Diagnostics

Early diagnosis may permit successful treatment with only low levels of medication. Consult a dermatologist or oral medicine specialist if there are any persistent skin or mouth lesions. Because they are so rare, pemphigus and pemphigoid are often the last disease considered during diagnosis.

For a definite diagnosis, doctors should consider:

  • Clinical presentation: visual examination of skin or oral lesions.
  • Lesion biopsy: A sample of the blistered skin is removed and examined under the microscope. Additionally, the layer of skin in which cell-to-cell separation occurs can be determined.
  • Direct immunofluorescence: The skin sample is treated to detect desmoglein antibodies in the skin. The presence of these antibodies indicates pemphigus.
  • Indirect Immunofluorescence or antibody titer test: This measures desmoglein autoantibodies in the blood serum. It may be used to obtain a more complete understanding of the course of the disease.
  • ELISA: A serum assay for desmoglein antibodies, known as ELISA, is also available. Although in many cases there is a correlation between ELISA and disease activity it is not so in every case.

Please note that immunoflourescent testing (testing for circulating antibodies) for MMP is highly unreliable and is negative in the majority of cases. It is important to obtain positive direct immunofluorescence results (biopsies), even if it requires repeat biopsies because it can mimic other diseases such as lichen planus.

Diagnostic Testing

Diagnosis of all bullous conditions is based on three measures:

  • Clinical features: appearance of lesions, erosions and blisters, Nikolsky sign, presence or absence of scarring and distribution of lesions.
  • Biopsy of skin or mucous membrane, with characteristic histological features.
  • Direct and indirect immunofluorescence: detection of autoantibodies either in a biopsy specimen (direct) or in the patient’s serum (indirect). Indirect (circulating) antibodies are helpful in confirming the diagnosis. The enzyme-linked immunoabsorbent assay (ELISA) is helpful for diagnosis, particularly if the immunofluorescence studies are negative, and to differentiate PV from PF; in the future newer more specific ELISAs hold promise as a prognostic indicator.

The following investigations are also recommended during disease assessment and management:

  • Full blood count and differential
  • Blood urea and electrolytes
  • Liver function tests
  • Blood glucose
  • Antinuclear antibody (differential of pemphigus erythematosus)
  • Thiopurine methyltransferase (TPMT) levels (if azathioprine is to be used)
  • Chest X-ray
  • Urinalysis
  • Blood pressure
  • Bone density scan (early in the course of treatment is recommended, and repeated periodically)
  • PPD
  • G6PD and reticulocytes if dapsone is to be used
  • Opthalmologic exam

Diagnostic Pathway Data

In October 2011, KJT Group was commissioned by the IPPF to conduct an awareness and diagnostic pathways survey. Diagnosed pemphigus and pemphigoid (P/P) patients (N=87) completed a 15-minute online survey. Of patients surveyed, 25.3% were male and 74.7% were female. The average age of patients surveyed was 55 years, with 67.8% having pemphigus and 32.2% having pemphigoid. Roughly half (54%) of patients were diagnosed within the last 12 months and 46% were diagnosed within the last 12-36 months. All patients were from the United States.

  • Almost 80% of patients sought medical attention within the first three months of symptom onset.
  • The majority (63.2%) of patients’ initial symptoms were lesions in and/or on the mouth, lip, gums, or throat.
  • Dentists were one of the top clinicians seen first, with 23% of patients seeing a dentist as their first clinician. Almost half of patients (46%) saw a dentist at some point regarding their symptoms.
  • On average, patients saw five healthcare providers in pursuit of a correct diagnosis, and 10% reported seeing more than 10 healthcare providers.
  • On average, it took patients 10 months to achieve a correct diagnosis.
  • More than half of patients reported extreme difficulty in finding a doctor knowledgeable enough to accurately diagnose (56%) and effectively treat (51.2%) their condition.
  • Of patients who saw a dentist, almost half (46%) reported they were not knowledgeable about their P/P symptoms and performed no action relevant to their P/P. Forty percent reported being referred to another healthcare provider, and 13% said they received a diagnosis.
  • The majority (83%) of patients reported having a negative experience when seeking a diagnosis.
  • More than half (60.1%) of patients felt the time it took them to be diagnosed was too long.
  • Almost all patients (96.6%) were unaware of P/P prior to their diagnosis.
  • When asked to indicate the one emotion that best described their experience from the time symptoms appeared to be receiving an accurate diagnosis, 49.4% of patients said “frustrated”; 18.4% said “anxious”; and 11.5% said “confused.” Only 1.1% said “satisfied.”

