Immunobullous Skin Diseases Screening

  • Diagnosis
  • Algorithms
  • Background
  • Lab Tests
  • References
  • Related Topics
  • Videos

Indications for Testing

  • Blistering or other inflammatory skin disease without obvious etiology
  • See Immunobullous Skin Diseases Testing algorithm

Laboratory Testing

  • Initial testing
    • Perilesional skin biopsy for direct immunofluorescence (DIF) plus appropriate serum antibody tests by indirect immunofluorescence (IFA) and enzyme-linked immunosorbent assay (ELISA) are important for initial diagnosis of immunobullous skin diseases
      • Skin tissue biopsy specimens are more sensitive than serum tests but serum tests permit distinguishing the various disorders and monitoring disease activity
    • Serum antibody tests – distinguish between the various disorders and permit monitoring of disease activity
      • Pemphigus and pemphigoid panels (tissue transglutaminase [tTG] or epithelial antibodies for dermatitis herpetiformis)
        • Autoantibodies correlate with disease activity and are useful in monitoring response to therapy after established diagnosis
        • Autoantibodies may be present in normal individuals, although usually in low titers and/or levels – correlate with clinical findings
Predictive Value of Immunodermatology Tests

Disease

Serology
(Cutaneous IFA and ELISA)

Histology
(Cutaneous DIF)

Pemphigus

70-80% of patients demonstrate IgG antibodies to epithelial cell surface components by IFA; 90% or more have desmoglein 1 and/or desmoglein 3 IgG antibodies by ELISA (desmoglein 1 IgG antibodies predominate in pemphigus foliaceus, and desmoglein 3 IgG antibodies predominate in pemphigus vulgaris)

Respective antibodies correlate with disease activity

>90% of patients have epidermal or epithelial cell surface IgG and/or C3 staining in perilesional skin

(Rarely, IgA cell surface antibodies in IgA pemphigus; note that IgA pemphigus is much less common than other pemphigus types)

Bullous pemphigoid

70-80% of patients demonstrate IgG antibodies to basement membrane zone (BMZ) components by IFA, with epidermal or combined epidermal-dermal staining on split skin

80% or more have BP230 (BPAg1) and/or BP180 (BPAg2) IgG antibodies by ELISA, which may be more sensitive than IFA and may correlate with disease activity

>90% of patients have characteristic linear deposition of IgG and C3 (also IgA) along the BMZ in perilesional skin
Epidermolysis bullosa acquisita ~50% of patients demonstrate IgG antibodies to BMZ components, with dermal staining on split skin by IFA >95% of patients show strong IgG and C3 in a thick linear BMZ band in perilesional skin; other immunoglobulins may also be present
Linear IgA disease 70-80% of patients demonstrate IgA antibodies to BMZ components by IFA, with epidermal, combined epidermal-dermal, or (rarely) dermal staining on split skin 100% of patients have characteristic linear staining of IgA along the BMZ in perilesional skin; C3 and/or IgG and IgM linear staining may also be present
Dermatitis herpetiformis

70-80% of patients demonstrate IgA endomysial antibodies by IFA (highly sensitive and specific for the disease)

IgA tissue transglutaminase antibodies by ELISA – slightly less specific but highly sensitive

Respective antibodies correlate with disease activity

>95% of patients have granular and/or fibrillar IgA in dermal papillae of perilesional skin
Bullous lupus erythematosus

Antinuclear antibodies and circulating antibodies to BMZ components by IFA are typically IgG in a combined epidermal-dermal or dermal staining pattern on split skin; IgG BP180 antibodies detected by ELISA may be present (but are rarely IgG BP230 antibodies); type VII collagen antibodies are also commonly present (dermal pattern staining on split skin)

Rare disorder – predictive values not available

Linear and/or dense granular IgG, IgM, and often IgA staining along BMZ in perilesional skin; immunohistological findings are often used to make the diagnosis (>95% likely have these findings)

Rare disorder – predictive values not available

Chronic ulcerative stomatitis

IgG stratified epithelial-specific antinuclear antibodies on specific esophagus substrates

Newly described entity; predictive values not available

100% have IgG antibodies to nuclei of basal and lower 1/3 of keratinocyte cell layers, with stratified epithelial-specific antinuclear antibody pattern

Subset also demonstrates linear to shaggy fibrinogen BMZ staining pattern

Pemphigoid (herpes) gestationis

~85% of patients demonstrate HG factor (HG IgG) by complement fixing IFA and BP180 (BPAg2) antibodies by ELISA

~25% have IgG BMZ antibodies

>95% of patients have intense linear C3 at BMZ; 25-50% show linear IgG BMZ staining in perilesional skin
Vasculitis Antinuclear antibodies and/or antineutrophilic cytoplasmic antibodies 50-60% of patients with immune-mediated vasculitis demonstrate antibodies in dermal blood vessels in early lesion (24-48 hours old)

