesions in pemphigus vulgaris. Frontiers in Medicine, 2020;7, 449.
Ohzono A, Sogame R, Li X, Teye K, Tsuchisaka A, Numata S, et al. Clinical and immunological findings in 104 cases of paraneoplastic pemphigus. Br J Dermatol. 2015;173:1447–52.
Maruta CW., Miyamoto D., Aoki V., Carvalho RGRD., Cunha BM., Santi CG. Paraneoplastic pemphigus: a clinical, laboratorial, and therapeutic overview. Anais brasileiros de dermatologia, 2019; 94, 388-398.
Radoš J. Autoimmune blistering diseases: Histologic meaning. Clin Dermatol 2011; 29:377–88.
Kridin K., Patel PM., Jones VA., Cordova A., Amber KT. IgA pemphigus: A systematic review. Journal of the American Academy of Dermatology, 2020;82(6), 1386-1392.
Delgado JC, Turbay D, Yunis EJ, et al. A common major histocompatibility complex class II allele HLADQB10301 is present in clinical variant of pemphigoid. Proc Nat Acad Sci 1996;93:8569–71.
Risser J, Lewis K,WeinstockMA,Mortality of Bullous Skin Disorders From, Through 2002 in the United States. Arch Dermatol 1979;2009:145.
Setterfield J, Shirlaw PJ, Kerr-Muir M, Neill S, Bhogal BS, Morgan P, Et Al. Mucous Membrane Pemphigoid: A Dual Circulating Antibody Response With IgG and IgA Signifies A More Severe and Persistent Disease. Br J Dermatol 1998;138:602–10.
Chan LS, Ahmed AR, Anhalt GJ, Bernauer W, Cooper KD, Elder MJ, et al. The First International Consensus on Mucous Membrane Pemphigoid. Arch Dermatol 2002; 138.
Sadler E, Lazarova Z, Sarasombath P, Yancey KB. A widening perspective regarding the relationship between anti-epiligrin cicatricial pemphigoid and cancer. J Dermatol Sci 2007;47:1–7.
Laskaris G, Sklouvanou A, Stratigos J. Bullous pemphigoid,cicatricial pemphigoid, and pemphigus vulgaris.Oral Surg Oral Med, Oral Pathol 1982;54:656–62.
Suresh L, Neiders ME. Definitive and differential diagnosis of desquamative gingivitis through direct immunofluorescence studies. J Periodontol 2012;83:1270–8.
Chan LS. Ocular and oral mucous membrane pemphigoid (cicatricial pemphigoid). Clin Dermatol 2012;30:34–7.
Ojha J, Bhattacharyya I, Stewart C, Katz J. Cicatricial pemphigoid with severe gingival and laryngeal involvement in an 18-year-old female. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:363–7.
Suresh L, Kumar V. Significance of IgG4 in the diagnosis of mucous membrane pemphigoid. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104: 359–62.
Lings K, Bygum A. Linear IgA bullous dermatosis: a retrospective study of 23 patients in Denmark. Acta Derm Venereol. 2015;95:466–71.
Horiguchi Y, Ikoma A, Sakai R, Masatsugu A, Ohta M, Hashimoto T. Linear IgA dermatosis: report of an infantile case and analysis of 213 cases in Japan. J Dermatol 2008;35:737–43
Fortuna G, Marinkovich MP. Linear immunoglobulin A bullous dermatosis. Clin Dermatol 2012;30:38–50.
Khan I, Hughes R, Curran S, Marren P. Drug-associated linear IgA disease mimicking toxic epidermal necrolysis. Clin Exp Dermatol 2009;34:715–7.
Wojnarowska F, Marsden RA, Bhogal B, Black MM. Chronic bullous disease of childhood, childhood cicatricial pemphigoid, and linear IgA disease of adults: a comparative study demonstrating clinical and immunopathologic overlap. J Am Acad Dermatol. 1988;19:792–805.
Eguia del Valle A, Aguirre Urízar JM, Martínez Sahuquillo A. Oral manifestations caused by the linear IgA disease. Med Oral 2004;9:39–44.
Csorba K, Schmidt S, Florea F, Ishii N, Hashimoto T, Hertl M, et al. Development of an ELISA for sensitive and specific detection of IgA autoantibodies against BP180 in pemphigoid diseases. Orphanet J Rare Dis 2011;6:31.
