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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bullous pemphigoid &#40;BP&#41;&#44; a chronic autoimmune cutaneous blistering disorder affecting predominantly the elderly&#44; is characterized by skin tense bullae formation and pruritus symptoms&#46; At present&#44; the main treatment options are represented by corticosteroids and immunosuppressant drugs&#46; Steroids often need to be administered in high doses&#44; with subsequent adverse events and safety issues&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Safer treatment modalities are therefore needed&#46; Dupilumab is a biologic agent used to treat BP in recent years&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Here&#44; we describe an elderly patient with recalcitrant BP successfully treated with dupilumab&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 89-year-old woman was admitted to our department with a 1-month history of severely itchy erythema&#44; vesicles and blistering&#46; On examination&#44; there were urticarial plaques and vesicles on the trunk&#44; and extremities&#46; Isolated tense blisters could be observed on the abdomen and bilateral thighs &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; with sparing of mucosal surfaces&#46; While the lesions evolved into erosions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; the Nikolsky sign was negative&#46; In addition&#44; the patient had type 2 diabetes mellitus on metformin and hypothyroidism on levothyroxine for over 20 years&#44; she denied taking any new medications&#46; Laboratory investigations revealed mild eosinophilia&#59; however&#44; no other significant abnormalities were present&#46; An extensive workup for underlying malignancy and rheumatologic diseases with imaging and laboratory test results proved unremarkable&#46; Skin biopsy demonstrated subepidermal blister formation with eosinophilic infiltrate &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Direct immunofluorescence revealed subepidermal separation with continuous linear depositions of IgG and C3 along the basement membrane zone&#46; The clinical picture in combination with the histologic and immunologic findings confirmed the diagnosis of BP&#46; She was started on prednisone 80&#8239;mg&#44; and after 2 flares during tapering of prednisone&#44; the decision was made to proceed with azathioprine 200&#8239;mg&#44; and tetracycline 500&#8239;mg&#46; Although moderate doses of prednisone effectively reduced the severity of blistering lesions&#44; her pruritus and diabetes were not sufficiently controlled&#46; Attempts to very slowly taper her prednisone resulted in disease flares and severe pruritus itching over three years&#46; Given the patient&#8217;s severe disease status and treatment limitations&#44; her treatment was transitioned to a therapeutic trial of dupilumab&#44; with an initial loading dose of 600&#8239;mg administered subcutaneously followed by weekly 300&#8239;mg subcutaneous injections&#46; At the 6-month follow-up&#44; there was a complete resolution of bullae and pruritus after treatment with dupilumab alone &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">BP is an autoimmune disease that mainly occurs in the elderly&#44; severely affecting their health and quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Treatment often entails topical&#47;systemic corticosteroids&#44; antibiotics&#44; azathioprine&#44; dapsone&#44; methotrexate&#44; and mycophenolate mofetil&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> These regimens carry significant adverse effects&#44; and careful consideration is warranted in elderly patients&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Type 2 inflammation is an immune response that exerts an important role in host defense against parasites and is predominantly mediated by group 2 Innate Lymphoid Cells &#40;ILC2s&#41;&#44; type 2 T-helper &#40;Th2&#41; cells&#44; eosinophils&#44; and relevant cytokines&#44; such as IL-4&#44; IL-5&#44; and IL-13&#46; A large number of stimuli can trigger type 2 inflammation&#44; including helminths&#44; various allergies&#44; certain viral or bacterial infections&#44; and endogenous molecules&#46; The process involves both innate and adaptive immune responses&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> An increasing number of studies revealed that BP is a Th2-dominant disease with subsequent overexpression of Th2-type cytokines such as IL4&#44; IL5&#44; and IL13&#46; IL4 is specifically associated with the recruitment of eosinophils which contribute to the incessant pruritis present with the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Dupilumab is a recently developed monoclonal antibody that blocks the signaling of IL-4 and IL-13&#44; both of which are crucial cytokines in the T2 response&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a> For this reason&#44; the hypothesis is that the reduction in disease activity obtained in