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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 55-56

A case of pemphigus vulgaris developing after platelet-rich plasma treatment


1 Department of Dermatology and Venereology, Başkent University Medical School, Adana Dr. Turgut Noyan Application and Research Center, Antalya, Turkey
2 Department of Pathology, Akdeniz University Medical School, Antalya, Turkey
3 Department of Dermatology and Venereology, Akdeniz University Medical School, Antalya, Turkey

Date of Submission24-Mar-2020
Date of Decision30-Mar-2020
Date of Acceptance30-Mar-2020
Date of Web Publication16-Jun-2020

Correspondence Address:
Dr. Ali Haydar Eskiocak
Department of Dermatology and Venereology, Baskent University Medical School, Adana Dr. Turgut Noyan Application and Research Center, Adana
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TJD.TJD_24_20

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  Abstract 


Platelet-rich plasma (PRP) which is peripheral blood originated product contains high concentrated platelet and many growth factors. It has been used in dermatology for many indications, including alopecias and chronic nonhealing wounds. Pemphigus vulgaris (PV) is a chronic autoimmune bullous disease of the skin and mucous membranes. We report a case of PV induced after the treatment of PRP for female pattern hair loss. The first lesions of PV occurred on the application site of PRP in this case. The diagnosis of mucocutaneous PV was established according to the clinical, cytological, and serological findings. Many physical agents and drugs were reported to induce PV. As far as is known, there is no PRP-related PV case in the literature. An in vitro study demonstrated that PRP may trigger the acantholysis in a genetically susceptible patient and may lead to pemphigus. Virtually, there is no enough evidence showing PRP to cause pemphigus. However, PRP treatment should be performed carefully in such patients.

Keywords: Pemphigus vulgaris, platelet-rich plasma, treatment


How to cite this article:
Eskiocak AH, Başsorgun C&, Uzun S. A case of pemphigus vulgaris developing after platelet-rich plasma treatment. Turk J Dermatol 2020;14:55-6

How to cite this URL:
Eskiocak AH, Başsorgun C&, Uzun S. A case of pemphigus vulgaris developing after platelet-rich plasma treatment. Turk J Dermatol [serial online] 2020 [cited 2020 Oct 23];14:55-6. Available from: https://www.tjdonline.org/text.asp?2020/14/2/55/286897




  Introduction Top


Platelet-rich plasma (PRP) which is a peripheral blood originated product contains high concentrated platelet and many growth factors. It has been widely used for the treatment of chronic ulcers, orthopedic surgery, and dentistry.[1],[2],[3] In dermatology, PRP has been used for the facial rejuvenation, treatment of striae, androgenetic alopecia, alopecia areata, and scars and its utilization is getting increased more and more.[4] Pemphigus vulgaris (PV) is a chronic autoimmune bullous disease of the skin and mucous membranes. The pathogenesis of blistering in PV is based on developing autoantibodies against desmosomal adhesion proteins.[5] We present a case developed pemphigus lesions on scalp after PRP application.


  Case Report Top


An 42-year old woman referred to our outpatient clinic for eroded lesions on her head, trunk, and mouth in February 2016. The lesions first started on her scalp 10 months before the first admission. The patient was treating with PRP for female pattern hair loss bimonthly in another hospital for a year. The first eroded lesions appeared on the scalp after a month from the last and 6th session of the PRP therapy. The patient was treated with various topical drugs and oral antibiotics without any improvement. A parenteral corticosteroid injection temporarily stopped the enlargement of the lesions. However, new blisters occured on the back, in the nose and eventually in the mouth after 3, 6, and 9 months subsequent to scalp lesions, respectively. There was no history of autoimmune disease with her family. Dermatological examination revealed eroded lesions with serous drainage on vertex and on back, erosions on the buccal mucosa and the ventral surface of the tongue [Figure 1].
Figure 1: The eroded lesion on vertex. Female pattern hair loss is prominent

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A Tzanck smear from the lesions demonstrated acantholytic cells. The histopathological examination from the scalp lesions revealed suprabasal and intraepidermal acantholysis [Figure 2].
Figure 2: Intraepidermal acantholysis along with suprabasal dissociation (H and E, ×400)

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Direct immunofluorescence examination was negative, but anti-desmoglein 1 and anti-desmoglein three antibody titers were 75 and 194 IU/ml with ELISA, respectively. The diagnosis of mucocutaneous PV was established according to the clinical, cytological, and serological findings. The disease was controlled by a moderate dose of oral methylprednisolone, and the patient is on complete remission with minimal therapy until now.


