Three patients with longstanding multiple sclerosis (MS) who developed bullous pemphigoid (BP) are reported. All patients had immunological features of typical BP as determined by immunofluorescence and Western immunoblotting studies. The clinical features, however, differed from those observed in typical BP. In two the BP started near an indwelling catheter and two had striking involvement of the soles. None of our patients, or a further nine cases reported in the literature, had mucous membrane involvement. In MS patients BP appears to develop at a younger age. Multiple drugs were taken by the MS patients; these, however, appear not to play a role in triggering their BP. The course of BP in patients with MS is moderate, although the majority require systemic treatment.
We report two patients with vulval signs suggestive of lichen sclerosus. This diagnosis was never substantiated histologically and microscopic appearances were non-specific. In both cases the development of lesions at other cutaneous and mucosal sites alerted us to the possibility that the autoimmune bullous disease, cicatricial pemphigoid, accounted for the entire clinical picture. Lichen sclerosus and cicatricial pemphigoid are distinctive conditions which clinically are usually readily differentiated on cutaneous surfaces. When the site of presentation is on the vulva the clinical picture may become obscure and this can lead to diagnostic confusion. It is important to establish the correct diagnosis as this predicts the clinical course and prognosis in each case.
Twenty-one patients are reported who developed basal cell carcinomas on the lower leg. The commonest presentation was of a chronic 'stasis' ulcer which usually occurred at atypical sites. It is suggested that the development of basal cell carcinoma changes on the lower leg is a not infrequent complication of chronic venous stasis.
Pemphigus is an autoimmune blistering disease with high mortality if untreated. The cases of 10 patients who had minocycline 100 mg daily added as adjuvant therapy are reported. Prior to the use of minocycline, all patients had active disease, nine were on prednisolone (10-40 mg) and five were on azathioprine (100-200 mg). The response was assessed on clinical improvement and reduction of immunosuppressive (IS) drugs. It was graded into four categories: major, minor, equivocal and no significant response. A major response was seen in four patients, minor in two, equivocal in one and no improvement in three patients. The prednisolone dose in the six responders was reduced to 0-6 mg (0 mg in three patients), with an average decrease of 21 mg. The average time to respond was 8 months. Of the six responders, three were on azathioprine, which was ceased in two patients and reduced by two-thirds in the other patient. No patient ceased minocycline because of side effects. In conclusion, minocycline 100 mg daily is a simple, safe and well tolerated treatment that should be tried in patients with pemphigus to reduce disease activity and/or the dose of potent IS agents.
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