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
- Cicatricial pemphigoid
What is cicatricial pemphigoid?
Cicatricial pemphigoid is an autoimmune disease that is characterised by blistering lesions on mucous membranes. It is also called
benign mucous membrane pemphigoid or
oral pemphigoid. Areas commonly involved are the oral mucosa (lining of the mouth) and conjunctiva (mucous membrane that coats the inner surface of the eyelids and the outer surface of the eye). Other areas that may be affected include the nostrils, oesophagus, trachea and genitals. Sometimes the skin may also be involved where blistering lesions can be found on the face, neck and scalp.
Brunsting Perry cicatricial pemphigoid is a rare variant in which localised crops of recurrent blisters arise within urticarial plaques, usually on the head and neck. The blisters may burst resulting in blood-crusted plaques and scars.
Who gets cicatricial pemphigoid?
Cicatricial pemphigoid is predominantly a disease of the elderly with a peak incidence at around 70 years. However, childhood cases have been reported. It appears to be twice as common in women than men.
What are the signs and symptoms of cicatricial pemphigoid?
- Sensation of grittiness or pain
- Lesions form, erode and heal to leave scar tissue
- May lead to impaired vision or blindness
- Blisters form first on the gums near the teeth
- Palate, tongue, lips, buccal mucosa, floor of the mouth and throat may be affected
- Painful and make it difficult to eat
- Lesions occurring in the throat (oesophagus, trachea and larynx) can become life-threatening
- Blisters on the skin develop in 25-30% of patients
- May be itchy
- Bleeding may occur if traumatised
- Nose bleeds after blowing the nose
- Crusting causing discomfort
- Painful blisters and erosions on the clitoris, labia, shaft of the penis, perianal area
What causes cicatricial pemphigoid?
Cicatricial pemphigoid is an autoimmune blistering disease, which basically means that an individual's immune systems starts reacting against his or her own tissue. In this particular instance autoantibodies react with proteins found in mucous membranes and skin tissue resulting in blistering lesions. The binding site appears to be within the anchoring filaments that help the epidermis (outside layer of skin) stick to the dermis (inner layer of skin).
Full article from DermNet NZ
Vanguard Health is the latest company that's signed up with the Dossia Consortium to offer its employees electronic health records as a work benefit.
But when will it become mainstream for any and all patients to access their health records electronically, rather than it being a rare job perk for some?
The HITECH federal stimulus legislation signed into law in February not only offers healthcare providers financial rewards starting in 2011 for their meaningful use of e-medical record and other health IT systems. The law also gives patients the right to access to their personal health information electronically, too.
That might seem like a given-- of course it makes sense for patients to have access to their medical data-- after all, it's information about their health, right? But with all the challenges involved with hospitals and doctors making the transition from paper to electronic records, and them figuring out how to share patient data (and many aren't anxious to do that for competitive and other reasons,) you have to wonder how much effort they'll spend--at least initially--in their IT project plans to provide patients with access to their digitized data.
How much of this information should they show patients? Could the data be misunderstood or taken out of context by patients? What about security and privacy worries? Those are just a few of the many concerns some healthcare providers have about giving patients an electronic window into their health data.
While healthcare providers figure that all out, some employers--like Dossia member companies-- have already decided to get a jump on providing patients access to at least some of their health data in the hopes that it will help employees better manage chronic and other medical problems they and their dependents face. So far, much of the data for Dossia e-health records comes from the payers, health plans, pharmacies that provide various services to Dossia employees via their health benefit packages. The data for the most part isn't coming directly from the actual doctors and hospitals caring for these patients.
Since so many Americans get their health coverage from their jobs, it's not all that surprising that many patients who also have electronic access to their health data are able to do so because their employers are providing e-health records as a work perk.
But the goal is that eventually for more patients to see their health data because their doctors and hospitals are providing secure access to that information, too.
The function of the immune system was critical to survival of our species. Prior to the 20th century man’s greatest killers were, in fact, infectious diseases. It is important to note that not everyone’s immune system functions in the same way because genetic diversity determines how one individual will react to a given infection. Diversity in the immune response has protected us from devastating events. For example, not everyone who got the bubonic plaque died. Some individual had a genetically programmed immune response that was more effective than others and they were able to survive. There are many examples of that throughout history of our species.
Because of this the immune system has to be adaptable enough to identify even infectious agents that hadn’t existed before. The HIV virus is a good example. To generate such enormous diversity, the controls of the immune system are extraordinarily complex. For these reasons, autoimmunity - which is a malfunctioning of the control of the normal immune system - is also complex and multi-factorial.
A reporter asked me a very important question, “Why should I put an article about pemphigus in my paper since it is such a rare disease and only affects such a few number of people?” Well, the answer is that autoimmune diseases are actually the 3rd most common human ailment behind cardiovascular disease and cancer. The prevalence of autoimmunity has been under-appreciated because many of the diseases are so organ specific that they fractionated to the “turf” of individual specialties. For example, thyroiditis is an endocrine problem. Lupus is a rheumatologic disease. Inflammatory bowel disease is seen by gastroenterologists. Multiple sclerosis is a neurologic disease. However, if you lump all autoimmune diseases together, it is an incredible important problem for our population. Advances in understanding one autoimmune disease can often translate into better understanding of other autoimmune diseases.
What are the key components of the immune system? There are cells that are called antigen presenting cells. These cells ingest and process foreign organisms such as a virus, a fungus, or bacteria which invade the body. They are then presented to the immune system so that the immune system can respond. There are two different kinds of cells that direct the immune response: T-Cells and B-Cells. These are your soldiers of the immune response. T-Cells are the killer cells and the production of protective antibodies is directed by B-Cells. Some B-Cells mature into plasma cells and they produce a serum protein called an antibody. These antibodies then protect you against foreign organisms. For example, when you get a diphtheria shot as a child, you make antibodies against that diphtheria toxin and those antibodies neutralizes any toxin they encounter. These antibodies keep some diseases away.
In pemphigus, the key players are antibodies because the disease and the damage to the skin is caused by antibodies. Not by the killer cells – T-Cells, but by antibody. Actually antibodies look like a little a “Y”. Antibodies directed against the skin attack the skin cells and cause them to fall apart.
The immune system is very specific. Certain cells are programmed to produce certain antibodies. It is kind of a lock and key type recognition system. Antibodies will bind to only those proteins that it is programmed to bind against. In pemphigus, desmogleins (the “glue”) in skin cells are recognized as an invading organism. Anti-desmoglein antibodies are then produced. Pemphigus is difficult to treat and there are known reasons for that. Antibodies in the normal state are directed against invading organisms and are protective proteins. These antibodies are protective proteins with long half lives, and cannot be destroyed because they are not recognized as being harmful to the body. The immune system thinks it is doing “the right thing” by producing autoantibodies against pemphigus antigens.
Antibodies last a long time; they have a half life of about 3 weeks. Once programmed to respond they are very durable. So the disease is not going to respond to treatment rapidly. It takes time - time and a lot of intensive therapy over months and years to try to down regulate that effect. The other problem is that we don’t know how to block the instructions from the immune system that reacts against a single protein, such as to block that one protein against desmoglein.
In PV we know of 2 specific genes that are involved with the disease process. In Jews it is the DR4 gene, and in Northern India, China and Japan it is DQ1. There are also other less frequent genes that can predispose a person to this disease, but these are the key ones.
The basic approaches used to treat pemphigus are: Prednisone, Immunosuppressive drugs, and new therapies like IVIg and Rituximab. However, to date there is nothing that targets the specific protein. The Peptimmune trial drug, if it works, will target the specific protein.