Objective:To investigate the current status of multidrug-resistant bacteria (MDRO) wound infections in patients with autoimmune bullous diseases (AIBDs), and to analyze their risk factors.Methods:A retrospective study was conducted, and inpatients with AIBDs accompanied by wound infections were collected from Hospital of Dermatology, Chinese Academy of Medical Sciences from January 2020 to December 2022. A descriptive analysis was carried out to analyze the basic characteristics of these patients and pathogenic characteristics of MDRO. Univariate and binary logistic regression models were used to analyze independent risk factors for MDRO infections in patients with AIBDs. Differences between the MDRO infection group and common bacterial infection group were analyzed by using t test, Mann-Whitney U test and chi-square test. Results:Totally, 271 patients with AIBDs accompanied by wound infections were included, including 159 males (58.7%) and 112 females (41.3%), and 142 patients (52.4%) were aged over 60 years. Most patients with AIBDs were diagnosed with pemphigus vulgaris (131 cases, 48.3%), or bullous pemphigoid (99 cases, 36.5%). Bacterial culture was positive in all the patients, and 74 (27.3%) were infected with MDRO; a total of 108 strains of MDRO were detected, with relatively high detection rates of Staphylococcus (82 strains, 75.9%) and Enterobacter (15 strains, 13.9%). Significant differences were observed between the MDRO infection group and the common bacterial infection group in the duration of hospitalization, involved body surface area, proportions of patients self-modificating drug dosage, proportions of patients topically using antibiotic ointments, proportions of patients using immunosuppressants, duration of glucocorticoid use, maximum dose of glucocorticoids and the first albumin level at admission (all P < 0.05), while there were no significant differences in the gender, age, proportions of patients at first hospitalization, types of AIBDs, duration of education, body mass index, disease duration, proportions of smoking patients, proportions of drinking patients, proportions of patients with comorbid chronic diseases, surgical history, prevalence of hypoalbuminemia, prevalence of mucosal involvement, proportions of patients receiving topical glucocorticoids, proportions of patients using biological agents, duration of antibiotic use, and the first total protein level at admission between the two groups (all P > 0.05). Logistic regression analysis showed that the use of topical antibiotic ointments, use of immunosuppressants, maximum dose of glucocorticoids, and self-modification of drug dosage were independent risk factors for MDRO infections (all P < 0.05) . Conclusions:The patients with AIBDs were prone to develop MDRO infections in wounds, and Staphylococcus infections were the most common. The use of topical antibiotic ointments, use of immunosuppressants, high dose of glucocorticoids, and self-modification of drug dosage may increase the risk of infections in patients with AIBDs.

Objective:To investigate clinical, immunoserological, and therapeutic characteristics of patients with linear IgA bullous dermatosis (LABD) .Methods:Clinical data were collected from patients with LABD in Hospital of Dermatology, Chinese Academy of Medical Sciences from 2016 to 2023, and their clinical, immunoserological, and therapeutic characteristics were retrospectively analyzed.Results:Twenty-six patients were included, comprising 12 males and 14 females, with a median age ( Q1, Q3) of 32 (11, 48) years. Among the 26 patients, 12 (46.2%) presented with annular erythema and blisters, while 14 (53.8%) with atypical lesions (erythema and blisters not in an annular arrangement). Direct immunofluorescence assay yielded positive results in 14 out of 19 patients (73.7%). Indirect immunofluorescence on salt-split skin showed IgA with or without IgG deposited in the epidermis of the salt-split skin in 53.8% (14/26) of the patients. The positive rate of IgA antibody detected by Western blot analysis was 88.5% (23/26). Western blot analysis with epidermal extracts as substrates showed that 18 patients (69.2%) had serum IgA recognizing the linear IgA bullous dermatosis autoantigen LAD-1 with a relative molecular weight of 120 000, of whom 4 (15.4%) also had IgA recognizing BP180; in 1 case (3.8%), the serum IgA could recognize a protein with a relative molecular weight of about 170 000 in the epidermal extracts; another 1 (3.8%) had IgA recognizing BP230 and a protein with a relative molecular weight of 140 000 in the epidermal extracts at the same time; additionally, the serum IgA recognizing type Ⅶ collagen with a relative molecular weight of 290 000 in the dermal extracts was detected in 1 case (3.8%). Among 23 patients receiving dapsone treatment, 21 well responded, 1 showed poor response, and 1 was intolerant; in addition, the latter two patients could not achieve complete remission by tofacitinib. Minocycline, colchicine, and sulfasalazine were effective in another 3 patients. Conclusions:In this study, LABD mainly occurred in middle-age individuals, and LAD-1 was determined to be a major autoantigen. Western blot analysis showed an increased positive rate of IgA antibody compared with immunofluorescence assay, and could be an important means of differential diagnosis. Although the LABD patients responded well to dapsone, it is still necessary to explore other safe and effective medications.