Immunobullous skin diseases are autoimmune blistering diseases affecting skin and mucous membranes and are caused by or associated with the deposition of specific antibodies on cutaneous structures. They include the following

Epidemiology

  • Incidence – 1-2/1,000,000
    • Pemphigoid – 10-13/1,000,000
    • Pemphigus – 1-5/1,000,000
  • Age – usually occurs in 40s-50s; can occur in childhood
    • Linear IgA disease – most common immunobullous childhood disease; appears as a chronic bullous disease
    • Pemphigoid (herpes) gestationis occurs in females during childbearing years
    • Incidence of bullous pemphigoid significantly increases after age 70 (15-18/100,000)
  • HLA class II associations

Clinical Presentation

  • Although the various immunobullous skin diseases are characterized by clinical and histological features, presentation is often atypical and shows overlap with other immunobullous diseases or with more common skin diseases (eg, eczema, urticaria)
  • Classic features – blistering or erosive lesions
  • Wide range and variability of lesional types, often with prominent itching, secondary lesions, eczema, or urticaria
  • Histology varies with each immunobullous disease
    • Eosinophil infiltration and eosinophil-associated spongiosis common in IgG autoantibody immunobullous disease
    • Neutrophil infiltration common in IgA autoantibody immunobullous disease
Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Cutaneous Direct Immunofluorescence, Biopsy 0092572
Method: Direct Immunofluorescence

Limitations 

May be inaccurate if tissue not taken from correct perilesional location (attached/intact epithelium or epidermis needed)

Not possible to reliably distinguish pemphigoid from epidermolysis bullosa acquisita or to distinguish pemphigus subtypes based on direct immunofluorescence (DIF); concurrent serum testing needed

Tissue must be submitted in Michel’s or Zeus medium; this test cannot be performed on formalin-fixed tissue

Follow-up 

Initial concurrent and repeat serum testing with pemphigoid and pemphigus panels is the most sensitive for diagnosis, for determining antibody profiles, and for following disease activity

Patients with indeterminate results should have repeat DIF biopsy

Patients with changing clinical features should have repeat DIF biopsy because antibody profiles may change over time

Pemphigoid Antibody Panel - Epithelial Basement Membrane Zone Antibodies, IgG and IgA, BP180 and BP230 Antibodies, IgG 0092001
Method: Enzyme-Linked Immunosorbent Assay/Indirect Fluorescent Antibody

Limitations 

Clinical correlation necessary because the incidence of false positives, although rare, increases with age

Because of clinical overlap among immunobullous diseases and similar names, pemphigoid testing may be confused with pemphigus testing and inadvertently misordered

Follow-up 

Use pemphigoid panel to monitor pemphigoid disease activity; use relevant tests to monitor other immunobullous disease activity

Repeat pemphigoid panel for indeterminate results and/or continuing clinical consideration of immunobullous disease

Pemphigus Antibody Panel - Epithelial Cell Surface Antibodies and Desmoglein 1 and Desmoglein 3 Antibodies, IgG 0090650
Method: Enzyme-Linked Immunosorbent Assay/Indirect Fluorescent Antibody

Limitations 

Clinical correlation is necessary because cell surface antibodies by IFA, usually in low titers, may be found in normal individuals (possible blood group reactivity) or in patients with fungal infections, burns, drug reactions, and other dermatoses, including other immunobullous diseases

Because of clinical overlap among immunobullous diseases and similar names, pemphigoid testing may be confused with pemphigus testing and inadvertently misordered

Testing for IgG pemphigus antibody types (most common) also may be confused with IgA pemphigus testing (rare disorder)

Follow-up 

Use pemphigus panel to monitor pemphigus disease activity; use relevant tests to monitor other immunobullous disease activity

Repeat pemphigus panel for indeterminate results and/or continuing clinical consideration of immunobullous disease

Epithelial Skin Antibody 0090299
Method: Indirect Immunofluorescence
(Indirect Fluorescent Antibody)

Limitations 

Does not include testing for antibodies to target pemphigoid antigens, BP180 and BP230, or to target pemphigus antigens desmoglein 1 and 3 which may be more sensitive diagnostic markers in some cases (levels  correlate with disease activity)

Although helpful in screening for immunobullous disease, test is not as sensitive as combination of pemphigus and pemphigoid panels

Follow-up 

Use epithelial skin antibody test or both pemphigoid and pemphigus panels to follow patients with changing clinical features because antibody profiles may change over time

Herpes Gestationis Factor (Complement-Fixing Basement Membrane Zone Antibody IgG) 0092283
Method: Quantitative Indirect Immunofluorescence

