to let people know as soon as
possible, and maybe, by chance,
someone contacts us saying that
they know somebody who needs
This goes to show no volunteering
act is too small. We all have it
in us to spread awareness and can
start by looking for opportunities
in our own communities.
On October 9, 2014, Dr. Vidya
Sankar presented at the American
Dental Association’s (ADA)
Annual Meeting in San Antonio,
Texas. Her presentation, “The Dental
Detective: Investigating Autoimmunity,”
addressed the common
symptoms and referral patterns
for several different autoimmune
diseases, including PV and MMP.
This served as an excellent way to
provide continuing education on
these illnesses to the entire dental
“The oral health care professional
will commonly encounter
patients with an array of oral and
systemic health needs,” Dr. Sankar
said. “The ADA offered us a
platform to review some of these
lesser known conditions in order
to identify patients with potentially
undiagnosed needs and act as
a conduit to aid in diagnosis and
management. Additionally, linking
up the dental professionals
with professional societies such
as the IPPF will help to increase
awareness and access to care and
potentially increase our patients’
quality of life.”
The IPPF thanks Carlos, Dell,
and Dr. Sankar for their collaboration
on this project and their devotion
to raising awareness.
Together we can raise awareness
and promote early diagnosis
of PV and MMP. We all have ways
we can contribute. These are just
three of the many more tales of
awareness there are to share.
What’s yours? The IPPF encourages
our Community to get
involved with the Awareness
Campaign. If you are interested in
learning more about the campaign
or getting involved, please contact
Kate E. Frantz, MPH, CTTS, is
the Awareness Program Manager
at the IPPF living in Dixon,
CA. She is a contributor to
the Quarterly newsletter in her
“Awareness and You” column.
Kate can be reached at awareness@
. . .continued from AWARENESS, page 6
Vidya Sankar, DMD, MHS, University of
Texas Health Science Center, San Antonio
generous. It has been overwhelming and we have
done really well so far. The IPPF has helped us, too, by
providing promotional material that we handed out.
We also had T-shirts and a banner made, which have
definitely helped raise awareness of PV. Please check
out the IPPF Facebook page to see photographs of
Thanks entirely to the funds we raised, I received
my first rituximab infusion two weeks ago, and it went
well. I am due for my second infusion next week, and
while I know I have a long wait, I am feeling very positive
about the outcome.
I just hope and pray it will work for me. I have been
advised that it normally takes at least three months
to determine whether or not rituximab is effective,
and I understand it is likely I will need further infusions.
Over the next few weeks, I will hopefully be
reducing the steroids and immunosuppressents.
As you can imagine, trying to cope with this disease
over a number of years has taken its toll. I have gone
from being a very fit and healthy man to being overweight
with a painful, incurable disease. This whole
period has been a depressing and difficult time for
me and my whole family. The most difficult aspect of
living with this disease is the excruciating pain I have
had to endure, and therefore I am looking forward to
returning to a life free of pain where I can enjoy keeping
fit and healthy and return to my weekly cycling
event with my brothers.
. . .continued from ROAD TO REMISSION, page 13
Scott is an Operations/Call Center Manager
who lives and works in West Midlands, United
Kingdom. Scott is happy to raise P/P awareness
by telling his story in the Quarterly. Once he is
feeling better, he hopes to continue to raise
funds for other PV sufferers. If you would like
to support Scott’s treatment fund, please visit
a time . . . what else could I do?
In December one of the doctors
noted that along with the
predominantly oral presentation,
I had some skin symptoms, but it
wasn’t until July 2011 as a result of
my skin condition worsening with
blisters on my scalp and face that
I was referred to a dermatologist.
In September 2011, as my dermatologist
had suspected, my
PV diagnosis was confirmed and
refined as pemphigus with predominant
involvement. Unfortunately, my
dermatologist moved to another
country and I was referred to a
new dermatologist. I was now being
seen by both an oral consultant
and a dermatologist. I continued
a variety of different treatments
(Dermovate, Protopic ointment,
Elidel, Betnesol nasal spray, and
prednisolone mouth wash) and
drugs (prednisolone, azathioprine,
mycophenolate). None of them
were particularly effective.
During this time, the erosions
had spread all over my face and
nose and were particularly severe
on the top of my head. I was then,
and I still am, obese due to the
large amount of steroids. The disease
is extremely painful; so much
so it affected my sleep because I
cannot rest my head on the pillow
at night. I remember visiting
the hospital one day, when my lesions
were particularly bad and the
nurse thought I had been in a car
Every time I washed my hair
or face I would lose a piece of
skin. Every time I ate anything my
mouth would start to bleed. I can
honestly say at this point I was a
broken man with little quality of
life. I would hide the pain and discomfort
from my family. Many
times I said I was okay, but inside I
felt so depressed and despondent:
there did not seem to be any light
at the end of the tunnel. It felt like
no one could help me and there
was nowhere to go.
In an attempt to seek help and
get yet another opinion, my dermatologist
arranged for me to
see a world expert in dermatology
at Guys Hospital who determined
that my high daily steroid
requirement could not continue.
