A 43-year-old African American man presented with burning, hyperpigmented scaling patches on his face, chest, and back for 18 months. Previous biopsies and treatments for conditions like cutaneous lupus erythematosus were ineffective. A new biopsy found intercellular IgG staining in the epidermis consistent with pemphigus foliaceus (PF), which was confirmed by positive anti-desmoglein antibodies. The patient was given rituximab therapy and showed marked improvement. PF is an autoimmune disorder caused by antibodies against desmoglein-1, typically presenting with thick scaling without blisters on the face and trunk.

1. A CASE REPORT ON PEMPHIGUS FOLIACEUS
Presented by Krishna . M
ABSTRACT
A middle aged man presented to the dermatology clinic with an
complaint of photo distributed , burning , hyperpigmented scaling patches and
plaques involving the malar cheeks , upper chest and upper back. physicians
included pf , cutaneous lupus , erythematosus diseasein the working of the
diagnosis when patients present with sever back pain and evidence of past
history treated with CLE and seborrheic dermatitis . A biopsies , ELISA
performed examination confirmed the diagnosis of pemphigus foliaceus .
INTRODUCTION
Pemphigus foliaceus (PF) is a rareautoimmune disorder characterized
by Subcorneal acantholysis mediated by IgG anti-desmoglein-1 (DSG1)
antibodies. We encountered a case of PF in a Hispanic patient seen initially by
the emergency roomphysician. The clinical presentation of this condition is
characterized by often-thick keratotic scale on an erythematous basewith
neither bullae formation nor mucosalinvolvement, as was the casewith our
patient. Immunofluorescencepatterns and specific antibody titers help to
establish the PF diagnosis; however, thepresentation may at times overlap
significantly with other forms of pemphigus, so it is important for the
practitioner to obtain a biopsy. Thereis no Gold standard algorithm for
pemphigus management,1 and patients and physicians should be awarethat it
may be chronic and difficult to treat, requiring multiple follow up . Patients
should be informed that treatment may need to be adjusted throughoutthe
clinical courseof the disease to maintain remission.
CASE PRESENTATION
A 43 years old African American male presented to the dermatology clinic
with an 18 month history of photo distributed , burning , hyperpigmented
scaling patches and plaques involving the malar cheek , upper chest and chest
back . He had been evaluated at an outside institution and treated for CLE and
seborrheic dermatitis. Repeated biopsies from the trunk and face revealed non
specific spongiotic dermatitis on both occasions . He denied any other

2. symptoms of systemic lupus erythematous . He was tested extensively for
connective tissue disease. ANA , anti ds DNA antibody ,anti smith antibody ,
and anti-histone , antibody were all negative.
He was referred to the walter reed national military medical center
dermatology department for evaluation after severalmonths of treatment
with topical tacrolimus and fluocinonide, without resolution of his rash. Upon
examining the patient , the clinical differential included PF , Cutaneous lupus
erythematous , inflammatory seborrheic dermatitis and pemphigus
erythematous . biopsies for routine staining and DIF wereperformed . DIF
demonstrated intercellular IgG Staining in the epidermis most prominentin the
superficialepidermis , consistentwith PF . upon closer review of pervious
biopsies , focal areas of acantholysis and dyskeratosis werenoted in the
granular layer , also highly suggestiveof PF . Additionally , enzyme-linked
immunosorbentassay (ELISA)for antidesmoglein and anti desmoglein
antibodies was performed on the patient’s serum,which showed an increased
presenceof the former, supportiveof PF . After reaching a satisfactory
diagnosis, the patient began a one month courseof rituximab with marked
improvement .
Discussion
There are six major types of disorders in the pemphigus family, features of
which can overlap in the samepatient: pemphigus vulgaris, pemphigus
herpetiformis, IgA pemphigus, paraneoplastic pemphigus, drug-induced
pemphigus, and pemphigus foliaceus. Pemphigus foliaceus has three subtypes:
1) classic or sporadic PF, 2) pemphigus erythematosus, a more limited form of
the disease, and 3) endemic PF (fogo selvagem), typically seen in indigenous
South American populations. The three entities present with identical
histological findings. While pemphigus foliaceus occurs globally, the
epidemiology of the diseasecan change based on location. For example, in
Brazil, endemic PF occurs 20 times more frequently than pemphigus vulgaris.5
In a Finnish study, pemphigus erythematosus was themost common
pemphigus disorder out of 44 patients, and pemphigus vulgaris and pemphigus
foliaceus occurred at the same rate.6 A study of 148 pemphigus patients in
Turkey found that 83.1% of patients had pemphigus vulgaris, 8.8% had
pemphigus foliaceus, and 4% had pemphigus erythematosus.4 HLA
polymorphisms can be dependent on the geographic location of patients,
which may account for the regional variations in pemphigus-foliaceus