To report the first case of cutaneous chronic active Epstein-Barr virus disease manifesting as persistent erythema multiforme in China. The 12-year-old female patient presented with recurrent erythema and blisters all over the body, accompanied by oral erosions for more than 5 months. Skin examination showed dark erythema scattered on the right upper eyelid and cheeks, as well as erosions and blisters arising in the dark erythema on the lower jaw; broad bean- to pigeon egg-sized blisters with clear fluids arising in erythema were scattered on the back, buttocks, and limbs, and some manifested as atypical targetoid lesions; there was a mung bean-sized erosion on the mucosa of the lower lip and the right buccal region each; the patient also presented with moon face and multiple striae atrophicae on the lower limbs. Histopathological examination of the skin lesions on the lower limb revealed basket-weave hyperkeratosis, epidermal necrosis, liquefaction degeneration of basal cells with subepidermal blister formation, and perivascular lymphocytic infiltration in the superficial dermis; direct immunofluorescence assay showed negative staining for IgG, IgM, IgA, and complement C3 among epidermal cells and at the basement membrane zone; enzyme-linked immunosorbent assay showed negative staining for serum antibodies against desmoglein 1/3 (Dsg1/3), BP180, and type Ⅶ collagen; immunohistochemical examination demonstrated partial positive staining for CD3, CD4, CD5, CD8, CD56, granzyme B, and Epstein-Barr virus-encoded RNA, positive staining for Ki67 (> 70%), but negative staining for CD20. The Epstein-Barr virus DNA level was measured to be 1.97 × 10 6 IU/ml in whole blood samples and 2.65 × 10 7 IU/ml in blister fluid samples. No mutation sites with functional significance were identified by whole-exome sequencing. Based on these findings, a diagnosis of cutaneous chronic active Epstein-Barr virus disease manifesting as persistent erythema multiforme was made. The patient was treated with methylprednisolone at a dose of 40 mg/d, intravenous drips of ganciclovir at 200 mg twice daily, etc., and discharged after improvement.

