Coexistent Psoriasis and Bullous Pemphigoid Responding to Mycophenolate Mofetil Monotherapy

Abstract

A 73-year-old woman with a 50-year history of psoriasis was referred to our clinic with a 4-month duration of tense bullae on erythematous base and erosions localized on her lower extremities and torso (Figure 1A). Neither the oral nor the ocular mucosa had been involved. The lesions were intensively pruritic, significantly affecting the quality of her life. At the time of the examination, the patient presented with psoriatic plaques with adherent scales confined on the scalp (Figure 2A). According to the patient's history, her limited psoriasis was partially controlled with occasional topical medications (topical corticosteroids, calcipotriol, and tar shampoo). She also had insulin-dependent diabetes mellitus, asthmatic bronchitis, and partially controlled hypertension with hyperlipidemia. A biopsy specimen was taken from lesional skin on her feet, and a histological examination showed a subepidermal blister with an inflammatory cell infiltrate in the upper dermis. No drugs were incriminated, and diagnosis of bullous pemphigoid was confirmed by Western immunoblotting of serum. Laboratory investigation revealed mild thrombocytopenia of 110,000/mm(3), cholesterol 279 mg/dL, and triglycerides 210 mg/dL. The patient could not tolerate prednisolone and cyclosporine because of hypertension and diabetes, or azathioprine because of the mild thrombocytopenia; she did not consent to receiving biologics. Mycophenolate mofetil (MMF) was then considered a choice. The patient agreed, and she was initially administered 1000 mg/d. After 2 weeks, the dosage increased to 1000 mg twice a day because of the formation of new blisters. Within 8 weeks of treatment with MMF 2000 mg/d, marked improvement was observed and her pruritus resolved. Complete remission of bullous pemphigoid and psoriasis was achieved within 3 and 4 months, respectively. Routine laboratory studies were performed before treatment and every month during therapy, and MMF was tolerated without side effects. The treatment was continued for 6 months with no subsequent relapse of the dermatoses (Figure 1B and Figure 2B).

Mucous Membrane Pemphigoid

“…A marked improved effect with the combination of MMF with corticosteroids in the treatment of MMP has been reported. 64–66 Staines et al reported that treatment of MMP with MMF in uncontrolled case series resulted in control of inflammation in the majority of patients with minimal side effects. 64 MMF may be an effective and safe therapeutic option in MMP.…”

Concomitant Psoriasis and Bullous Pemphigoid – a Case Report / Udružena pojava psorijaze i buloznog pemfigoida – prikaz slučaja

“…Two independent cases of psoriasis associated with bullous pemphigoid have been successfully treated with azathioprine and cyclosporine (15). Mycophenolate mofetil monotherapy (2000 mg per day) has proven to be effective (16). Systemic steroids that current treatment, although often effective, does not provide a satisfactory long-term solution.…”

Psoriasis: What is new in nonbiologic systemic therapy in the era of biologics?

“…[65] MMF is a good choice in psoriasis patients concurrently suffering from immunobullous disorders. [66] RETINOIC ACID METABOLISM BLOCKING AGENTS: LIAROZOLE, TALAROZOLE (RAMBAZOLE)…”