eMedicine Specialties > Dermatology > Bullous Diseases

Pemphigus, Drug-Induced: Differential Diagnoses & Workup

Author: Diane M Scott, MD, Dermatologist and Dermatopathologist, Palm Beach Dermatology
Coauthor(s): Daniel Davis, MD, Associate Professor, Departments of Dermatology, Otolaryngology, and Pathology, University of Arkansas for Medical Sciences; Kimberly I Soderberg, MD, Consulting Staff, Oyster Point Dermatology
Contributor Information and Disclosures

Updated: Nov 13, 2009

Differential Diagnoses

Pemphigus Erythematosus
Pemphigus Foliaceus
Pemphigus Herpetiformis
Pemphigus Vulgaris
Pemphigus, Paraneoplastic

Workup

Other Tests

  • Indirect immunofluorescence: Circulating autoantibodies are present in approximately 70% of patients with drug-induced pemphigus. When positive, indirect immunofluorescence findings usually reveal low titers of antibodies, which do not correlate with the severity of the disease. These antibodies recognize the pemphigus foliaceus antigen (desmoglein 1), pemphigus vulgaris antigen (desmoglein 3), or both. Circulating autoantibodies have been demonstrated to be more likely to occur in patients with non-thiol–induced pemphigus. In this group, the immunologic pattern and clinical course are similar to that of idiopathic pemphigus vulgaris.11
  • Direct immunofluorescence: Tissue-bound intercellular immunoglobulin G antibodies are diagnostic of pemphigus and are found in most patients (75-90%) with drug-induced pemphigus.

Histologic Findings

Histologic features of established lesions correlate with the clinical appearance. Lesions resembling pemphigus foliaceus reveal superficial epidermal acantholysis, while those resembling pemphigus vulgaris reveal suprabasal acantholysis. Eosinophilic spongiosis may be present. It is not possible to distinguish between idiopathic and drug-induced pemphigus based on histologic features.12

More on Pemphigus, Drug-Induced

Overview: Pemphigus, Drug-Induced
Differential Diagnoses & Workup: Pemphigus, Drug-Induced
Treatment & Medication: Pemphigus, Drug-Induced
Follow-up: Pemphigus, Drug-Induced
References
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References

  1. 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].

  2. 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].

  3. 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].

  4. 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].

  5. 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].

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

  7. 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].

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

  9. 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].

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

  11. 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].

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

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

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

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

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

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

  18. 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].

  19. 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].

  20. 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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Further Reading

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Keywords

pemphigus, drug-induced pemphigus, antibiotic-induced pemphigus, medication-induced pemphigus, thiol-induced pemphigus, pyrazolone-induced pemphigus

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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.

Medical Editor

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.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
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.

Managing Editor

Jeffrey J Miller, MD, Associate Professor of Dermatology, Penn State University College of Medicine; Staff Dermatologist, Penn 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.

CME Editor

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, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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