Miyamoto D, Santi CG, Aoki V, Maruta CW. Bullous pemphigoid. An Bras Dermatol. 2019 Mar-Apr;94(2):133-146.
Budimir J, Mihić LL, Situm M, Bulat V, Persić S, Tomljanović-Veselski M. Oral lesions in patients with pemphigus vulgaris and bullous pemphigoid. Acta Clin Croat 2008; 47:13–8.
Otten JV, Hashimoto T, Hertl M, Payne AS, Sitaru C. Molecular diagnosis in autoimmune skin blistering conditions. Curr Mol Med 2014;14:69–95.
Schmidt E, Zillikens D. Pemphigoid diseases. Lancet. 2013;381:320-32.
Ramos-e-SilvaM, Ferreira A, Jacques C de-Moura-Castro. Oral involvement in autoimmune bullous diseases. Clin Dermatol 2011;29:443–54.
Ishii N, Hamada T, Dainichi T, et al. Epidermolysis bullous acquisita: what's new. J Dermatol 2010;37:220-30.
Clarindo MV, Possebon AT, Soligo EM, Uyeda H, Ruaro RT, Empinotti JC. Dermatitis herpetiformis: pathophysiology, clinical presentation, diagnosis and treatment. An Bras Dermatol 2014;89:865–75.
West J, Fleming KM, Tata LJ, Card TR, Crooks CJ. Incidence and prevalence of celiac disease and dermatitis herpetiformis in the UK over two decades: population based study. Am J Gastroenterol 2014;109:757–68.
Luke MC, Darling TN, Hsu R, et al. Mucosal morbidity in patients with epidermolysis bullosa acquisita. Arch Dermatol 1999;135: 954-9.
Aine L, Mäki M, Reunala T. Coeliac-type dental enamel defects in patients with dermatitis herpetiformis. Acta Derm Venereol 1992;72:25-7.
Mendes FBR, Hissa-Elian A, de Abreu MAMM, Gonçalves VS. Review: dermatitis herpetiformis. An Bras Dermatol 2013;88:594–9.
González-Moles MA, Scully C. Vesiculo-erosive oral mucosal disease–management with topical corticosteroids: (1) Fundamental principles and specific agents available. J Dent Res 2005;84:294–301.
Cheng S, Kirtschig G, Cooper S, Thornhill M, Leonardi-Bee J, Murphy R. Interventions for erosive lichen planus affecting mucosal sites. Cochrane Database Syst Rev 2012;2.
Eisen D, Ellis CN, Voorhees JJ. Topical cyclosporine for oral bullous disorders. J Am Acad Dermatol 1990;23:936–7.
Vincent SD, Lilly G, Baker KA. Clinical, historic, and therapeutic features of cicatricial pemphigoid. Oral Surg Oral Med Oral Pathol 1993;76:453–9.
Lozada-Nur F, Miranda C, Maliksi M. Double-blind clinical trial of 0.05% clobetasol proprionate ointment in orabase and 0.05% fluocinonide ointment in orabase in the treatment of patients with oral vesiculoerosive diseases. Oral Surg Oral Med Oral Pathol 1994;77:598–604.
González-Moles MA, Scully C. Vesiculo-erosive oral mucosal disease–management with topical corticosteroids: (2) Protocols, monitoring of effects and adverse reactions, and the future. J Dent Res 2005;84:302–8.
Lee HY, Blazek C, Beltraminelli H, Borradori L. Oral mucous membrane pemphigoid: complete response to topical tacrolimus. Acta Derm Venereol 2011;91:604–5.
Han A. A practical approach to treating autoimmune bullous disorders with systemic medications. J Clin Aesthet Dermatol. 2009 May;2(5):19-28.
Culton DA, Diaz LA. Treatment of subepidermal immunobullous diseases. Clin Dermatol 2012;30:95–102.
Harman KE, Albert S, Black MM, Association British, of Dermatologists, Guidelines for the management of pemphigus vulgaris. Br J Dermatol 2003;149:926–37.
Younger IR, Harris WS, Colver GB. Azathioprine in dermatology. J Am Acad Dermatol. 1991;25:281–286.
Cockburn I. Assessment of the risks of malignancy and lymphoma developing in patients using Sandimmune. Transplant Proc. 1987;19:1804–1807.
