Case Report: Coexistence of bullous pemphigoid and psoriasis: Therapeutic challenge and IL17A-targeted parallel treatment strategy

Abstract

Autoimmune blistering diseases of the skin have all been reported in patients with psoriasis, bullous pemphigoid (BP) being the most frequently observed. The pathophysiologic triggers for BP in psoriatic patients are unclear. Recent observational studies have suggested that chronic psoriatic inflammation may cause pathological changes to the basement membrane zone, thus inducing autoimmunity against BP antigens through cross reactivity and "epitope spreading." The coexistence of BP and psoriasis poses challenging therapeutic dilemmas related to the incompatibility of their standard treatments. Considering the probable common immunologic mechanisms in the pathogenesis of these inflammatory skin disorders, a suitable treatment regimen should be applied for their parallel control. We report three patients, who developed BP in the course of preceding long-lasting psoriasis. Secukinumab was administered as first-line treatment with promising therapeutic effect for both skin disorders and long-term disease control in two of the cases. In the third case, parallel disease control was initially achieved with methotrexate. A few years later, secukinumab was used for the treatment of a relapse of both dermatoses but worsening of BP was observed and methotrexate was reintroduced. Our experience on the therapeutic potential of secukinumab in BP is supported by the data in the literature. Recently, it was demonstrated that the proinflammatory cytokine IL17A has a functional role in the process of skin inflammation in BP, similarly to psoriasis. IL17A inhibition has emerged as a promising therapeutic strategy in patients with extensive or refractory BP but paradoxical development of BP after secukinumab treatment for psoriasis has also been described. This controversy emphasizes the need for further investigation into the development of optimal treatment strategies and recommendations.

Keywords: IL17A; biologics; bullous pemphigoid; psoriasis; secukinumab; treatment strategies.

FIGURE 1

Clinical, histological and immunofluorescent findings in patient 1: (a–c) Figurate and confluent psoriatic plaques with multiple tense blisters and crusted erosions on healthy and psoriatic skin; (d) histology from psoriatic plaque with abundant eosinophil infiltrate; (e) subepidermal clefting with abundant mixed infiltrate in papillary dermis and eosinophil predominance interstitially; (f) direct immunofluorescence with linear deposits of IgG along the BMZ in perilesional skin; (g) reduction of erythema, desquamation and blistering during secukinumab treatment.

FIGURE 2

Clinical presentation of patient 2: (a) Flare of both psoriasis and BP while on reduced dose of methotrexate; (b) worsening of BP during secukinumab treatment.

FIGURE 3

Clinical presentation of patient 3: (a) Diffuse scaly erythema on the trunk and extremities with superimposed multiple tense vesicles and bullae on both healthy and psoriatic skin; (b) complete control of both psoriasis and BP during secukinumab treatment.