Another study,* published in December 2000 by Dr. David Sirois, et al., surveyed 99 PV patients and found that 80% of patients experienced oral lesions as the first sign of PV, and 24% of patients only experienced oral lesions. Oral PV was less commonly recognized than cutaneous PV, with diagnostic delays commonly being greater than six months in duration.

*Sirois, D. et al., 2000. Archives of Dermatology. Vol 136. “Diagnostic Patterns and Delays in Pemphigus Vulgaris: Experience with 99 Patients.”

H&E and Direct Immunofluorescence Evaluation

Accurate diagnosis of oral blistering diseases is predicated on obtaining a satisfactory biopsy for both hematoxylin and eosin (H&E) and direct immunofluorescence (DIF) evaluation. To be diagnostic, the biopsy specimens must contain intact epithelium over the underlying connective tissue. However, in the oral cavity these lesions are often fragile and separation between the epithelium and connective tissue is common, rendering the specimen non-diagnostic. A biopsy should be performed by a dentist or dental specialist experienced in performing biopsies of vesiculobullous lesions.

Here are some general guidelines:

  • Do not sample the bed of an ulcer because there is no epithelium there, resulting in a non-specific diagnosis.
  • As a general rule, biopsies must contain intact epithelium and should be taken from perilesional (within 1 cm) or normal appearing tissue rather than the directly ulcerated tissue because an ulcer, by definition, is missing the epithelium. Without the epithelium, it is not possible to detect destruction between epithelial cells (as in PV) or between epithelial cells and the underlying connective tissue (as in MMP).
  • During the biopsy procedure, avoid any action that may cause separation of the epithelium from underlying connective tissue, e.g. rubbing the area with gauze to remove saliva or blood.
  • Two specimens must be taken with samples submitted for BOTH routine hematoxylin and eosin (H&E) stain (storing specimen in 10% formalin) AND for direct immunofluorescence testing (MUST submit sample in Michel’s transport medium and send to pathology laboratory as quickly as possible to preserve antibody detection).
  • When performing DIF biopsies, have Michel’s solution on hand. If planning to perform DIF biopsies, order and store in advance the Michel’s transport medium. Identify IN ADVANCE a commercial laboratory equipped to perform DIF studies.

Biopsy instructions

See these instructions from Dr. David Sirois, DDM, PhD, for more information about H&E and DIF biopsies, as well as IIF serum studies, to evaluate PV/MMP.

Biopsy Info

The below list includes 11 guidelines provided by Dr. Terry Rees, DDS, MSD, Professor of Periodontics, Director of Stomatology Center, Texas A&M Baylor College of Dentistry.

Many authorities have addressed this issue and the following general guidelines may apply:

