Abstract Autoimmune bullous dermatoses are a heterogeneous group of diseases with autoantibodies against structural skin proteins. Although the occurrence of autoimmune bullous dermatoses during pregnancy is low, this topic deserves attention, since the immunological and hormonal alterations that occur during this period can produce alterations during the expected course of these dermatoses. The authors review the several aspects of autoimmune bullous dermatoses that affect pregnant women, including the therapeutic approach during pregnancy and breastfeeding. Gestational pemphigoid, a pregnancy-specific bullous disease, was not studied in this review.

Abstract Plasmacytoid dendritic cells are part of the dendritic cells family and are a relevant link between innate and adaptive immunity. They are the most potent producers of type 1 interferon, generating antiviral response, stimulating macrophages and dendritic cells and inducing activation and migration of natural killer cells. Plasmacytoid dendritic cells also exert a role as antigen-presenting cells, promote T-lymphocyte responses, immunoregulation, plasma cells differentiation and antibody secretion. Even though plasmacytoid dendritic cells are not usually present in normal skin, their presence is detected in healing processes, viral infections, and inflammatory, autoimmune, and neoplastic diseases. In recent years, the presence of plasmacytoid dendritic cells in several dermatological diseases has been described, enhancing their potential role in the pathogenesis of such conditions. Future studies on the role of plasmacytoid dendritic cells in dermatology may lead to new therapeutic targets.

Abstract Eosinophilic spongiosis is a histological feature shared by some distinct inflammatory disorders, and is characterized by the presence of intraepidermal eosinophils associated with spongiosis. Most often, isolated eosinophilic spongiosis indicates the early stages of a subjacent autoimmune bullous dermatosis, such as the pemphigus group and bullous pemphigoid. Herein, the main causes of eosinophilic spongiosis are discussed, as well as the supplementary investigation needed to elucidate its etiology.

Abstract: Paraneoplastic pemphigus is a rare and severe autoimmune blistering disease characterized by mucocutaneous lesions associated with benign and malignant neoplasms. Diagnostic criteria include the presence of chronic mucositis and polymorphic cutaneous lesions with occult or confirmed neoplasia; histopathological analysis exhibiting intraepidermal acantholysis, necrotic keratinocytes, and vacuolar interface dermatitis; direct immunofluorescence with intercellular deposits (IgG and C3) and at the basement membrane zone (IgG); indirect immunofluorescence with intercellular deposition of IgG (substrates: monkey esophagus and simple, columnar, and transitional epithelium); and, autoreactivity to desmogleins 1 and 3, desmocollins 1, 2, and 3, desmoplakins I and II, envoplakin, periplakin, epiplakin, plectin, BP230, and α-2-macroglobulin-like protein 1. Neoplasias frequently related to paraneoplastic pemphigus include chronic lymphocytic leukemia, non-Hodgkin lymphoma, carcinomas, Castleman disease, thymoma, and others. Currently, there is no standardized treatment for paraneoplastic pemphigus. Systemic corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, rituximab, cyclophosphamide, plasmapheresis, and intravenous immunoglobulin have been used, with variable outcomes. Reported survival rates in 1, 2, and 5 years are 49%, 41%, and 38%, respectively.

Abstract: Bullous pemphigoid is the most frequent autoimmune bullous disease and mainly affects elderly individuals. Increase in incidence rates in the past decades has been attributed to population aging, drug-induced cases and improvement in the diagnosis of the nonbullous presentations of the disease. A dysregulated T cell immune response and synthesis of IgG and IgE autoantibodies against hemidesmosomal proteins (BP180 and BP230) lead to neutrophil chemotaxis and degradation of the basement membrane zone. Bullous pemphigoid classically manifests with tense blisters over urticarial plaques on the trunk and extremities accompanied by intense pruritus. Mucosal involvement is rarely reported. Diagnosis relies on (1) the histopathological evaluation demonstrating eosinophilic spongiosis or a subepidermal detachment with eosinophils; (2) the detection of IgG and/or C3 deposition at the basement membrane zone using direct or indirect immunofluorescence assays; and (3) quantification of circulating autoantibodies against BP180 and/or BP230 using ELISA. Bullous pemphigoid is often associated with multiple comorbidities in elderly individuals, especially neurological disorders and increased thrombotic risk, reaching a 1-year mortality rate of 23%. Treatment has to be tailored according to the patient's clinical conditions and disease severity. High potency topical steroids and systemic steroids are the current mainstay of therapy. Recent randomized controlled studies have demonstrated the benefit and safety of adjuvant treatment with doxycycline, dapsone and immunosuppressants aiming a reduction in the cumulative steroid dose and mortality.

