Drug-Induced Pemphigus Clinical Presentation

  • Author: Diane M Scott, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 13, 2012
 

History

  • Most patients develop the eruption a few weeks after starting therapy with the offending agent.
  • In penicillamine use, the eruption may not develop until 6 months after the onset of therapy.
  • Some patients may give a history of a nonspecific eruption prior to the development of pemphigus type lesions.
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Physical

  • Clinical manifestations of drug-induced pemphigus depend on the pathomechanism involved.
  • Disease caused by thiol drugs tends to present with the clinical findings of pemphigus foliaceus. Erythematous, scaly, crusted plaques occur primarily on the trunk. Occasional superficial vesicles and bullae may be seen, but usually, they are ruptured. Oral lesions do not occur.
  • Nonthiol drug-induced pemphigus presents predominantly as pemphigus vulgaris. Flaccid bullae and erosions occur on normal-appearing skin and, also, on the oral mucosa.[6]
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Causes

  • Speculation exists that genetic predisposition may be important in non-thiol–triggered pemphigus.
  • Human leukocyte antigen DR4 (HLA-DR4) is associated with idiopathic pemphigus; however, few studies have provided data concerning HLA typing in cases of drug-induced pemphigus.
  • Drugs implicated in drug-induced pemphigus are as follows:
    • Thiols
      • Penicillamine[7]
      • Bucillamine[8]
      • Captopril
      • Lisinopril[9]
      • Pyritinol
      • Thiopronine
      • Piroxicam
      • Thiamazole
      • 5-Thiopyridoxine
      • Gold sodium thiomalate
    • Antibiotics
      • Penicillin and derivatives
      • Cephalosporins
      • Quinolones[10]
      • Rifampicin
    • Pyrazolone derivatives
      • Phenylbutazone
      • Aminopyrine
      • Azapropazone
      • Oxyphenylbutazone
    • Miscellaneous drugs
      • Propanolol
      • Levodopa
      • Heroin
      • Progesterone
      • Carbamazepine[11]
      • Phenobarbital
      • Lysine acetylsalicylate
      • Imiquimod[12]
      • Glibenclamide[13]
      • Cilazapril[13]
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Contributor Information and Disclosures
Author

Diane M Scott, MD  Dermatologist and Dermatopathologist, Palm Beach Dermatology

Diane M Scott, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel Davis, MD  Associate Professor, Departments of Dermatology, Otolaryngology, and Pathology, University of Arkansas for Medical Sciences

Disclosure: Nothing to disclose.

Kimberly I Soderberg, MD  Consulting Staff, Oyster Point Dermatology

Kimberly I Soderberg, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Arkansas Medical Society, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David Woodley, MD  Co-Chair, Professor, Department of Medicine, Division of Dermatology, University of Southern California

David Woodley, MD is a member of the following medical societies: American Academy of Dermatology, American Association for the Advancement of Science, American College of Emergency Physicians, American College of Physicians, American Federation for Medical Research, American Society for Clinical Investigation, New York Academy of Medicine, Society for Investigative Dermatology, and Southern Medical Association

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD  Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Feng S, Zhou W, Zhang J, Jin P. Analysis of 6 cases of drug-induced pemphigus. Eur J Dermatol. Sep-Oct 2011;21(5):696-9. [Medline].

  2. Brenner S, Goldberg I. Drug-induced pemphigus. Clin Dermatol. Jul-Aug 2011;29(4):455-7. [Medline].

  3. Wolf R, Brenner S. An active amide group in the molecule of drugs that induce pemphigus: a casual or causal relationship?. Dermatology. 1994;189(1):1-4. [Medline].

  4. Brenner S, Bialy-Golan A, Anhalt GJ. Recognition of pemphigus antigens in drug-induced pemphigus vulgaris and pemphigus foliaceus. J Am Acad Dermatol. Jun 1997;36(6 Pt 1):919-23. [Medline].