  1. If lesions are located in several mucosal sites including the gingiva, it is usually preferable to avoid a gingival biopsy. This is true because gingiva is thin and tends to be fragile. Most authorities report a relatively low diagnostic success rate with gingival biopsies.1-4
  2. If a gingival biopsy is required it should be taken apical to the marginal gingiva to avoid the inflammation found in gingival crevices which may mask the autoimmune disease histologic features.
  3. Avoid direct infiltration of local anesthetic into the biopsy site to prevent hemorrhage or artificial separation of epithelium from the connective tissue.
  4. The cutting force should be directed internally only, to avoid lateral stresses that may disrupt the epithelium/connective tissue interface.4
  5. As a general rule, biopsies should be taken from perilesional (within 1 cm) or normal appearing tissue rather than directly from an erosive lesion since the lesion epithelium has potentially been lost.5
  6. In cases of extreme erosive lesions caused by suspected autoimmune diseases it may be preferable to take the biopsy from distant normal tissue such as buccal mucosa and submit it only for DIF analysis.6
  7. When possible, two or more biopsies should be obtained to submit for H&E and DIF analysis. This avoids having to split a single biopsy into two components since this may disrupt the epithelial/connective tissue interface. On occasion, only a single biopsy specimen can be obtained so it must be split for analysis. In this event be certain that the direction of the separation cut is only internal without applying any lateral force.
  8. Early oral manifestations of autoimmune diseases may be confined to the gingiva (desquamative gingivitis). In this event, gingival biopsies are required and special surgical techniques may improve the likelihood of obtaining diagnostic specimens (Punch biopsy, stab and roll technique).
  9. Several authorities have recommended a punch biopsy for intraoral lesions. However, this technique, as recommended includes the application of a rotational and internal force, which may create lateral stresses on the tissue and dislodge the epithelium. To date there are no studies reporting on the success of this technique when obtaining gingival biopsies. Limiting the cutting direction of force to only an internal direction appears likely to insure more predictable success.
  10. Recently a “stab and roll” biopsy technique has been described for gingival biopsies, which limits the cutting force to an internal direction only. In this technique a #15 scalpel blade is used. The point of the scalpel is gently applied until the underlying bone is reached. Then the blade is rolled from its tip along the entire cutting edge resulting in application of only internal forces. In larger specimens the scalpel tip is reapplied into the incision line and the procedure is repeated. Using this technique it was possible to obtain biopsy specimens with intact epithelial surfaces in 51 of 52 biopsies (98.1%). Perhaps most importantly, intact epithelium was retained in 26 of 27 lesion or perilesional biopsies.4
  11. It is essential that biopsy tissues be appropriately transported to the laboratory. For H&E evaluation formalin is the required medium but for DIF a special transport solution (Michel’s transport medium) is used. The DIF specimen should only be sent to a laboratory that performs direct immunofluorescence studies.

References/Suggested Reading

  1. Siegel Ma. Intraoral biopsy techniques for direct immunofluorescence studies. Oral Surg Oral Med Oral Pathol 1991; 72:681-684.
  2. Daniels TE, Quadra-White C. Direct immunofluorescence in oral mucosal disease: A diagnostic analysis of 130 cases. Oral Surg Oral Med Oral Pathol 1981; 51:38-47.
  3. Casiglia J, Woo SB, Ahmed AR. Oral involvement in autoimmune blistering diseases. Clin Dermatol 2001; 19:737-747.
  4. Endo H, Rees TD, Allen EP, Kuyama K, Aoki S, Yamamoto H, Ito T. A stab-and-roll biopsy technique to maintain gingival epithelium for desquamative gingivitis. J Periodontol 2014; 85:802-809.
  5. Sano SM, Quarracino MC, Aquas SC et al. Sensitivity of direct immunofluorescence in oral diseases. Study of 125 cases. Med Oral Pathol Oral Cir Bucal 2008; 13:E287-E291.
  6. Mutasim DF, Adams BB. Immunofluorescence in dermatology. J Am Acad Dermatol 2001; 45:803-822.
  7. Suresh L, Neiders ME. Definitive or differential diagnosis of desquamative gingivitis through direct immunofluorescence studies. J Periodontal 2012; 83: 1270-1275.
  8. Eisen D. The oral mucosal punch biopsy. A report of 140 cases. Arch Dermatol 1992; 128:815-817.
  9. Seoane J, Varela-Centelles PI, Limeres-Posse J, Seoane-Romero JM. A punch technique for gingival incisional biopsy. Laryngoscope 2013; 123:398.
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