Can a Joint Oral Medicine and Dermatology Clinic Improve Management of Autoimmune Blistering Diseases?

🔍 Key Finding A combined oral medicine and dermatology clinic effectively manages complex multisite autoimmune blistering diseases like pemphigus vulgaris and mucous membrane pemphigoid, benefiting both patients and clinicians through enhanced, integrated care and professional development. This multidisciplinary approach facilitates shared decision-making, utilizes a range of topical and systemic treatments, and addresses challenges posed by the multisite nature of these diseases.

🔬 Methodology Overview

• Design: Retrospective service evaluation of a joint oral medicine and dermatology clinic.
• Data Source: CareFlow electronic patient record database (System C, UK) of the Bristol Joint Oral Medicine and Dermatology Combined Clinic (BJOMDCC).
• Patient Selection: Patients diagnosed with pemphigus vulgaris (PV) or mucous membrane pemphigoid (MMP) between January 2017 and December 2022.
• Data Collection: Patient demographics, clinical features (intra-oral and extra-oral sites of involvement), investigations performed, treatment regimens, and adverse effects.
• Analysis Approach: Descriptive analysis and reporting of collected data. No formal statistical comparisons were performed.
• Scope: To describe the patient characteristics, diagnostic approaches, and treatment strategies employed in a specialist joint clinic setting for PV and MMP.

📊 Results

• Demographics: 14 patients with PV (6 men, 8 women, mean age 64) and 25 patients with MMP (9 men, 16 women, mean age 69) were included in the study.
• Clinical Presentation (PV): Most common oral site was buccal mucosa (100%), followed by tongue (79%). Skin involvement was present in 79% of PV patients.
• Clinical Presentation (MMP): Most common oral site was gingiva (88%), followed by buccal mucosa (48%). Skin involvement was present in 88% of MMP patients, with ocular involvement in 28%.
• Investigations: Histopathology and direct immunofluorescence were performed in all patients for both PV and MMP. Indirect immunofluorescence was performed in 86% of PV and 68% of MMP patients. ELISA testing was limited.
• Treatment (PV): All patients received systemic therapy, most commonly prednisolone (100%), followed by mycophenolate mofetil (MMF) (79%). Combination therapy was used in 93% of PV patients.
• Treatment (MMP): All patients received systemic therapy, most commonly prednisolone (84%), followed by MMF (56%). Combination therapy was used in 88% of MMP patients.
• Adverse Events: MMP showed higher rates of irreversible complications, including pharyngeal scarring and conjunctival scarring. Systemic therapy adverse events were reported for both PV and MMP, including gastrointestinal upset, bone marrow suppression, and hepatotoxicity.

💡 Clinical Impact Mucous membrane pemphigoid (MMP) and pemphigus vulgaris (PV) significantly impact quality of life and can cause substantial morbidity, often involving multiple sites. Multidisciplinary clinics combining dermatology and oral medicine expertise are effective for managing these complex diseases, improving patient outcomes and facilitating shared decision-making.

🤔 Limitations

• Limited robust epidemiological data for PV.
• Limited data on long-term safety and efficacy of newer anti-CD20 agents like rituximab.
• Lack of routine quality of life metrics or oral disease severity scores collection.
• Limited universal availability of ELISA testing for Dsg1, Dsg3, BP180, and BP230 within secondary and tertiary care.
• Costs and logistical challenges associated with multi-specialty clinic operations limit the inclusion of other specialties like otolaryngology.
• Wide variation in access to and uptake of biologic therapy for AIBDs within the UK.

✨ What It Means For You This research supports the creation of multidisciplinary clinics for autoimmune blistering diseases (AIBDs) like pemphigus vulgaris and mucous membrane pemphigoid to improve patient care and outcomes through collaborative expertise and shared decision-making. This model also benefits clinicians by fostering professional development and facilitating more informed treatment decisions, particularly regarding complex cases and the use of newer biologic therapies.

Reference Davis G, Hathway R, Shipley D, Staines K. The management of pemphigus vulgaris and mucous membrane pemphigoid in a joint oral medicine and dermatology clinic: a five-year narrative review. Br Dent J. 2024;236:311-316. https://doi.org/10.1038/s41415-024-7074-8