Wolverton SE. Systemic corticosteroids. In: Wolverton SE, editor. Comprehensive Dermatologic Drug Therapy. Philadelphia: WB Saunders; 2001. pp. 109–138.
Ahmed AR, Hombal SM. Cyclophosphamide (Cytoxan): a review on relevant pharmacology and clinical uses. J Am Acad Dermatol. 1984;11(6):1115–1126.
Roenigk HH, Jr., Auerbach R, Maibach H, Weinstein G, Lebwohl M. Methotrexate in psoriasis: consenses conference. J Am Acad Dermatol. 1998;38:478–485.
Kneisel A, Hertl M. Autoimmune bullous skin diseases. Part 2: diagnosis and therapy. J Dtsch Dermatol Ges 2011;9:927–47.
Referanslar
Rashid H., Lamberts A., Diercks GF., Pas HH., Meijer JM., Bolling MC., Horváth B. Oral Lesions in Autoimmune Bullous Diseases: An Overview Of Clinical Characteristics And Diagnostic Algorithm. American Journal Of Clinical Dermatology, 2019;20:847-861.
Mustafa M B., Porter SR., Smoller BR., Sitaru C. Oral Mucosal Manifestations Of Autoimmune Skin Diseases. Autoimmunity Reviews, 2015; 14(10): 930-951.
Casiglia J., Woo SB., Ahmed AR. Oral İnvolvement İn Autoimmune Blistering Diseases. Clinics İn Dermatology,2001; 19(6):737-741.
Kasperkiewicz M, Ellebrecht CT, Takahashi H Et Al. Pemphigus. Nat Rev Dis Primers 2017; 3: 17026.
Van Beek N, Zillikens D, Schmidt E. Diagnosis Of Autoimmune Bullous Diseases. J Dtsch Dermatol Ges. 2018;16(9):1077-1091.
Schmidt E, Zillikens D. Pemphigoid Diseases. Lancet 2013; 381:320–2.
Goletz S, Zillikens D, Schmidt E. Structural Proteins Of The Dermal-Epidermal Junction Targeted By Autoantibodies in Pemphigoid Diseases. Exp Dermatol 2017;26: 1154–62.
Pollmann R., Schmidt T., Eming R., Hertl, M. Pemphigus:A Comprehensive Review On Pathogenesis, Clinical Presentation And Novel Therapeutic Approaches. Clinical Reviews İn Allergy & İmmunology 2018;54:1-25.
Ahmed AR., Blose DA. Pemphigus vegetans. Neumann type and Hallopeau type. International journal of dermatology, 1984;23(2), 135-141.
Fernández S, España A, Navedo M, Barona L. Study of oral, ear, nose and throat involvement in pemphigus vulgaris by endoscopic examination. Br J Dermatol 2012;167:1011–6.
Scully C, Paes De Almeida O, Porter SR, Gilkes JJ. Pemphigus vulgaris: the manifestations and long-term management of 55 patients with oral lesions. Br J Dermatol 1999;140:84–9.
Mignogna MD, LoMuzio L, Bucci E. Clinical features of gingival pemphigus vulgaris. J Clin Periodontol 2001;28:489–93.
Kavala M, Altıntaş S, Kocatürk E, Zindancı I, Can B, Ruhi C, et al. Ear, nose and throat involvement in patients with pemphigus vulgaris: correlation with severity, phenotype and disease activity. J Eur Acad Dermatol Venereol 2011;25:1324–7.
Sindhuja T., De D., Handa S., Goel S., Mahajan R., Kishore K. Pemphigus oral lesions intensity score (POLIS): A novel scoring system for assessment of severity of oral lesions in pemphigus vulgaris. Frontiers in Medicine, 2020;7, 449.
Ohzono A, Sogame R, Li X, Teye K, Tsuchisaka A, Numata S, et al. Clinical and immunological findings in 104 cases of paraneoplastic pemphigus. Br J Dermatol. 2015;173:1447–52.
Maruta CW., Miyamoto D., Aoki V., Carvalho RGRD., Cunha BM., Santi CG. Paraneoplastic pemphigus: a clinical, laboratorial, and therapeutic overview. Anais brasileiros de dermatologia, 2019; 94, 388-398.
Radoš J. Autoimmune blistering diseases: Histologic meaning. Clin Dermatol 2011; 29:377–88.