Objective:To analyze clinical, immunoserological, and therapeutic features of patients with anti-p200 pemphigoid.Methods:Clinical data were collected from patients with confirmed anti-p200 pemphigoid at the Hospital of Dermatology, Chinese Academy of Medical Sciences from January 2015 to February 2024. Their clinical, immunoserological, and therapeutic characteristics were retrospectively analyzed.Results:A total of 35 patients were included, with a male-to-female ratio of 2.5∶1 (25 males and 10 females) and ages of 57.74 ± 17.12 years. Two (5.71%) patients were accompanied by psoriasis. In these patients, anti-p200 pemphigoid exhibited heterogeneous clinical phenotypes, mimicking classic bullous pemphigoid (20 cases, 57.14%), linear IgA bullous dermatosis (8 cases, 22.86%), or eczema (4 cases, 11.43%). The positive rates of direct immunofluorescence (DIF), indirect immunofluorescence on salt-split skin (ss-IIF), Western blot analysis with dermal extracts as substrates, and Western blot analysis with laminin γ1 C-terminal region (Lnγ1C) as substrates were 100% (24/24), 82.86% (29/35), 100% (35/35), and 80.64% (25/31), respectively. Among the 35 patients, treatment and follow-up information was available for analysis in 33. Six patients (18.18%) received non-glucocorticoid systemic therapy and topical glucocorticoid therapy, with a follow-up period ( M [ Q1, Q3]) of 19.50 (6.50, 69.25) months, and 1 withdrew the drugs. Sixteen patients received systemic glucocorticoids combined with traditional anti-inflammatory drugs, with a follow-up period of 13.50 (4.25, 18.00) months, the initial dose of glucocorticoids was equivalent to 0.30 - 0.50 mg·kg -1·d -1 of prednisone, and the time to disease control was 15.31 ± 5.23 days; among the 16 patients, 3 experienced fluctuations in disease condition which were alleviated by adding dapsone, and 1 discontinued glucocorticoids. Five patients (15.15%) received systemic glucocorticoids combined with immunosuppressants, with a follow-up period of 26.00 (14.00, 90.00) months, the initial dose of glucocorticoids was equivalent to 0.50 - 0.75 mg·kg -1·d -1 of prednisone, and the time to disease control was 10.20 ± 3.27 days; among the 5 patients, 2 received maintenance treatment with glucocorticoids (5 - 10 mg/d prednisone), 2 withdrew the drugs, and 1 relapsed after discontinuing glucocorticoids. One patient (3.03%) received systemic glucocorticoids combined with rituximab therapy, with a follow-up period of 53 months, and discontinued glucocorticoids thereafter. One patient (3.03%) received systemic glucocorticoids combined with dupilumab therapy, which proved to be effective. Four patients (12.12%) received systemic glucocorticoids combined with Janus kinase inhibitors, and 3 responded well. Conclusions:Anti-p200 pemphigoid presented a heterogeneous clinical profile in this series of patients, but scarring and milia were rare. Some patients showed negative results in Western blot analysis with Lnγ1C as substrates. The prognosis of anti-p200 pemphigoid was usually favorable, and most patients could achieve complete remission and ultimately discontinue medication.

Objective:To analyze clinical and immunoserological features of patients with epidermolysis bullosa acquisita (EBA) .Methods:Clinical data were collected from patients with confirmed EBA at the Hospital of Dermatology, Chinese Academy of Medical Sciences from January 2017 to January 2022, and their clinical and immunoserological characteristics were retrospectively analyzed.Results:A total of 20 patients were collected, including 7 males and 13 females, and they were aged 41.85 ± 18.43 years. Ten patients presented with the classical phenotype of EBA, 8 with the inflammatory phenotype of EBA, and 2 with the mixed phenotype of EBA. Mucosal involvement occurred in 19 cases, nail involvement occurred in 4, scarring was observed in 9, and milia in 13. Indirect immunofluorescence on salt-split skin showed IgG deposition on the dermal side in 19 cases. Enzyme-linked immunosorbent assay for type Ⅶ collagen revealed positive results in 19 cases, with a diagnostic sensitivity of 95%. Western blot analysis with dermal extracts as substrates revealed a protein band with a relative molecular mass of 290 000 in 16 cases, with a diagnostic sensitivity of 80%, and multiple autoantibodies against different basement membrane zone antigens were identified in 3 cases. Fifteen patients received systemic glucocorticoids, including 2 receiving combined immunosuppressive agents and 13 receiving combined anti-inflammatory agents with dapsone and colchicine as the first and second commonly used anti-inflammatory agents respectively; among 5 patients receiving non-glucocorticoid therapy, 2 with inflammatory EBA were sensitive to dapsone and colchicine, while the other 3 patients were lost to follow-up. Totally, 17 patients were followed up for an average duration of 26.21 months. Among the 17 patients, 1 achieved complete remission off therapy, 2 achieved complete remission on minimal therapy, and the remaining 14 patients achieved partial remission.Conclusions:The treatment of EBA is challenging, and anti-inflammatory agents such as dapsone and colchicine are often used. Immunoserological tests are of great value in the diagnosis of EBA.

