Using this pattern recognition by direct immunofluorescence microscopy we discovered several cases of EBA which would otherwise have been erroneously diagnosed as a form of pemphigoid or linear IgA disease.

IntroductionGeneralized atrophic benign epidermolysis bullosa (GA-BEB) is a form of nonlethal junctional epidermolysis bullosa characterized by universal alopecia and atrophy of the skin. We report a deficiency of the 180-kD bullous pemphigoid antigen in three patients with GABEB from unrelated families. We screened specimens of clinically normal skin from nine junctional epidermolysis bullosa patients (3 GABEB, 4 lethal, 1 cicatricial, 1 pretibial) by immunofluorescence using monoclonal antibodies to the 180-kD and 230-kD bullous pemphigoid antigens (BP180 and BP230). In the skin of the three GABEB patients there was no reactivity with antibodies to BP180, whereas staining for BP230 was normal. In the skin of the other six, non-GABEB patients, included in this study the expression of BP180 and BP230 was normal. Immunoblot analysis of cultured keratinocytes from one of the GABEB patients also failed to detect BP180 antigen, whereas BP230 was present in normal amounts. In previous studies on the expression of the bullous pemphigoid antigen in JEB, sera from bullous pemphigoid (BP) patients were used, the specificity of which had not been analyzed by immunoblotting (6-9). The expression was found to be normal or variable. Later it became apparent that BP-serum is a mixture of polyclonal antibodies, which are very difficult to characterize, even after affinity-purification (10). Fortunately, reliable monospecific antibodies for each of the two major bullous pemphigoid antigens have now become available (1 1, 12).In this study we used monoclonal antibodies specific for BPI 80 and BP230 (11,12). In addition we studied the expression of the newly described 500-kD hemidesmosomal plaque protein HD1 (13)

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This study shows that in a considerable number of supposedly IgG-mediated pemphigus patients IgA to Dsg1 and Dsg3 is also present. In most cases the antigen specificity of the IgA follows the antigen specificity of the IgG, although in a small number of cases IgA is present against the Dsg not recognized by IgG.