Kridin K., Patel PM., Jones VA., Cordova A., Amber KT. IgA pemphigus: A systematic review. Journal of the American Academy of Dermatology, 2020;82(6), 1386-1392.
Delgado JC, Turbay D, Yunis EJ, et al. A common major histocompatibility complex class II allele HLADQB10301 is present in clinical variant of pemphigoid. Proc Nat Acad Sci 1996;93:8569–71.
Risser J, Lewis K,WeinstockMA,Mortality of Bullous Skin Disorders From, Through 2002 in the United States. Arch Dermatol 1979;2009:145.
Setterfield J, Shirlaw PJ, Kerr-Muir M, Neill S, Bhogal BS, Morgan P, Et Al. Mucous Membrane Pemphigoid: A Dual Circulating Antibody Response With IgG and IgA Signifies A More Severe and Persistent Disease. Br J Dermatol 1998;138:602–10.
Chan LS, Ahmed AR, Anhalt GJ, Bernauer W, Cooper KD, Elder MJ, et al. The First International Consensus on Mucous Membrane Pemphigoid. Arch Dermatol 2002; 138.
Sadler E, Lazarova Z, Sarasombath P, Yancey KB. A widening perspective regarding the relationship between anti-epiligrin cicatricial pemphigoid and cancer. J Dermatol Sci 2007;47:1–7.
Laskaris G, Sklouvanou A, Stratigos J. Bullous pemphigoid,cicatricial pemphigoid, and pemphigus vulgaris.Oral Surg Oral Med, Oral Pathol 1982;54:656–62.
Suresh L, Neiders ME. Definitive and differential diagnosis of desquamative gingivitis through direct immunofluorescence studies. J Periodontol 2012;83:1270–8.
Chan LS. Ocular and oral mucous membrane pemphigoid (cicatricial pemphigoid). Clin Dermatol 2012;30:34–7.
Ojha J, Bhattacharyya I, Stewart C, Katz J. Cicatricial pemphigoid with severe gingival and laryngeal involvement in an 18-year-old female. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:363–7.
Suresh L, Kumar V. Significance of IgG4 in the diagnosis of mucous membrane pemphigoid. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104: 359–62.
Lings K, Bygum A. Linear IgA bullous dermatosis: a retrospective study of 23 patients in Denmark. Acta Derm Venereol. 2015;95:466–71.
Horiguchi Y, Ikoma A, Sakai R, Masatsugu A, Ohta M, Hashimoto T. Linear IgA dermatosis: report of an infantile case and analysis of 213 cases in Japan. J Dermatol 2008;35:737–43
Fortuna G, Marinkovich MP. Linear immunoglobulin A bullous dermatosis. Clin Dermatol 2012;30:38–50.
Khan I, Hughes R, Curran S, Marren P. Drug-associated linear IgA disease mimicking toxic epidermal necrolysis. Clin Exp Dermatol 2009;34:715–7.
Wojnarowska F, Marsden RA, Bhogal B, Black MM. Chronic bullous disease of childhood, childhood cicatricial pemphigoid, and linear IgA disease of adults: a comparative study demonstrating clinical and immunopathologic overlap. J Am Acad Dermatol. 1988;19:792–805.
Eguia del Valle A, Aguirre Urízar JM, Martínez Sahuquillo A. Oral manifestations caused by the linear IgA disease. Med Oral 2004;9:39–44.
Csorba K, Schmidt S, Florea F, Ishii N, Hashimoto T, Hertl M, et al. Development of an ELISA for sensitive and specific detection of IgA autoantibodies against BP180 in pemphigoid diseases. Orphanet J Rare Dis 2011;6:31.
Miyamoto D, Santi CG, Aoki V, Maruta CW. Bullous pemphigoid. An Bras Dermatol. 2019 Mar-Apr;94(2):133-146.
Budimir J, Mihić LL, Situm M, Bulat V, Persić S, Tomljanović-Veselski M. Oral lesions in patients with pemphigus vulgaris and bullous pemphigoid. Acta Clin Croat 2008; 47:13–8.
Otten JV, Hashimoto T, Hertl M, Payne AS, Sitaru C. Molecular diagnosis in autoimmune skin blistering conditions. Curr Mol Med 2014;14:69–95.
Schmidt E, Zillikens D. Pemphigoid diseases. Lancet. 2013;381:320-32.