Abstract: Background: Urticarias are frequent diseases, with 15% to 20% of the population presenting at least one acute episode in their lifetime. Urticaria are classified in acute ( ≤ 6 weeks) or chronic (> 6 weeks). They may be induced or spontaneous. Objectives: To verify the diagnostic and therapeutic recommendations in chronic spontaneous urticaria (CSU), according to the experience of Brazilian experts, regarding the available guidelines (international and US). Methods: A questionnaire was sent to Brazilian experts, with questions concerning diagnostic and therapeutic recommendations for CSU in adults. Results: Sixteen Brazilian experts answered the questionnaire related to diagnosis and therapy of CSU in adults and data were analyzed. Final text was written, considering the available guidelines (International and US), adapted to the medical practices in Brazil. Diagnostic work up in CSU is rarely necessary. Biopsy of skin lesion and histopathology may be indicated to rule out other diseases, such as, urticarial vasculitis. Other laboratory tests, such as complete blood count, CRP, ESR and thyroid screening. Treatment of CSU includes second-generation anti-histamines (sgAH) at licensed doses, sgAH two, three to fourfold doses (non-licensed) and omalizumab. Other drugs, such as, cyclosporine, immunomodulatory drugs and immunosuppressants may be indicated (non-licensed and with limited scientific evidence). Conclusions: Most of the Brazilian experts in this study partially agreed with the diagnostic and therapeutic recommendations of the International and US guidelines. They agreed with the use of sgAH at licensed doses. Increase in the dose to fourfold of sgAH may be suggested with restrictions, due to its non-licensed dose. Sedating anti-histamines, as suggested by the US guideline, are indicated by some of the Brazilian experts, due to its availability. Adaptations are mandatory in the treatment of CSU, due to scarce or lack of other therapeutic resources in the public health system in Brazil, such as omalizumab or cyclosporine.

Chronic urticaria has been explored in several investigative aspects in the new millennium, either as to its pathogenesis, its stand as an autoimmune or auto-reactive disease, the correlation with HLA-linked genetic factors, especially with class II or its interrelation with the coagulation and fibrinolysis systems. New second-generation antihistamines, which act as good symptomatic drugs, emerged and were commercialized over the last decade. Old and new drugs that may interfere with the pathophysiology of the disease, such as cyclosporine and omalizumab have been developed and used as treatments. The purpose of this article is to describe the current state of knowledge on aspects of chronic urticaria such as, pathophysiology, diagnosis and the current therapeutic approach proposed in the literature.

FUNDAMENTOS: Tem sido demonstrado que os neutrófilos, eosinófilos e monócitos, sob estímulo apropriado, podem expressar fator tecidual e, portanto, ativar a via extrínseca da coagulação. Realizamos um estudo transversal e caso-controle de pacientes com urticária crônica e pacientes com psoríase em nosso ambulatório para avaliar a produção de dímero-D. OBJETIVO: Avaliar níveis de dímero-D em pacientes com urticária crônica e sua possível correlação com a atividade da doença. PACIENTES E MÉTODOS: O estudo foi conduzido de outubro de 2010 até março de 2011. Nós selecionamos 37 pacientes consecutivos da Unidade de Alergia e Unidade de Psoríase, divididos em três grupos para análise estatística: (i) 12 pacientes com urticária crônica ativa; (ii) 10 pacientes com urticária crônica em remissão e (iii) 15 pacientes com psoríase (uma doença com a pele infiltrado inflamatório constituído por neutrófilos, linfócitos e monócitos). Outros cinco pacientes com vasculite urticariforme foram alocados em nosso estudo, mas não incluídos na análise estatística. Os níveis séricos de D-dímero foram medidos por Enzyme Linked Fluorescent Assay (ELFA), e os resultados foram medidos em ng / ml FEU. RESULTADOS: Os pacientes com urticária crônica ativa tinham níveis séricos mais altos de dímero-D (p <0,01), quando comparados aos pacientes com urticária crônica em remissão e ao grupo controle (pacientes com psoríase). CONCLUSÕES: Os pacientes com urticária crônica ativa têm níveis séricos mais elevados de dímero-D, quando comparados aos pacientes com urticária crônica em remissão e aos pacientes com psoríase. Encontramos níveis elevados de dímero-D entre os pacientes com vasculite urticariforme.

