Clinical Efficacy and Pathogenetic Substantiation of Adjuvant

Extracorporeal Photochemotherapy in Pemphigus Vulgaris

A. V. Molochkov

, Yu. V. Molochkova

, A. V. Kildyushevsky

, O. V. Karzanov

and M. G. Kartashova

Head of the Chair of Dermatovenereology and Dermatooncology of Doctors Improvement Faculty Moscow Regional

Research and Clinical Institute, Moscow, Russia

Head of Department of Dermatovenereology of Moscow Regional Research and Clinical Institute, Moscow, Russia

Leading Research Fellow, Surgical Hemocorrection and Detoxication Department of Moscow Regional Research and

Clinical Institute, Moscow, Russia

Senior Research Fellow, Department of Dermatovenereology of Moscow Regional Research and Clinical Institute,

Moscow, Russia

Keywords: Pemphigus Vulgaris, Extracorporeal Photochemotherapy, Extracorporeal Blood Irradiator "Kit-A".

Abstract: This article reportson our clinical experience of application of extracorporeal photochemotherapy conducted

with the ultraviolet extracorporeal blood irradiator or "KIT-A" (SJJ NPP "Cyclone-Test", Russia) as an

adjuvant method in treatment of pemphigus vulgaris. We assess pathogenetic substantiation and clinical

results of the proposed method as well as discussion on dynamics of immunological parameters in patients

receiving actual treatment. Also current article analyze the possibility of applyingextracorporeal

photochemotherapy method as an adjuvant treatment of pemphigus vulgaris with typicaldisease course.

https://orcid.org/0000-0003-3388-9224

https://orcid.org/0000-0001-9021-6494

https://orcid.org/0000-0002-7079-8383

https://orcid.org/0000-0002-6176-1394

https://orcid.org/0000-0003-0376-2644

1 INTRODUCTION

Pemphigus vulgaris (PV) is an autoimmune disorder

of skin and mucous membranes histologically

characterized by acantholysis resulting in the

formation of intraepidermal blisters (Stanley,1999).

Despite PV is one of the well studied tissue-specific

autoimmune diseases, autoantibodies against

keratinocyte antigens are presented not only by anti-

desmoglein antibodes. Number of studies have

demonstrated that T-cells are also actively involved

in the immunopathogenesis of this disease

(Veldman, et al,.,2003;Hertl & Riechers, 1999; Lin,

et al., 1997). An increased number of T cells, mainly

due to CD4, characterized by a Th2 - cytokine

profile (IL-4, IL-6) capable to modulate B-cells

pathogenic production of IgG4 are observed in PV

patients peripheral blood (Edelson, 2000).

Therefore, reports on the application of

extracorporeal photochemotherapy (ECP)- method

proposed by R. Edelson for patients with T-cell skin

lymphomas- in PV are of great interest (Edelson, et

al.,1987). Currently ECP is considered as first line

therapy for erythrodermic mycosis fungoides and

Sézary syndrome (Scarisbrick, et al., 2008). In

clinical practice of our Institution ECP was also

successfully used in patients with cutaneous T-cell

lymphoma and other autoimmune dermatoses

(Molochkov, et al.,2012; Molochkova, et al., 2019;

Molochkov, et al., 2016; Kil’dyushevskiy A.V., et

al., 2014).

The EСP method is based on the biological effect

of 8-methoxypsoralene (8-MOP) and ultraviolet A

(UVA) irradiation on mononuclear cells, collected

by apheresis and reinfused to the patient after UVA

exposure (Edelson, et al.,1987).

For a long time, until the clarification of the

dendritic cells role, mechanism of ECP’s therapeutic

Molochkov, A., Molochkova, Y., Kildyushevsky, A., Karzanov, O. and Kartashova, M.

Clinical Efﬁcacy and Pathogenetic Substantiation of Adjuvant Extracorporeal Photochemotherapy in Pemphigus Vulgaris.

