Indian Journal of Dermatology
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CORRESPONDENCE
Year : 2015  |  Volume : 60  |  Issue : 1  |  Page : 93-94
A case of pemphigus foliaceus aggravated in an irradiated area by radiotherapy against breast cancer


Department of Dermatology, Division of Cutaneous Science, Nihon University School of Medicine, Itabashi-ku, Tokyo, Jamaica

Date of Web Publication26-Dec-2014

Correspondence Address:
Toru Inadomi
Department of Dermatology, Division of Cutaneous Science, Nihon University School of Medicine, Itabashi-ku, Tokyo
Jamaica
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.147818

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How to cite this article:
Inadomi T. A case of pemphigus foliaceus aggravated in an irradiated area by radiotherapy against breast cancer. Indian J Dermatol 2015;60:93-4

How to cite this URL:
Inadomi T. A case of pemphigus foliaceus aggravated in an irradiated area by radiotherapy against breast cancer. Indian J Dermatol [serial online] 2015 [cited 2020 Sep 23];60:93-4. Available from: http://www.e-ijd.org/text.asp?2015/60/1/93/147818


Sir,

There have been some case reports, [1],[2] in which autoimmune bullous diseases were induced or relapsed following radiotherapy. Since autoimmune bullous diseases are often accompanied by internal malignancies, dermatologists should recognize what can happen following radiotherapy to treat malignancies.

65-year-old female patient visited our hospital in June 2009, complaining of scaly erythema on her face and trunk [Figure 1]. Based on histological findings and immunofluorescence observations, a diagnosis of pemphigus foliaceus (PF) was confirmed. The titer of anti-desmoglein 1 antibodies (Dsg 1) was 113 (positive >9) and anti-desmoglein 3 antibodies were negative. Oral administration of 30 mg/day of prednisolone (PSL) effectively controlled the disease. The dose was then reduced and she had been stably controlled with 4-5 mg/day PSL for 2 years, when the titer of Dsg1 had decreased to around 50. In 2011, an annual physical examination found a breast cancer, which was in T2N0M0, on her left chest. Electron beam therapy, totaling 50 Gy, controlled the cancer completely.
Figure 1: Scaly erythema, together with erosions was observed on her trunk, extremities, forehead and cheeks

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Two months after the radiotherapy, erosions appeared on her left chest, which had been exposed to the electron beam [Figure 2]. Histological examination revealed acantholysis in the squamous layer [Figure 3]. IgG and C3 deposits were observed among the upper layer of keratinocytes through direct immunofluorescence and the titer of Dsg 1 was 45.
Figure 2: Two months after the radiotherapy, erosions appeared on her left chest, which had been exposed to the electron beam

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Figure 3: At recurrence, acantholysis in the squamous layer and deposits of IgG were observed in the area (H and E, ×200)

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The skin eruptions improved after administration of PSL at 30 mg/day. The patient is in complete remission, with oral PSL of 4 mg/day and the titer of Dsg 1 has remained around 50.

Radiotherapy against breast cancer has been a common trigger that can cause bullous diseases relapse. Vigna-Taglianti et al. reported a case of pemphigus vulgaris (PV) where radiotherapy induced the recurrence of PV within the irradiated fields. [2] Badri et al. observed antibodies reacting with a 110 kDa antigen, which appeared following radiotherapy and was believed to induce PV. [1] Srifi et al. reported a case where radiotherapy induced bullous pemphigoid (BP) in a woman treated for squamous cell carcinoma with surgery and adjuvant radiotherapy. [3] Since skin eruptions began from the irradiated area, suggesting localized BP, [4] they speculated that the radiotherapy caused changes in the antigenic properties, resulting in the production of autoantibodies so that bullous lesions disseminated afterward. Igawa et al. reported a case of PF exacerbated by UV-irradiation, demonstrating acantholysis even in the uninvolved skin. [5] Although it remains unclear whether the pathomechanisms by which autoimmune bullous diseases worsen locally following radiotherapy are the same as the pathomechanisms that induce the systemic lesions, these observations seem to suggest that radiotherapy can lead to systemic disorders in patients with bullous diseases.

However, the dissociation between the titer of anti-Dsg and the local recurrence in our case suggests that the recurrence of PF is due to alterations restricted to the irradiated area, at least in the beginning. Considering the fact that autoimmune bullous diseases are often accompanied by internal malignancies, the possible risk of their recurrence following radiotherapy should be recognized.

 
   References Top

1.
Badri T, Hammami H, Lachkham A, Benmously-Mlika R, Mokhtar I, Fenniche S. Radiotherapy-induced pemphigus vulgaris with autoantibodies targeting a 110 kDa epidermal antigen. Int J Dermatol 2011;50:1475-9.  Back to cited text no. 1
    
2.
Vigna-Taglianti R, Russi EG, Denaro N, Numico G, Brizio R. Radiation-induced pemphigus vulgaris of the breast. Cancer Radiother 2011;15:334-7.  Back to cited text no. 2
    
3.
Srifi N, Benomar S, Zaghba N, Qasmi S, Senouci K, Elgueddari B, et al. Generalized bullous pemphigoid induced by radiotherapy. Ann Dermatol Venereol 2011;138:311-4.  Back to cited text no. 3
    
4.
Mehta V, Balachandran C. Localized flexural bullous pemphigoid. Indian J Dermatol 2008;53:157-8.  Back to cited text no. 4
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5.
Igawa K, Matsunaga T, Nishioka K. Involvement of UV-irradiation in pemphigus foliaceus. J Eur Acad Dermatol Venereol 2004;18:216-7.  Back to cited text no. 5
    


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