BACKGROUND: It has been demonstrated that neutrophils, eosinophils and monocytes, under appropriated stimulus, may express tissue factor and therefore, activate the extrinsic pathway of coagulation. We performed a transversal and case-control study of patients with chronic urticaria and patients with psoriasis, in our outpatient clinic to evaluate the production of D-dimer. OBJECTIVE: To evaluate D-dimer serum levels in patients with chronic urticaria and its possible correlation with disease activity. PATIENTS AND METHODS: The study was conducted from October 2010 until March 2011. We selected 37 consecutive patients from our Allergy Unit and Psoriasis Unit, and divided them into three groups for statistical analysis: (i) 12 patients with active chronic urticaria (CU); (ii) 10 patients with chronic urticaria under remission and (iii) 15 patients with psoriasis (a disease with skin inflammatory infiltrate constituted by neutrophils, lymphocytes and monocytes). Another five patients with urticarial vasculitis were allocated in our study, but not included in statistical analysis. The serum levels of D-dimer were measured by Enzyme Linked Fluorescent Assay (ELFA), and the result units were given in ng/ml FEU. RESULTS: Patients with active chronic urticaria had the highest serum levels of D-dimer (p<0.01), when compared to patients with CU under remission and the control group (patients with psoriasis). CONCLUSIONS: Patients with active chronic urticaria have higher serum levels of D-dimer, when compared to patients with chronic urticaria under remission and patients with psoriasis. We found elevated serum levels of D-dimer among patients with urticarial vasculitis.

INTRODUCTION: Pemphigoid gestationis, also known as herpes gestationis, is a rare autoimmune blistering disease associated with pregnancy. It usually occurs during the second or third trimester, but it may be present at any stage of pregnancy or the puerperium. The clinical, histologic, and immunopathological features of pemphigoid gestationis are similar to those of the pemphigoid group of disorders. METHODS: We hereby report seven patients who were diagnosed with pemphigoid gestationis and followed at the Autoimmune Blistering Disease Clinic in the Department of Dermatology of the University of Sao Paulo Medical School between 1996 and 2008. DISCUSSION: Demographic and clinical findings, such as median age, sites of involvement, and gestational age of onset of our patients, coincide with those described in previous reports. The majority of patients (85%) exhibited complement C3 or C3 and immunoglobulin G (IgG) deposition along the basement membrane zone (BMZ) on immunofluorescence. Herpes gestationis factor (HG) factor was postitive in four out of six patients (67%), and three out of five patients recognized the bullous pemphigoid recombinant antigen (BP180) by ELISA. CONCLUSION: This study revealed a good outcome of the newborns from pemphigoid gestationis affected mothers, based on the absence of pemphigoid gestationis cutaneous lesions, mean birth weight, and normal Apgar scores and gestational age at birth.

Os pênfigos são dermatoses bolhosas auto-imunes, em que há a produção de auto-anticorpos direcionados contra moléculas de adesão dos epitélios, levando à perda da coesão celular. A produção de auto-anticorpos ocorre quando os pacientes desenvolvem um desequilíbrio da resposta imune (quebra da tolerância imunológica), passando a reconhecer antígenos próprios. A resposta é geralmente direcionada contra um único epítopo alvo; entretanto, como conseqüência da resposta inflamatória do processo primário e do extenso dano tecidual ocasionado, pode haver exposição de componentes protéicos ocultos, levando à produção de diferentes auto-anticorpos. Assim, é possível que surja uma nova doença cutânea auto-imune, em decorrência do fenômeno intra ou intermolecular de epitope spreading. São revistos os principais conceitos desse fenômeno e sua ocorrência nas dermatoses bolhosas auto-imunes, com ênfase nos pênfigos, grupo de dermatoses bolhosas autoimunes mais prevalente no Brasil.