  Discussion Top


Many physical agents and drugs were reported to induce PV, including surgery, dental procedures, blunt trauma, radiotherapy, angiotensin-converting enzyme inhibitors, D-penicillamine, and calcium channel blockers.[6] However, blood cell-containing products such as erythrocytes and platelets have not been reported to induce PV. Moreover, PRP has been used to cure resistant oral ulcers of PV patients and has found to be as effective as intralesional triamcinolone.[7] Furthermore, Šijan et al. treated a traumatic intractable leg ulcer of a PV patient in remission using homolog platelet gel.[8] The study of Hunziker et al., in which the platelet-derived materials demonstrated to enhance the acantholysis caused by plasma of the pemphigus patient, points that platelets may have an effect on PV.[9] In the present case, the first lesions of PV started on vertex, where the PRP was applicated. Then, the lesions got widespread on the other skin areas and also occurred on the oral mucosa. It can be hypothesized that PRP may trigger the acantholysis in a genetically susceptible patient and exposing the antigens caused to produce anti-desmoglein antibodies, which lead to widespread skin and mucosal erosions. Another assumption is that PRP microneedling could make Nikolsky effect on the patient with subclinical disease of PV without any influence of platelets. Current findings imply that the platelet-derived products should be used with caution in the patients of PV.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zapata MJ, Carvajal AJ, Solà I, Expósito JA, Bolíbar I, Rodríguez L, et al. Autologous platelet-rich plasma for treating chronic wounds. Cochrane Database Syst Rev 2016;(5):CD006899.  Back to cited text no. 1
    
2.
Wang D, Rodeo SA. Platelet-rich plasma in orthopaedic surgery: A critical analysis review. JBJS Rev 2017;5:e7.  Back to cited text no. 2
    
3.
Stähli A, Strauss FJ, Gruber R. The use of platelet-rich plasma to enhance the outcomes of implant therapy: A systematic review. Clin Oral Implants Res 2018;29 Suppl 18:20-36.  Back to cited text no. 3
    
4.
Zhang M, Park G, Zhou B, Luo D. Applications and efficacy of platelet-rich plasma in dermatology: A clinical review. J Cosmet Dermatol 2018;17:660-5.  Back to cited text no. 4
    
5.
Kasperkiewicz M, Ellebrecht CT, Takahashi H, Yamagami J, Zillikens D, Payne AS, et al. Pemphigus. Nat Rev Dis Primers 2017;3:17026.  Back to cited text no. 5
    
6.
Tavakolpour S. Pemphigus trigger factors: Special focus on pemphigus vulgaris and pemphigus foliaceus. Arch Dermatol Res 2018;310:95-106.  Back to cited text no. 6
    
7.
El-Komy MH, Saleh NA, Saleh MA. Autologous platelet-rich plasma and triamcinolone acetonide intralesional injection in the treatment of oral erosions of pemphigus vulgaris: A pilot study. Arch Dermatol Res 2018;310:375-81.  Back to cited text no. 7
    
8.
Šijan G, Vojvodić A, Milićević S, Vučetić D, Petrov N, Kozarski J, et al. Platelet gel in wound treatment in patient with pemphigus vulgaris and Type 2 diabetes mellitus: Case report. Dermatol Ther 2019;32:e13099.  Back to cited text no. 8
    
9.
Hunziker T, Nydegger UE, Lerch PG, Vassalli JD. Platelet-derived factors enhance pemphigus acantholysis in skin organ cultures. Clin Exp Immunol 1986;64:442-9.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2]



 

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