Objective:To summarize clinical, histopathological, immunoserological, and therapeutic features of patients with autoimmune subepidermal bullous diseases characterized by annular erythema and blisters.Methods:Clinical data were collected from patients with autoimmune subepidermal bullous diseases characterized by annular erythema and blisters in the Hospital of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College from 2015 to 2022, and their clinical, pathological, immunoserological and therapeutic characteristics were retrospectively analyzed.Results:A total of 25 patients were enrolled, including 10 males and 15 females, aged 39.21 ± 24.65 years; there were 9 patients with linear IgA bullous dermatosis (LABD), 7 with bullous pemphigoid (BP), 5 with anti-P200 pemphigoid and 4 with epidermolysis bullosa acquisita (EBA), and 20 (80%) patients suffered from pruritus to different extents. Dermal eosinophil infiltration was observed in 15 (60%) patients, elevated peripheral blood eosinophil counts in 11 (44%), and both were observed in 7 (28%). Indirect immunofluorescence on salt-split skin and Western blot analysis showed that both IgG and IgA anti-basement membrane zone antibodies were present in 9 patients, including 4 with BP, 1 with LABD, 2 with anti-P200 pemphigoid, and 2 with EBA; and multiple antibodies against different basement membrane zone antigens were present in 5. All the 7 BP patients were treated with systemic glucocorticoids, including 5 (71.4%) receiving combined immunosuppressive agents, and 2 receiving combined minocycline; the patients with LABD, anti-P200 pemphigoid or EBA were sensitive to anti-inflammatory drugs and dapsone.Conclusion:Multiple types of autoimmune subepidermal bullous diseases may manifest as annular erythema and blisters, and it is necessary to make a differential diagnosis based on immunoserological tests.

Objective:To optimize indirect immunofluorescence on salt-split skin (IIF-SSS), and to evaluate its performance in detection of bullous pemphigoid (BP) antibodies.Methods:Normal human foreskin and non-foreskin skin tissues were used to prepare salt-split substrates under 3 different experimental conditions: traditional group rotated at 4 ℃ for 48 - 72 hours, low-temperature immersion group soaked at 4 ℃ for 48 - 72 hours, room-temperature immersion group soaked at 25 ℃ (range: 23 - 27 ℃) for 24 hours. Serum samples were obtained from 20 patients with bullous pemphigoid (BP) in Hospital of Dermatology, Chinese Academy of Medical Sciences between August 2019 and August 2020, and subjected to IIF on the intact skin or salt-split substrates by using a multiple dilution method. Paired-sample t test was used for comparisons of means between two paired samples. Results:No dermal-epidermal separation was observed in the substrates prepared in the low-temperature immersion group at 48 - 72 hours, while dermal-epidermal separation occurred in the lower lamina lucida of the foreskin and non-foreskin substrates in the room-temperature immersion group and the traditional group. For the 20 patients with BP, the reciprocal end-point titers ( M[ Q1, Q3]) detected with the salt-split non-foreskin skin and salt-split foreskin in the room-temperature immersion group, and with the salt-split non-foreskin skin in the traditional group were 5 120 (2 560, 17 920), 1 280 (640, 2 560), 1 280 (640, 2 560), respectively. Moreover, 19 (95%) patients with BP showed that the reciprocal end-point titers detected with the substrates in the room-temperature immersion group were 1 - 5 times those in the traditional group ( t = 8.04, P<0.001), suggesting that the performance of salt-split skin in the room-temperature immersion group was superior to that in the traditional group in the detection of BP antibodies; however, there was no significant difference in the reciprocal end-point titers of BP antibodies between the salt-split foreskin in the room-temperature immersion group and salt-split non-foreskin skin in the traditional group ( t<0.001, P>0.05). The reciprocal end-point titers in 20 BP sera detected by conventional IIF on the intact non-foreskin skin and foreskin were 320 (160, 640) and 480 (160, 1 120), respectively; the reciprocal end-point titers detected by IIF on the salt-split foreskin and non-foreskin skin in the room-temperature immersion group, as well as on the salt-split non-foreskin skin in the traditional group, were all consistent with or 1 - 7 times higher than those detected by conventional IIF ( t = 6.47, 14.83, 5.26, respectively, all P<0.001) . Conclusion:The soaking method at room temperature 25 ℃ (23 - 27 ℃) for preparing salt-split substrates has advantages of short duration and simple procedure, and the sensitivity of IIF-SSS using the substrates prepared by this method is equal or superior to the traditional salt-split method for detecting BP antibodies.