Ramos-e-SilvaM, Ferreira A, Jacques C de-Moura-Castro. Oral involvement in autoimmune bullous diseases. Clin Dermatol 2011;29:443–54.
Ishii N, Hamada T, Dainichi T, et al. Epidermolysis bullous acquisita: what's new. J Dermatol 2010;37:220-30.
Clarindo MV, Possebon AT, Soligo EM, Uyeda H, Ruaro RT, Empinotti JC. Dermatitis herpetiformis: pathophysiology, clinical presentation, diagnosis and treatment. An Bras Dermatol 2014;89:865–75.
West J, Fleming KM, Tata LJ, Card TR, Crooks CJ. Incidence and prevalence of celiac disease and dermatitis herpetiformis in the UK over two decades: population based study. Am J Gastroenterol 2014;109:757–68.
Luke MC, Darling TN, Hsu R, et al. Mucosal morbidity in patients with epidermolysis bullosa acquisita. Arch Dermatol 1999;135: 954-9.
Aine L, Mäki M, Reunala T. Coeliac-type dental enamel defects in patients with dermatitis herpetiformis. Acta Derm Venereol 1992;72:25-7.
Mendes FBR, Hissa-Elian A, de Abreu MAMM, Gonçalves VS. Review: dermatitis herpetiformis. An Bras Dermatol 2013;88:594–9.
González-Moles MA, Scully C. Vesiculo-erosive oral mucosal disease–management with topical corticosteroids: (1) Fundamental principles and specific agents available. J Dent Res 2005;84:294–301.
Cheng S, Kirtschig G, Cooper S, Thornhill M, Leonardi-Bee J, Murphy R. Interventions for erosive lichen planus affecting mucosal sites. Cochrane Database Syst Rev 2012;2.
Eisen D, Ellis CN, Voorhees JJ. Topical cyclosporine for oral bullous disorders. J Am Acad Dermatol 1990;23:936–7.
Vincent SD, Lilly G, Baker KA. Clinical, historic, and therapeutic features of cicatricial pemphigoid. Oral Surg Oral Med Oral Pathol 1993;76:453–9.
Lozada-Nur F, Miranda C, Maliksi M. Double-blind clinical trial of 0.05% clobetasol proprionate ointment in orabase and 0.05% fluocinonide ointment in orabase in the treatment of patients with oral vesiculoerosive diseases. Oral Surg Oral Med Oral Pathol 1994;77:598–604.
González-Moles MA, Scully C. Vesiculo-erosive oral mucosal disease–management with topical corticosteroids: (2) Protocols, monitoring of effects and adverse reactions, and the future. J Dent Res 2005;84:302–8.
Lee HY, Blazek C, Beltraminelli H, Borradori L. Oral mucous membrane pemphigoid: complete response to topical tacrolimus. Acta Derm Venereol 2011;91:604–5.
Han A. A practical approach to treating autoimmune bullous disorders with systemic medications. J Clin Aesthet Dermatol. 2009 May;2(5):19-28.
Culton DA, Diaz LA. Treatment of subepidermal immunobullous diseases. Clin Dermatol 2012;30:95–102.
Harman KE, Albert S, Black MM, Association British, of Dermatologists, Guidelines for the management of pemphigus vulgaris. Br J Dermatol 2003;149:926–37.
Younger IR, Harris WS, Colver GB. Azathioprine in dermatology. J Am Acad Dermatol. 1991;25:281–286.
Cockburn I. Assessment of the risks of malignancy and lymphoma developing in patients using Sandimmune. Transplant Proc. 1987;19:1804–1807.
Wolverton SE. Systemic corticosteroids. In: Wolverton SE, editor. Comprehensive Dermatologic Drug Therapy. Philadelphia: WB Saunders; 2001. pp. 109–138.
Ahmed AR, Hombal SM. Cyclophosphamide (Cytoxan): a review on relevant pharmacology and clinical uses. J Am Acad Dermatol. 1984;11(6):1115–1126.
Roenigk HH, Jr., Auerbach R, Maibach H, Weinstein G, Lebwohl M. Methotrexate in psoriasis: consenses conference. J Am Acad Dermatol. 1998;38:478–485.
Kneisel A, Hertl M. Autoimmune bullous skin diseases. Part 2: diagnosis and therapy. J Dtsch Dermatol Ges 2011;9:927–47.