Pemphigus comprises autoimmune blistering skin diseases in which autoantibodies directed against antigens (epithelial adhesion molecules) are found, leading to loss of cell cohesion. The production of autoantibodies occurs due to an immune imbalance (break of immune tolerance) driving to recognition of self- antigens. The response is usually directed against an exclusive target epitope; however, due to the inflammatory response and to the extensive tissue damage, it is possible that the exposure of hidden protein components leads to distinct autoantibody production. Hence, a new autoimmune disease may occur in consequence of an intra- or intermolecular epitope spreading phenomenon. The authors review the main concepts of this phenomenon, and its occurrence in autoimmune blistering diseases, with emphasis on pemphigus, the most prevalent disease of this group in our country.

FUNDAMENTO: O diagnóstico da alergia ao níquel é estabelecido com a realização do teste de contato. OBJETIVO: Desenvolver um método diagnóstico mais sensível e específico. CASUÍSTICAS E MÉTODOS: Dezenove pacientes com teste de contato positivo para o níquel e 25 controles foram submetidos ao teste da proliferação linfocitária. As células mononucleadas foram isoladas do sangue venoso periférico e cultivadas em triplicatas, em placas de cultura (2x10(5) células/orifício) com: meio de cultura apenas; sulfato de níquel (156,25; 78,13; 19,53; 9,77 e 2,44µM) e concentrações ideais do antígeno Candida albicans e dos mitógenos pokeweed, fito-hemaglutinina A e anticorpo anti-CD3 (OKT3). Timidina tritiada foi adicionada às placas, a radioatividade incorporada pelas células medida e os resultados expressos pelo índice de estimulação (IE). RESULTADOS: A resposta proliferativa dos linfócitos dos casos foi superior à dos controles em todas as concentrações de níquel testadas. Considerando teste positivo para níquel quando IE > 3, nenhum dos controles e 16 (84,21%) dos casos apresentaram teste positivo em pelo menos uma das cinco concentrações usadas. As respostas à Candida albicans e aos mitógenos foram semelhantes nos casos e controles, demonstrando a integridade da imunidade celular em ambos os grupos. CONCLUSÃO: O teste da proliferação linfocitária mostra-se útil no diagnóstico da alergia ao níquel.

BACKGROUND: The diagnosis of nickel sensitivity is made by epicutaneous patch testing. OBJECTIVE: To develop a more sensitive and specific test. PATIENTS AND METHODS: Nineteen patients with positive patch test reactions to nickel and 25 controls were submitted to lymphocyte proliferation test. Mononuclear cells were isolated from peripheral venous blood and cultivated in triplicate in culture plates (2x10(5) cells/well) with: culture medium only, nickel sulfate (156.25; 78.13; 19.53; 9.77 and 2.44µM) and optimal concentrations of Candida albicans antigen as well as pokeweed, phytohemagglutinin A and anti-CD3 antibody (OKT3) mitogens. Tritiated thymidine was added to plates, radioactivity incorporated by cells was measured and the results expressed by the stimulation index (SI). RESULTS: The lymphocyte proliferative response was higher in cases than in controls in all nickel concentrations tested. Considering positive test reactions when SI > 3, none of the controls and 16 (84.21%) cases were positive in at least one of five concentrations used. The proliferative responses to Candida albicans and mitogens were similar in cases and controls, demonstrating normal cellular immunity in both groups. CONCLUSION: The lymphocyte proliferation test is useful in diagnosis of nickel sensitivity.

O acometimento ungueal no pênfigo vulgar é um achado raro. Descrevemos cinco doentes com pênfigo vulgar e alterações ungueais. As alterações ungueais descritas no pênfigo vulgar são, em ordem decrescente de ocorrência: paroníquia crônica, onicomadese, onicólise, linhas de Beau e traqueoníquia. Paroníquia crônica foi a forma de acometimento ungueal encontrada em todos os doentes deste estudo e um deles apresentou, também, linhas de Beau. As manifestações cutâneo-mucosas e ungueais foram controladas, em todos os casos, com o uso de prednisona e/ou ciclofosfamida.

Nail involvement in pemphigus vulgaris is rare. We describe 5 patients with pemphigus vulgaris presenting nail involvement. In this disease, nail manifestations present, by order of frequency, as chronic paronychia, onychomadesis, onycholysis, Beau's lines and trachyonychia. All our 5 cases presented with paronychia, and 1 of them also had Beau's lines. Treatment with prednisone and/or cyclophosphamide controlled mucocutaneous and nail manifestations in all cases.