Objective:To evaluate the value of indirect immunofluorescence on salt-split skin (IIF-SSS) in the diagnosis of bullous pemphigoid (BP) .Methods:A single-center clinical retrospective study was conducted. Totally, 163 patients with newly diagnosed BP were collected from Hospital of Dermatology, Chinese Academy of Medical Sciences from January 2013 to January 2019, so were 404 controls, including 161 with pemphigus, 67 with eczema, 26 with drug eruption, 23 with erythema multiforme, 18 with prurigo nodularis, etc. Blood samples were collected before the treatment, and IIF-SSS, BP180 NC16A enzyme-linked immunosorbent assay (ELISA) and direct immunofluorescence (DIF) assay were performed to evaluate the value of IIF-SSS in the diagnosis of BP. Measurement data were compared by using t test and Mann-Whitney test, and enumeration data were compared by using chi-square test and Fisher′s exact test or McNemar test. Results:The number of cases positive for IIF-SSS, BP180 NC16A ELISA and DIF assay was 160, 153 and 127 respectively in the BP group, and 0, 18 and 26 respectively in the control group. The sensitivities of IIF-SSS, BP180 NC16A ELISA and DIF assay for the diagnosis of BP were 98.15%, 93.86% and 77.91% respectively, and their specificities were 100%, 95.54% and 93.56% respectively. There was strong consistency in the diagnosis of BP between IIF-SSS and DIF (Kappa coefficient= 0.767, P < 0.001) . Conclusion:IIF-SSS has relatively high sensitivity and specificity for the diagnosis of BP, and can serve as a routine method for diagnosing BP.

Virus infection is one of the common complications of pemphigus. In recent years, related studies on pemphigus complicated by virus infection have mainly focused on the herpes simplex virus (HSV) . Studies have shown that HSV infection can affect the course of disease, therapeutic effect, and even the morphology of skin lesions in patients with pemphigus. However, due to considerable differences in sample sizes and test methods, the incidence and clinical characteristics of HSV infection in patients with pemphigus markedly differ among different studies. This review summarizes the incidence and clinical characteristics of pemphigus complicated by HSV infection, aiming to improve clinicians′ understanding of the disease and provide a basis for its diagnosis and treatment.

Objective:To analyze clinical and immunoserological features of patients with anti-p200 pemphigoid.Methods:Clinical data were collected from patients with confirmed anti-p200 pemphigoid in Hospital of Dermatology, Chinese Academy of Medical Sciences from January 2015 to October 2021, and their clinical and immunoserological characteristics were retrospectively analyzed.Results:Seven patients with anti-p200 pemphigoid were included. Indirect immunofluorescence on salt-split skin (IIF-SSS) showed that serum IgG antibodies of the 7 patients were located in the dermis of the salt-split skin, and Western blot analysis with dermal extracts as substrates revealed a protein band with a relative molecular mass of 200 000. Four patients presented with classic bullous pemphigoid-like skin lesions, 2 initially presented with eczematous lesions, and 1 presented with linear IgA bullous dermatosis-like skin lesions. Circulating IgG antibodies could recognize the recombinant laminin γ1 C-terminal region in 6 cases. Four patients received different doses of systemic glucocorticoids, 1 of whom was resistant to high-dose systemic glucocorticoids (equivalent to 1.4 mg·kg -1·d -1 prednisone) ; 2 responded well to minocycline and dapsone; 1 was lost to follow-up. Four patients achieved complete remission and discontinued the treatment at a mean follow-up of 22.5 months; 2 received complete remissiona on minimal therapy at a mean follow-up of 8 months. Conclusion:Patients with anti-p200 pemphigoid presented with heterogeneous clinical manifestations, and the recombinant C-terminal fragment of laminin γ1 can serve as a reliable antigen substrate for the detection of autoantibodies in patients with anti-p200 pemphigoid; some patients can eventually achieve complete remission off treatment.