In pemphigus vulgaris and pemphigus foliaceus (PF), autoantibodies against desmoglein-3 and desmoglein-1 induce epidermal cell detachment (acantholysis) and blistering. Activation of keratinocyte intracellular signaling pathways is emerging as an important component of pemphigus IgG-mediated acantholysis. We previously reported activation of p38 mitogen-activated protein kinase (MAPK) in response to pathogenic pemphigus vulgaris and PF IgG. Inhibition of p38MAPK blocked pemphigus IgG-induced cytoskeletal reorganization in tissue culture and blistering in pemphigus mouse models. We now extend these observations by demonstrating two peaks of p38MAPK activation in pemphigus tissue culture and mouse models. Administration of the p38MAPK inhibitor SB202190 before PF IgG injection blocked both peaks of p38MAPK phosphorylation and blister formation, consistent with our previous findings; however, administration of the inhibitor 4 h after PF IgG injection blocked only the later peak of p38MAPK activation but failed to block blistering. Examination of the temporal relationship of p38MAPK phosphorylation and apoptosis showed that apoptosis occurs at or after the second peak of p38MAPK activation. The time course of p38MAPK activation and apoptotic markers, as well as the ability of inhibitors of p38MAPK to block activation of the proapoptotic proteinase caspase-3, suggest that activation of apoptosis is downstream to, and a consequence of, p38MAPK activation in pemphigus acantholysis. Furthermore, these observations suggest that the earlier peak of p38MAPK activation is part of the mechanism leading to acantholysis, whereas the later peak of p38MAPK and apoptosis may not be essential for acantholysis.Pemphigus is a group of related autoimmune diseases characterized by blistering in the skin. The histologic hallmark of these disorders is termed acantholysis, which describes the loss of adhesion between adjacent epithelial cells. The two major variants are pemphigus foliaceus (PF) 2 and pemphigus vulgaris (PV). In PF, acantholysis is observed beneath the stratum corneum and within the granular layer of epidermal epithelia, whereas in PV, blister formation occurs above the basal layer of epidermal epithelia and mucosal epithelium. Passive transfer of IgG purified from both PV and PF patient sera reproduces the clinical, histological, and immunologic features of the human diseases, demonstrating that these autoantibodies are pathogenic (1, 2). In PF, autoantibodies target the desmosomal cadherin desmoglein (dsg) 1, whereas in PV, autoantibodies initially target dsg3 (3, 4) in mucosal PV and then subsequently target both dsg1 and dsg3 in mucocutaneous PV (5-7). The mechanism by which pemphigus autoantibodies induce blistering has been under investigation. Work from a number of laboratories has suggested that activation of intracellular events is induced by binding of PF or PV IgG to dsg1 and dsg3, respectively (8 -14). Previously, we have reported that PV IgG activate p38MAPK and heat shock protein (HSP) 27 in human keratinocy...