He recommended a drug called
rituximab and initiated a request
for funding via National Health
Service (NHS) of England. Unfortunately,
the funding request was
declined. I was devastated.
My wife wrote to our local member
of Parliament hoping his support
would sway NHS to reconsider
their decision, but it didn’t. My
wife and family decided that we
had no alternative but to try and
raise the money ourselves, and as
a family we began our mission.
In preparation to receive rituximab,
I was advised to start weaning
off the drugs I had taken for so
long. This had disastrous consequences
and led to a massive flare
up — the worst I have ever had. I
had to be taken into hospital as an
emergency case, where for over
four days I received three pulsed
doses of IV methylprednisoloine
and IVIG infusions.
This made an enormous improvement
to my pemphigus and
for the first time in years I felt so
happy and such a sense of relief as
the pain had largely subsided.
I was aware IVIG is meant to be
an interim treatment and a temporary
solution. Generally patients
remain lesion-free for up to 30
days. In my case only two weeks
passed. I continued to receive IVIG
every two to four weeks, and it
seemed to stop disease progression.
Because I had to be hospitalized,
my consultant submitted
additional clinical information to
the NHS explaining my new circumstances.
Sadly, this renewed
request for funding of rituximab
was declined again.
One of my family’s first fundraising
events was a 100-mile
bicycle ride. I am so proud of my
son, brothers, and friends who
took part. Everyone who donated
tween the winter holidays and early January is the
most busy time of the year for mental health professionals,
in part because it is difficult during these
times of reflection not to become depressed, if that
is a struggle.
It is important for those who are affected in this way
to make a special effort to practice positive thinking
(mindfulness) and reflect not only on the unpleasant,
but also pleasant memories. I’ve suggested imagining
that you’re putting negatives into a box and taping it
up; then seeing yourself locking that box into a trunk;
then imagining wrapping chains around the trunk
and leaving it for a later date. You will know where the
trunk is and how to retrieve what is inside, but you
can also choose to keep all or most of the contents
locked up for a while. At this point you may be willing
to accept offers of help from others, which is among
the healthiest of escapes.
The holidays are also a good time to reach out to
others. We’ve all heard that it is truly more satisfying
to give than to receive. Inviting lonely people to an
event or volunteering at a nursing home or other facility,
for instance, will have a positive effect on your
mood. As a way to track your progress through the
difficult holiday period, keep a record of your mood
and activities or lack of activities. As regularly as you
can, rate your mood on a 1-to-10 scale with 1 being
the worst and 10 being the best. Also track your activities
or lack of them as a record of the patterns and
both positive and negative triggers. Everyone is different,
and how you are in this world and during this
time of year will not be the same as for others. Hold
onto necessary traditions, but allow yourself to have
new experiences. You may surprise yourself.
Besides these mindfulness approaches and techniques
related to reaching out to others, there are
a number of physical solutions that may help with
dealing with SADS. Vitamin D supplementation has
been found to be useful. As well, daylight spectrum
lamps (or just special bulbs put into existing lamps)
can also help counteract the seasonal lack of natural
sunlight. Still, many people will need different medications
or increased doses of their current medications.
Checking with your primary care physician or
having an evaluation by a psychiatrist or psychologist
can be helpful and may greatly increase the quality of
your holiday season.
After eight months of oral symptoms and appointments
with doctors and dental specialists, I received
my own PV diagnosis right before Thanksgiving. One
of the first posts I read on the P/P online discussion
group forum was from someone (Hi, Skip!) who recounted
feeling lucky to swallow mashed potatoes in
his first symptom-filled year. That really helped me
to put things in perspective.
I focused on what I could do, not what I could not
do. Unless you’re having a flare or going through a
particularly rough time physically, get out and do
things. Happiness is a choice, and all humans have
the ability to be happy.
Happy holidays and my best wishes for a terrific
- of COL17 to test the effect of BP (human) patient-derived
antibodies. Generally, mice are a great experimental
model for studying the human immune system
since the mouse and human systems have been
found to be mechanistically very similar.
The authors genetically removed C3 from the humanized
COL17 mice and showed that indeed, they
lack the complement system. The authors also isolated
four different autoantibodies from four different
BP patients and found they vary in the degree
to which they activate the complement system. All
of the BP antibodies could induce skin detachment
(characteristic of blisters) when injected into either
the normal mice or in the complement-deficient
mice, demonstrating the complement system is likely
not at play in BP blister formation.
They next developed new antibodies that recognize
the exact same portion of COL17 and found a
correlation between the level of COL17 recognized
by the autoantibodies and blister formation. Recent
studies have shown COL17 antibodies not only recognize
and bind COL17 but also deplete it from cultured
cells. Ujiie and colleagues repeated that result show it
is complement-independent. As well, they find the
same effect of COL17 depletion in the COL17-humanized
mice - the antibodies caused blisters and
simultaneously reduced the amount of COL17.
Finally, the authors found that this was due to an
induction of the ubiquitin-proteasome system, the
machinery of cells that acts as a garbage disposal for
unwanted proteins. In this case, the COL17 autoantibodies
somehow mark the otherwise normal COL17
for destruction, possibly setting the stage for BP
symptoms and disease.