Follow-up 

Use herpes gestationis factor test to monitor disease, including IgG BP180 antibody levels; use relevant tests to monitor other immunobullous disease activity 

Paraneoplastic Pemphigus Antibody Screen 0092107
Method: Indirect Fluorescent Antibody

Tissue Transglutaminase (tTG) Antibody, IgA with Reflex to Endomysial Antibody, IgA by IFA 0050734
Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay/Semi-Quantitative Indirect Fluorescent Antibody

Limitations 

Does not detect IgG or IgA BMZ or cell surface antibodies that characterize immunobullous diseases other than dermatitis herpetiformis

Follow-up 

Use tissue transglutaminase (tTG) antibody, IgA with reflex to endomysial antibody, IgA by IFA for initial diagnosis of dermatitis herpetiformis and to follow disease activity in dermatitis herpetiformis; use relevant tests to monitor other immunobullous disease activity

Repeat test for indeterminate results and/or continuing clinical consideration of immunobullous disease

Epithelial Basement Membrane Zone Antibody IgA 0092057
Method: Indirect Immunofluorescence
(Indirect Fluorescent Antibody)

Limitations 

Although helpful in screening for immunobullous disease, not as sensitive as combination of pemphigus and pemphigoid panels

Clinical correlation necessary because incidence of false positives, although rare, increases with age

Specific for IgA BMZ antibodies found in linear IgA disease and will not detect IgG BMZ antibodies found in pemphigoid and epidermolysis bullosa acquisita or cell surface antibodies found in pemphigus

Follow-up 

Use epithelial IgA BMZ IgA antibody or pemphigoid panel tests to monitor linear IgA disease activity and response to therapy; use relevant tests to monitor other immunobullous disease activity

Repeat epithelial IgA basement membrane zone IgA antibody or pemphigoid panel for indeterminate results and/or continuing clinical consideration of linear IgA disease

General References

Baum S, Sakka N, Artsi O, Trau H, Barzilai A. Diagnosis and classification of autoimmune blistering diseases. Autoimmun Rev. 2014; 13(4-5): 482-9. PubMed

Bos JD. Immunopathology of the skin (3rd edition) edited by E.H. Beutner, T.P. Chorzelski, V. Kumar, John Wiley & Sons, 1987. £78 (xxxix + 769 pages), ISBN 0 471 84074 2. Immunol Today. 1988; 9(2): 63. PubMed

Kalaaji A, Nicolas M. Mayo Clinic Atlas of Immunofluorescence in Dermatology: Patterns and Target Antigens, Rochester, MN: Mayo Foundation for Medical Education and Research, 2006.

Kershenovich R, Hodak E, Mimouni D. Diagnosis and classification of pemphigus and bullous pemphigoid. Autoimmun Rev. 2014; 13(4-5): 477-81. PubMed

Mihai S, Sitaru C. Immunopathology and molecular diagnosis of autoimmune bullous diseases. J Cell Mol Med. 2007; 11(3): 462-81. PubMed

Mintz EM, Morel KD. Clinical features, diagnosis, and pathogenesis of chronic bullous disease of childhood. Dermatol Clin. 2011; 29(3): 459-62, ix. PubMed

Parker SR, MacKelfresh J. Autoimmune blistering diseases in the elderly. Clin Dermatol. 2011; 29(1): 69-79. PubMed

Patrício P, Ferreira C, Gomes MM, Filipe P. Autoimmune bullous dermatoses: a review. Ann N Y Acad Sci. 2009; 1173: 203-10. PubMed

Plager D, Leiferman K, Pittelkow M. Structural and Functional Cutaneous Immunology. In Adkinson NF et al. Middleton’s Allergy Principles and Practice, 6th ed. Philadelphia: Mosby, 2003.

Pohla-Gubo G, Hintner H. Direct and indirect immunofluorescence for the diagnosis of bullous autoimmune diseases. Dermatol Clin. 2011; 29(3): 365-72, vii. PubMed

Sansaricq F, Stein SL, Petronic-Rosic V. Autoimmune bullous diseases in childhood. Clin Dermatol. 2012; 30(1): 114-27. PubMed

Schmidt E, Zillikens D. Modern diagnosis of autoimmune blistering skin diseases. Autoimmun Rev. 2010; 10(2): 84-9. PubMed

Sticherling M, Erfurt-Berge C. Autoimmune blistering diseases of the skin. Autoimmun Rev. 2012; 11(3): 226-30. PubMed

Tsuruta D, Dainichi T, Hamada T, Ishii N, Hashimoto T. Molecular diagnosis of autoimmune blistering diseases. Methods Mol Biol. 2013; 961: 17-32. PubMed

Medical Reviewers

Last Update: August 2016