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Pemphigus Foliaceus

By

Daniel M. Peraza

, MD, Geisel School of Medicine at Dartmouth University

Reviewed/Revised Feb 2024
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Topic Resources

Pemphigus foliaceus is an autoimmune blistering disorder in which lack of adhesion in the superficial epidermis results in cutaneous erosions. Diagnosis is by skin biopsy and direct immunofluorescence. Treatment depends on disease severity and includes topical or systemic corticosteroids. Other immunosuppressive therapies may be needed.

Bullae are elevated, fluid-filled blisters ≥ 10 mm in diameter.

Pemphigus foliaceus usually occurs in middle-aged patients, affecting men and women in equal numbers. An endemic form of pemphigus foliaceus, fogo selvagem, occurs in younger adults and children, particularly in South America. Pemphigus foliaceus may occur after use of penicillamine, nifedipine, or captopril.

Skin Cleavage Levels in Pemphigus and Bullous Pemphigoid

Pemphigus foliaceus blisters form in the superficial layers of the epidermis. Pemphigus vulgaris blisters can form at any epidermal level but typically form in the lower aspects of the epidermis. Bullous pemphigoid blisters form subepidermally (lamina lucida of the basement membrane zone). In this figure, the basement membrane zone is disproportionately enlarged to display its layers.

Skin Cleavage Levels in Pemphigus and Bullous Pemphigoid

General reference

  • 1. Russo I, De Siena FP, Saponeri A, et al: Evaluation of anti-desmoglein-1 and anti-desmoglein-3 autoantibody titers in pemphigus patients at the time of the initial diagnosis and after clinical remission. Medicine (Baltimore) 96(46):e8801, 2017. doi: 10.1097/MD.0000000000008801

Symptoms and Signs of Pemphigus Foliaceus

The primary lesion is a flaccid vesicle or bulla, but due to the superficial location of the epidermal split, lesions tend to rupture, so intact bullae or vesicles are rarely evident on examination. Instead, well-demarcated, scattered, crusted, erythematous lesions are common on the face, scalp, and upper trunk. Mucosal involvement is rare. Skin lesions can burn and cause pain, but patients are typically not severely ill. Pemphigus erythematosus tends to affect the malar cheeks.

Diagnosis of Pemphigus Foliaceus

  • Skin biopsy and immunofluorescence

Diagnosis of pemphigus foliaceus is by biopsy of a lesion and adjacent (perilesional) unaffected skin that shows IgG autoantibodies against the keratinocyte cell surface via direct immunofluorescence. Autoantibodies to desmoglein 1 can be detected in serum via direct immunofluorescence, indirect immunofluorescence, and enzyme-linked immunosorbent assay (ELISA). Sensitivity of ELISA is > 95% (1 Diagnosis reference Pemphigus foliaceus is an autoimmune blistering disorder in which lack of adhesion in the superficial epidermis results in cutaneous erosions. Diagnosis is by skin biopsy and direct immunofluorescence... read more Diagnosis reference ).

Diagnosis reference

  • 1. Joly P, Horvath B, Patsatsi Α, et al: Updated S2K guidelines on the management of pemphigus vulgaris and foliaceus initiated by the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol 34(9):1900-1913,2020. doi: 10.1111/jdv.16752

Treatment of Pemphigus Foliaceus

  • Corticosteroids, topical or systemic

If the disease is localized and not severe, high-potency topical corticosteroids are typically effective (1 Treatment reference Pemphigus foliaceus is an autoimmune blistering disorder in which lack of adhesion in the superficial epidermis results in cutaneous erosions. Diagnosis is by skin biopsy and direct immunofluorescence... read more Treatment reference ). More widespread or severe cases require systemic corticosteroids plus, at times, other immunosuppressive therapies, such as rituximab, plasma exchange, methotrexate, mycophenolate mofetil, or azathioprine. Topical calcineurin inhibitors have also been used.

Limited studies suggest that addition of a combination of tetracycline 500 mg orally 4 times a day or doxycycline 100 mg orally twice a day and nicotinamide 500 mg orally 3 times a day may be effective in some people.

Treatment reference

  • 1. Joly P, Horvath B, Patsatsi Α, et al: Updated S2K guidelines on the management of pemphigus vulgaris and foliaceus initiated by the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol 34(9):1900-1913,2020. doi: 10.1111/jdv.16752

Key Points

  • Pemphigus foliaceus is an autoimmune disorder that causes flaccid bullous skin lesions.

  • Diagnose using skin biopsy and direct immunofluorescence.

  • Treat with topical or systemic corticosteroids.

Drugs Mentioned In This Article

Drug Name Select Trade
Cuprimine, Depen, D-PENAMINE
Adalat, Adalat CC, Afeditab CR, Nifediac CC, Nifedical XL, Procardia, Procardia XL
Capoten
RIABNI, Rituxan, RUXIENCE, truxima
Jylamvo, Otrexup, Rasuvo, RediTrex, Rheumatrex, Trexall, Xatmep
CellCept, Myfortic
Azasan, Imuran
Emtet-500, Panmycin, Sumycin
Acticlate, Adoxa, Adoxa Pak, Avidoxy, Doryx, Doxal, Doxy 100, LYMEPAK, Mondoxyne NL, Monodox, Morgidox 1x, Morgidox 2x , Okebo, Oracea, Oraxyl, Periostat, TARGADOX, Vibramycin, Vibra-Tabs
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NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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