DOI: 10.5220/0010995500003123

In Proceedings of the 15th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2022) - Volume 1: BIODEVICES, pages 217-222

ISBN: 978-989-758-552-4; ISSN: 2184-4305

217

)

Figure 1: Ultraviolet extracorporeal blood irradiator or "KIT-A" (SJJ NPP "Cyclone-Test", Russia).

effect has remained unclear. Thus S. Berger et al.

had demonstrated not only induction of the

programmed death of the tumour cell clone during

ECP, but also an activation of monocytes with their

subsequent transformation into the immature

dendritic cells, which determined the mechanisms of

immunological tolerance (Berger, et al., 2001).

Thereby the purpose of this research was to study

efficiency of ECP conducted with the ultraviolet

extracorporeal blood irradiator or "KIT-A" (SJJ NPP

"Cyclone-Test", Russia) in treatment of PV and to

explore the role of T-cell immunity in the

pathogenesis of PV in order to justify development

of new approaches in the PV treatment based on the

extracorporeal photochemotherapy (ECP).

2 MATERIALS AND METHODS

Current study was performed on 28 PV patients (16

females, 12 males) hospitalized to the

dermatovenerology department of Moscow Regional

Scientific-Research Clinical Institute during acute

phase of the disease and receiving ECP in

combination with systemic corticosteroids. The

mean age of patients was 54 years (range: 34 - 72).

Diagnosis was made on the basis of a typical clinical

picture of the disease and in every case was verified

by cytological (acantholytic cells from the bottom of

erosion), histological (intraepidermal fissures and

blisters) and immunohistochemical (detection of

specific antibodies of the IgG class) examinations.

Duration of disease ranged from 1.5 months to 8

years (mean 1.2 years). 11 patients were suffering

from the disease for more than 2 years and their

condition had relapsing-remitting disease course; 17

patients were diagnosed PV for the first time.

Clinical results were compared with a group of 34

patients (20 females, 14 males), mean age 58 years

(range: 28-87), who received monotherapy with high

doses of systemic corticosteroids. 19 patients of

comparison group were diagnosed PV for the first

time (duration of disease ranged from 2 month to 1.5

years), and 15 patients of comparison group had

relapsing-remitting PV course with duration of

disease from 1.5 to 6 years.

3 ECP TECHNIQUE

In our practice we accomplished collection of the

peripheral blood mononuclear cells by apheresis,

using the cell separator Haemonetics MCS + (USA)

according to the PBSC (Peripheral Blood Stem Cell)

protocol, with the following irradiation of the cells

on the ultraviolet extracorporeal blood irradiator

registered in the Federal Service for Surveillance in

Healthcare of the Russian Federation

(Roszdravnadzor), registration number RZN

2021/15867 "KIT-A", produced by SJJ NPP

Cyclone-Test, Russia (Figure 1: a, b). The device is

equipped with 72 LED emitters that generate

electromagnetic energy with a wavelength of 365 +

10 nm. The emitters are located in two planes in

relation to the object - the upper and lower module

with 36 emitters, respectively. Also, device is

equipped with a tool for mixing of biological fluids

in a plastic container and a fan to maintain the set

temperature. The total power of ultraviolet radiation

is not more than 5 mW / cm2. The total exposure

dose for 10 minutes is 3.0 J / cm2. The exposure

time is 7 minutes, which corresponds to a radiation

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)

efore treatment

14 da

s after treatment

Figure 2: Female patient with pemphigus vulgaris. Widespread cutaneous process with extensive erosive surfaces.

Treatment with prednisolone (100 mg / day, per os) for 10 days without clinical effect with daily appearance of new lesions.

After adding the adjuvant therapy with ECP technique, new lesions ceased to develop; during the next 2 weekswas noted

rapid epithelialization of erosions, which made it possible to start reducing the dose of systemic corticosteroids.

dose of 2.0 J / cm2. Two hours before the ECP

session patient took peroral photosensitizer (8-

methoxypsoralen at the dose of 0.6 mg/kg). After the

exposure to the UV irradiation, the cell suspension

was reinfused to the patient for 30 min. Course of

treatment included 4 sessions, procedure was carried

out every 2 days.

4 RESULTS AND DISCUSSION

ECP sessions were well tolerated by all patients, no

complications or side events were observed. On

average, in 3-4 days after initiation of ECP therapy

in every case we observed improvement of general

well-being, and improvement of the cutaneous

manifestations, particularly discontinuation or

significant reduction of wound exudation or absence

of a new lesions.