the cases reported so far may be related to the reduction in Th2-type responses induced by the inhibition of IL-4 and IL-13 signal transduction induced by dupilumab&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The European Academy of Dermatology and Venereology already considers dupilumab as an optional treatment for refractory BP&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment of BP can be challenging&#44; especially in refractory cases&#46; However&#44; the role and efficacy of Dupilumab in the treatment of BP is not completely clear yet&#59; Certainly&#44; Dupilumab should not be considered the first-choice treatment&#44; but as a rescue therapy for selected patients with recalcitrant BP&#46; While the present case highlights the use of dupilumab as a novel therapy in the treatment of BP&#44; additional studies are needed&#46; The mild side effect profile of dupilumab would make it an ideal option for treating the elderly and patients with comorbidities&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0040" class="elsevierStylePara elsevierViewall">Daniela de Abreu e Silva Martinez&#58; Preparation and writing of the manuscript&#59; intellectual participation in propaedeutic and&#47;or therapeutic management of studied cases&#59; approval of the final version of the manuscript&#59; critical literature review&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Amanda de Freitas Sampaio Periquito&#58; Preparation and writing of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Graciela Galva Roa&#58; Preparation and writing of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Jo&#227;o Pedro Lupi&#58; Preparation and writing of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Curt Mafra Treu&#58; Preparation and writing of the manuscript&#59; intellectual participation in propaedeutic and&#47;or therapeutic management of studied cases&#59; approval of the final version of the manuscript&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Omar Lupi&#58; Preparation and writing of the manuscript&#59; intellectual participation in propaedeutic and&#47;or therapeutic management of studied cases&#59; approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter - Therapy
Bullous pemphigoid successfully treated with dupilumab
Daniela de Abreu e Silva Martineza,
Autor para correspondência
daniela.dasm@gmail.com

Corresponding author.
, Amanda de Freitas Sampaio Periquitob, Graciela Galva Roab, João Pedro Lupic, Curt Mafra Treub, Omar Lupia,b
a Department of Immunology, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
b Department of Dermatology, Policlínica Geral do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
c Department of Medicine, Hospital Universitário Pedro Ernesto, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bullous pemphigoid &#40;BP&#41;&#44; a chronic autoimmune cutaneous blistering disorder affecting predominantly the elderly&#44; is characterized by skin tense bullae formation and pruritus symptoms&#46; At present&#44; the main treatment options are represented by corticosteroids and immunosuppressant drugs&#46; Steroids often need to be administered in high doses&#44; with subsequent adverse events and safety issues&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Safer treatment modalities are therefore needed&#46; Dupilumab is a biologic agent used to treat BP in recent years&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Here&#44; we describe an elderly patient with recalcitrant BP successfully treated with dupilumab&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 89-year-old woman was admitted to our department with a 1-month history of severely itchy erythema&#44; vesicles and blistering&#46; On examination&#44; there were urticarial plaques and vesicles on the trunk&#44; and extremities&#46; Isolated tense blisters could be observed on the abdomen and bilateral thighs &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; with sparing of mucosal surfaces&#46; While the lesions evolved into erosions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; the Nikolsky sign was negative&#46; In addition&#44; the patient had type 2 diabetes mellitus on metformin and hypothyroidism on levothyroxine for over 20 years&#44; she denied taking any new medications&#46; Laboratory investigations revealed mild eosinophilia&#59; however&#44; no other significant abnormalities were present&#46; An extensive workup for underlying malignancy and rheumatologic diseases with imaging and laboratory test results proved unremarkable&#46; Skin biopsy demonstrated subepidermal blister formation with eosinophilic infiltrate &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Direct immunofluorescence revealed subepidermal separation with continuous linear depositions of IgG and C3 along the basement membrane zone&#46; The clinical picture in combination with the histologic and immunologic findings confirmed the diagnosis of BP&#46; She was started on prednisone 80&#8239;mg&#44; and after 2 