Several mechanisms may still be at play to mediate
the effects of COL17 autoantibodies generated
by BP patients (see figure). These include a degradation
system, as suggested from the current work or
COL17 may be internalized into cells upon binding of
the autoantibodies, as has been seen in studies from
other labs. It is also possible that COL17 gets internalized
first and then the intracellular proteasome
system degrades it. In any case, COL17 targeting by
BP autoantibodies is a probably occurring by a more
direct mechanism than if it involved the complement
It is possible that BP shares a mechanistic basis with
other autoimmune mucocutaneous diseases such as
pemphigus vulgaris, where autoantibodies recognize
desmoglein proteins Dsg1 and Dsg3 in keratinocytes
of the epidermis. Therefore, understanding the underlying
mechanisms at play in blister formation in
the various P/P diseases will be applicable to all patients
- Awareness Campaign
- Awareness Campaign
- Psychologically Speaking
- One of the first things to remember about illnesses and the side effects of medications is the effects of illness are not just physical. There is an emotional component as well.
For example, the prednisone roller coaster is both physical and emotional. The ups and downs often have patterns and triggers, and these are not always predictable. The mere fact of having an illness can lead to depression, with or without side effects from medications.
Psychologists have been called “an angry bunch of shrinks” (Newsweek, December 2013) because of their collective response to new and unsettling upcoming changes in current diagnostic criteria and standards. The Diagnostic and Statistical Manual (DSM-IV) of the American Psychological Association has been the “bible” of the psychiatric profession for more than a decade, with the new version (DSM-V) going into effect in October 2015. The physicians’ ICD-10 (or International Statistical Classification of Diseases and Related Health Problems) will also be issued at that time.
In this article I will review some current diagnoses and criteria related to depression. With the aforementioned changes more than a year away, now is a good time to go over the diagnostic criteria for depression as outlined by the DSM and ICD standards. Lenore Sawyer Radloff’s Screening Test for Depression (see p. 17) can be used to monitor your own symptoms and patterns.
One mood disorder in the current DSM-IV is simply called “Mood Disorder Due to ____________.” The blank is filled in with a specific general medical condition, such as pemphigus vulgaris. The diagnosis may develop into a clinical depression over time, which has a different etiology. The diagnostic criteria for these generic mood disorders include:
A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following: Depressed mood or markedly diminished interest or pleasure in all, or almost all, activities. Elevated, expansive, or irritable mood.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
The disturbance is not better accounted for by another mental disorder so as to distinguish this general mood disorder from “Adjustment Disorder With Depressed Mood” in response to the stress of having a general medical condition, another clinical diagnosis.
The disturbance does not occur exclusively during the course of a delirium.
The symptoms cause clinically significant distress or impairment in social, occupational, or important areas of functioning.
Common symptoms of depression look different in each circumstance and with each individual. A diagnosis may be given if there is a prominent and persistent disturbance in mood that predominates in the clinical picture, and it is further characterized by five or more of the following:
Persistent feelings of sadness
Difficulty sleeping or excessive sleeping
Poor or increased appetite
Weight loss or weight gain
Anxiety, restlessness and agitation
Inertia: feeling “slowed down” or low in energy
Tearfulness or an inability to cry
Difficulty concentrating, remembering, or making decisions
Loss of interest in sex and other normal activities
Difficulty functioning at work, at home and/or in social situations
Suicidal thoughts or passive thoughts of death.
Ill people will often try to hide their symptoms until they lose the energy necessary to keep up the act. After all, the last thing most people want is more prescription medications or treatments. This is more so when their bodies have already “betrayed” them and medications are necessary just to not get sicker. It is important to understand what is happening emotionally and to get a proper diagnosis. With a diagnosis can come appropriate treatment.
The simple 20-question screening test for depression can be self-administered. I often recommend that anyone who is concerned or has symptoms they do not understand make copies and re-test themselves roughly every two weeks. This particular screen looks at the feelings and thoughts for the previous seven days, so you could use it weekly if you wanted to.
I often use this tool as a handout at presentations. Patients (and caregivers) usually come up to me and express surprise at how many statements they have endorsed. Many have no idea these particular feelings and thoughts were actually signs of depression. As I noted above, with diagnosis there is treatment.
My philosophy is to refer patients to a knowledgeable psychiatrist for evaluation for possible psychotropic medication. The psychotherapy component may be a fairly short-term cognitive-behavioral model, or a more lengthy psychodynamic approach. The bottom line is that everyone is unique, and no one needs to feel worse than absolutely necessary. For some people this means medication, especially in the beginning, or more frequent therapy appointments. The doctor will monitor and make changes as necessary. Having said that, the sooner the emotional diagnosis and the sooner treatment begins, the better and faster the positive effects will be in stopping any potential downward spirals.
It is often easier to speak with a professional than with someone in your personal network. The key is to identify any problem areas and to address them, not just put on a band-aid when emotional surgery is necessary.