bullos pemphigoid

8/12/2019 bullos pemphigoid

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JOURNAL READING

By : Vera Septia Nalurita (2008730129)

Preceptor : dr. Bowo Wahyudi, SpKK

RSUD KOTA BANJAR


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Background

Bullous pemphigus is a chronicdisease characterized by tense bullae

walled, often accompanied by

erythema Bullous pemphigus blistering skin

disease most common in adults

Parents have a low tolerance for oralcorticosteroid regimen


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Purpose

Is topical corticosteroid therapyeffective for both moderate and severe

bullous pemphigoid, and for better oral

corticosteroid therapy for extensivedisease?


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Method

A total of 341 patients with bullouspemphigoid were enrolled in arandomized, multicenter trial andstratified according to the severity of their

disease (moderate or extensive). Patients were randomly assigned to

receive either topical clobetasolpropionate cream (40 g per day) or oral

prednisone (0.5 mg per kilogram of bodyweight per day for those with moderatedisease and 1 mg per kilogram per dayfor those with extensive disease).


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Inclusion criteria

patients with newly diagnosed bullous pemphigoid

were eligible for entry if the following criteria weremet :

Clinical features suggestive of bullous pemphigoid

subepidermal blister on skin biopsy;

and linear deposits of IgG and C3 along thebasement-membrane zone

Exclusion criteria

Exclusion criteria were predominant or exclusivemucosal involvement

Treatment with oral or topical corticosteroids,dapsone, or immunosuppressive drugs during the

previous six months.


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Study Design

This randomized, nonblinded studycompared two parallel groups of patients

treated with topical or oral corticosteroids.

Randomization was stratified according tothe clinical center and the severity of

disease, which was determined on the

basis of the mean number of new bullae

that had appeared daily during the three

previous days

moderate disease was defined by 10 new

bullae daily


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The initial dose was maintained for 15 days

after control of the disease had beenattained. Thereafter, the dose was reducedby 15 percent every 3 weeks. Treatment wasstopped after 12 months

patients who were assigned to receive topicalcorticosteroids received a daily dose of 40 gof clobetasol propionate that was appliedtwice daily on the entire surface of the bodyuntil 15 days after control of the disease had

been attained. The doses were then gradually reduced to

20 g daily for one month, 10 g daily for twomonths, 10 g every other day for four months,

and finally 10 g twice a week for four months


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Statical Analysis

The primary end point was overallsurvival during the first year after theonset of bullous pemphigoid

Secondary end points were control ofthe disease at day 21 :the absence of new bullae for three

consecutive days

no severe side effects occur during thefirst year

cumulative hospital days (including theinitial hospitalization plus all

rehospitalizations).

R lt


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Result

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Among both patients with moderate bullous pemp higoid and patients with

extensive bullous pemphigoid, no significant differences were observed between

patients assigned to receive topical applications of clobetasol propionate cream

and those assigned to receive oral prednisone


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Result

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The corresponding figures among the patients with extensive disease were

44 of the 95 patients in the oral-prednisone group (46 percent; 95 percent

confidence interval, 36 to 56 percent) after a mean interval of 210133 days

and 34 of the 93 patients in the topical-corticosteroid group (37 percent; 95

percent confidence interval, 27 to 46 percent) after a mean interval of187118 days


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Result

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only cases of diabetes requiring insulin were included in the analysis of

severe (grade 3) or life-threatening (grade 4) adverse events.

Data include both clinically apparent fractures and vertebral fractures visible

on radiography


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Result

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Students t-test was used to compare the mean durations of

hospitalization


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Discussion

Systemic corticosteroids have beenconsidered the mainstay of treatment

for bullous pemphigoid for 40 years.

The present study confirms the poorprognosis of patients with bullous

pemphigoid who are treated with 1 mg

of prednisone per kilogram per day,among whom the one-year mortality

rate was 41 percent


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The present study was designed totest the hypothesis that topical

corticosteroids could be an effective

alternative treatment for patients withbullous pemphigoid and would result

in a decrease in the incidence of

severe adverse events Our results clearly demonstrate the

efficacy of clobetasol propionate

cream


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Topical treatments have lower toxicitythan the 1 mg of prednisone per

kilogram per day

Topical corticosteroids should beconsidered as a standard treatment

for patients with extensive bullous

pempigous


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Conclusion

Topical corticosteroid therapy is

effective for both moderate and

severe bullous pemphigoid andis superior to oral corticosteroid

therapy for extensive disease


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bullos pemphigoid

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