flares during tapering of prednisone&#44; the decision was made to proceed with azathioprine 200&#8239;mg&#44; and tetracycline 500&#8239;mg&#46; Although moderate doses of prednisone effectively reduced the severity of blistering lesions&#44; her pruritus and diabetes were not sufficiently controlled&#46; Attempts to very slowly taper her prednisone resulted in disease flares and severe pruritus itching over three years&#46; Given the patient&#8217;s severe disease status and treatment limitations&#44; her treatment was transitioned to a therapeutic trial of dupilumab&#44; with an initial loading dose of 600&#8239;mg administered subcutaneously followed by weekly 300&#8239;mg subcutaneous injections&#46; At the 6-month follow-up&#44; there was a complete resolution of bullae and pruritus after treatment with dupilumab alone &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">BP is an autoimmune disease that mainly occurs in the elderly&#44; severely affecting their health and quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Treatment often entails topical&#47;systemic corticosteroids&#44; antibiotics&#44; azathioprine&#44; dapsone&#44; methotrexate&#44; and mycophenolate mofetil&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> These regimens carry significant adverse effects&#44; and careful consideration is warranted in elderly patients&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Type 2 inflammation is an immune response that exerts an important role in host defense against parasites and is predominantly mediated by group 2 Innate Lymphoid Cells &#40;ILC2s&#41;&#44; type 2 T-helper &#40;Th2&#41; cells&#44; eosinophils&#44; and relevant cytokines&#44; such as IL-4&#44; IL-5&#44; and IL-13&#46; A large number of stimuli can trigger type 2 inflammation&#44; including helminths&#44; various allergies&#44; certain viral or bacterial infections&#44; and endogenous molecules&#46; The process involves both innate and adaptive immune responses&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> An increasing number of studies revealed that BP is a Th2-dominant disease with subsequent overexpression of Th2-type cytokines such as IL4&#44; IL5&#44; and IL13&#46; IL4 is specifically associated with the recruitment of eosinophils which contribute to the incessant pruritis present with the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Dupilumab is a recently developed monoclonal antibody that blocks the signaling of IL-4 and IL-13&#44; both of which are crucial cytokines in the T2 response&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a> For this reason&#44; the hypothesis is that the reduction in disease activity obtained in the cases reported so far may be related to the reduction in Th2-type responses induced by the inhibition of IL-4 and IL-13 signal transduction induced by dupilumab&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The European Academy of Dermatology and Venereology already considers dupilumab as an optional treatment for refractory BP&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment of BP can be challenging&#44; especially in refractory cases&#46; However&#44; the role and efficacy of Dupilumab in the treatment of BP is not completely clear yet&#59; Certainly&#44; Dupilumab should not be considered the first-choice treatment&#44; but as a rescue therapy for selected patients with recalcitrant BP&#46; While the present case highlights the use of dupilumab as a novel therapy in the treatment of BP&#44; additional studies are needed&#46; The mild side effect profile of dupilumab would make it an ideal option for treating the elderly and patients with comorbidities&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0040" class="elsevierStylePara elsevierViewall">Daniela de Abreu e Silva Martinez&#58; Preparation and writing of the manuscript&#59; intellectual participation in propaedeutic and&#47;or therapeutic management of studied cases&#59; approval of the final version of the manuscript&#59; critical literature review&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Amanda de Freitas Sampaio Periquito&#58; Preparation and writing of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Graciela Galva Roa&#58; Preparation and writing of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Jo&#227;o Pedro Lupi&#58; Preparation and writing of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Curt Mafra Treu&#58; Preparation and writing of the manuscript&#59; intellectual participation in propaedeutic and&#47;or therapeutic management of studied cases&#59; approval of the final version of the manuscript&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Omar Lupi&#58; Preparation and writing of the manuscript&#59; intellectual participation in propaedeutic and&#47;or therapeutic management of studied cases&#59; approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Informação do artigo
ISSN: 03650596
Idioma original: Inglês
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