  5. Ramseur WL, Richards F 2nd, Duggan DB. A case of fatal pemphigus vulgaris in association with beta interferon and interleukin-2 therapy. Cancer. May 15 1989;63(10):2005-7. [Medline].

  6. Venugopal SS, Murrell DF. Diagnosis and clinical features of pemphigus vulgaris. Dermatol Clin. Jul 2011;29(3):373-80, vii. [Medline].

  7. Nagao K, Tanikawa A, Yamamoto N, Amagai M. Decline of anti-desmoglein 1 IgG ELISA scores by withdrawal of D-penicillamine in drug-induced pemphigus foliaceus. Clin Exp Dermatol. Jan 2005;30(1):43-5. [Medline].

  8. Hur JW, Lee CW, Yoo DH. Bucillamine-induced pemphigus vulgaris in a patient with rheumatoid arthritis and polymyositis overlap syndrome. J Korean Med Sci. Jun 2006;21(3):585-7. [Medline].

  9. Patterson CR, Davies MG. Pemphigus foliaceus: an adverse reaction to lisinopril. J Dermatolog Treat. Jan 2004;15(1):60-2. [Medline].

  10. Anadolu RY, Birol A, Bostanci S, Boyvatt A. A case of pemphigus vulgaris possibly triggered by quinolones. J Eur Acad Dermatol Venereol. Mar 2002;16(2):152-3. [Medline].

  11. Patterson CR, Davies MG. Carbamazepine-induced pemphigus. Clin Exp Dermatol. Jan 2003;28(1):98-9. [Medline].

  12. Lin R, Ladd DJ Jr, Powell DJ, Way BV. Localized pemphigus foliaceus induced by topical imiquimod treatment. Arch Dermatol. Jul 2004;140(7):889-90. [Medline].

  13. Azad Khan AK, Johnston HH, Truelove SC. Proceedings: Bacterial breakdown of sulphasalazine (salazopyrin). Gut. Oct 1975;16(10):832. [Medline].

  14. Maruani A, Machet MC, Carlotti A, Giraudeau B, Vaillant L, Machet L. Immunostaining with antibodies to desmoglein provides the diagnosis of drug-induced pemphigus and allows prediction of outcome. Am J Clin Pathol. Sep 2008;130(3):369-74. [Medline].

  15. Landau M, Brenner S. Histopathologic findings in drug-induced pemphigus. Am J Dermatopathol. Aug 1997;19(4):411-4. [Medline].

  16. Anhalt GJ. Drug-induced pemphigus. Semin Dermatol. Sep 1989;8(3):166-72. [Medline].

  17. Brenner S, Bialy-Golan A, Ruocco V. Drug-induced pemphigus. Clin Dermatol. May-Jun 1998;16(3):393-7. [Medline].

  18. Brenner S, Wolf R, Ruocco V. Drug-induced pemphigus. I. A survey. Clin Dermatol. Oct-Dec 1993;11(4):501-5. [Medline].

  19. Grando SA. Cholinergic control of epidermal cohesion. Exp Dermatol. Apr 2006;15(4):265-82. [Medline].

  20. Mutasim DF, Pelc NJ, Anhalt GJ. Drug-induced pemphigus. Dermatol Clin. Jul 1993;11(3):463-71. [Medline].

  21. Nguyen VT, Arredondo J, Chernyavsky AI, Kitajima Y, Pittelkow M, Grando SA. Pemphigus vulgaris IgG and methylprednisolone exhibit reciprocal effects on keratinocytes. J Biol Chem. Jan 16 2004;279(3):2135-46. [Medline].

  22. Ruocco V, De Angelis E, Lombardi ML. Drug-induced pemphigus. II. Pathomechanisms and experimental investigations. Clin Dermatol. Oct-Dec 1993;11(4):507-13. [Medline].

  23. Uzun S, Durdu M, Akman A, et al. Pemphigus in the Mediterranean region of Turkey: a study of 148 cases. Int J Dermatol. May 2006;45(5):523-8. [Medline].

 
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