3. epidemiology. Pemphigus foliaceus is a rare immunobullous diseasethat can
have localized or diffusemanifestations. Ittypically occurs in patients aged 40
to 60 years and affects males and females equally.2 Classic features of PF
include erythematous papules and plaques with crusting, scaling and erosion,
without mucosalinvolvement, on the face, scalp and trunk, often called a
“seborrheic” distribution. Itcommonly presents as erosions demonstrating a
positive Nikolsky sign, as pemphigus vulgaris does. Patients are rarely
illappearing. The most severeform of PF presents with exfoliative
erythroderma.2 In allforms, there are detectable serum IgG antibodies against
DSG1. The primary histologic feature is subcornealacantholysis. This finding
may be indistinguishablefromthat seen in bullous impetigo, with which it
shares a common autoantigen. The key to PF diagnosis is direct
immunofluorescence(DIF) demonstrating IgG autoantibodies and C3 on the
epidermal cell surface. Pemphigus foliaceus has been associated with several
HLA polymorphisms, indicating a genetic predisposition.3 Endemic PF, also
known as fogo selvagem, presents like other PF subtypes but is most
commonly seen in Brazilian patients.11 Itis also found elsewhere in South
America as well as in Central America, Algeria, Finland, Morocco and Tunisia.5
Patients tend to be young adults who spend a good deal of time in outdoor
activities.12 The incidence of new cases increases at the end of the rainy
season.5 Thedisease tends to occur in patients of lower socioeconomic status,
and the condition improves when the living conditions improve.13 Itis
associated with IgMand IgEantibodies against DSG-1.12 Patients with endemic
pemphigus foliaceus havean association with HLA class II alleles, indicating a
possibleunderlying genetic susceptibility in these patients.14 There is evidence
that a prior antigenic responseto an environmental factor may help trigger the
DSG-1 antibodies.12 Morespecifically, patients may haveIgG1 againstDSG-1,
but the onsetof clinical disease appears to be associated with a significant rise
in IgG4.15 Thecondition typically affects the face and upper trunk. There is a
localized form, which has a good prognosis and may spontaneously remit. The
generalized formtends to be more aggressive.11 Systemic corticosteroids are
the therapy of choice for endemic PF. Pemphigus erythematosus (PE), also
known as Senear-Usher syndrome, can presentas vesicles, bullae, or scaly
plaques over seborrheic areas, the malar area, the trunk or the
extremities.3,16 PE is considered a localized form of pemphigus foliaceus. It
shares features with lupus erythematosus, including a positive ANA and
histological findings of IgG or IgM granular deposits and C3 at the

4. dermoepidermal junction.16 However, mostpatients with PE do not have
lupus erythematosus. Cases haveshown a possible link between psychiatric
disorders and pemphigus, with a recent reportof two cases of pemphigus
erythematosus associated with bipolar disorder.17 Therearealso severalcases
of thymoma associated with pemphigus erythematosus.
CONCLUSION
A 43 Years aged man presented to the dermatology clinic with an
complaint of photo distributed , burning , hyperpigmented scaling patches and
plaques involving the malar cheeks , upper chest and upper back may guide
the clinical suspension. Timely treatment of pemphigus foliaceus can avoid
extensive investigation , treatment delays and adverseeffect long term
outcomes , including compression fractures with neurological deficits.
REFERENCE
1. Tyler Vukmer, DO,* John Hassani, DO,** Adriana Ros, DO***
*Dermatology Resident, PGY3, Hackensack University Medical Center
at Palisades, NorthBergen, NJ**Hematology/Oncology Specialist, H.
Lee Moffitt Cancer Center, TampaBay, FL ***Program Director,
Dermatology Residency, Hackensack University Medical Center at
Palisades, NorthBergen, NJ
2. WWW.MDEDGE.COM