Epithelialization of epidermal defects,

accompanied by the decrease in IgG deposits in the

intercellular substance of the epidermis occurred in

7-14 days in all of the patients receiving treatment

with ECP (Figure 2: a, b). Thus, all patients in this

group had a complete clinical recovery.

In the comparison group, clinical recovery was

noted in 31 (91%) patients. In the majority of

patients (25 (74%)), complete epithelization of

epidermal defects occurred in 15 – 22 days, in 6

(18%) patients, clinical recovery was achieved, but

the effect was attained in a longer terms: from 1.5 to

2.5 months. In 3 (9%) patients, despite the ongoing

treatment with high doses of corticosteroid drugs,

clinical recovery was not achieved (1 patient had

new lesions, 2 patients had persistent oral erosions).

During investigation on the effectiveness of

provided treatment, it was noted that all

complications and side effects in both groups (23 of

the 28 patients in the control group (5 patients were

lost to follow-up, because after the therapy they have

left the country and 34 patients of comparison

group) were associated with systemic

corticosteroids. No complications associated with

the ECP procedure occured. In comparison, patients

of the control group in average had 3.1

complications per patients vs 4.5 complications per

patient in comparison group (Table 1). Also, in

control group we didn’t register such serious

complications as sepsis, stroke, myocardial

infarction, pneumonia, which occurred in

comparsion group and caused two deaths. Thus, high

clinical efficacy of therapy in control group was

combined with a significantly lower frequency of

adverse reactions and complications (follow-up

period 12-36 months).

Clinical Efﬁcacy and Pathogenetic Substantiation of Adjuvant Extracorporeal Photochemotherapy in Pemphigus Vulgaris

219

Table 1: Identified Complications and Side Effects of Sistemic Corticosteroid Therapy in Both Groups.

Complication Control group

(n=23)

Comparsion group

(n=34)

Cushing’s syndrome 23 34

Arterial hypertension 14 19

Stroke - 2

Myocardial infarction - 1

Pneumonia - 3

Sepsis - 1

Osteoporosis 5 15

Cataract 2 4

Erosive and ulcerative lesion of the gastrointestinal tract 9 18

Diabetes 2 8

Mucosal candidiasis 6 23

Pyoderma 9 21

Erysipelas 1 1

Thrombophlebitis of the lower extremities - 2

Total 71 152

Average (per one patient) 3.1 4.5

During the immunological study in patients with

PV, there was found a high level of correlation (r =

0.57, p <0.05) between the expression of the integrin

adhesion molecule MAC-1 (CD11b) and natural

killer (NK) cells (CD3-CD16 + CD56 +). Probably

it indicates the presence of this molecule on NK

cells, providing fixation of these cells on the

vascular endothelium with the subsequent

transendothelial migration into the lesion.

Patients with PV were characterized by the low

level of CD25 expression, - α-chain of the IL-2

receptor (1.89 ± 1.9%, at the normal rate of 4.2±

0.2%, p <0.05), as well as reduced content of Treg

cells with the phenotype: CD45RA + CD4 +

CD25

high

CD127

low

neg

(4.8 + 0.8%, with the normal

rate of 9.6 + 0.8% p <0.05). The interaction of the

CD25 molecule with its mediator IL-2 provides not

only proliferation and differentiation of the effector

cells, but primarily - activation and the proliferation

of Treg cells. Functionally active Treg cells are

characterized by the constitutive significant

expression of the α-chain of the receptor to IL-2

(CD25), through which suppressor function of these

cells is realized, providing the depletion of

autoreactive T-cells by triggering the apoptosis

processes in them, thus maintaining the tolerance to

their own antigens. Decrease of expression of CD25

molecule leads to insufficient control and

maintenance of the immunological tolerance to the

autoantigens in the periphery.

The detected immune disorders in patients with

PV were considered to be pathogenetic

substantiation for the immunomodulatory therapy of

this disease with the application of ECP.

As a result of the ECP course, clinical recovery

was achieved in all patients in 12 days on average,

resulting in reduction of the starting systemic

corticosteroid dosage during these period by 30%

and significant decrease of the side effects and

complications associated with high doses of

systemic corticosteroids (Table 1).

During immunological study after ECP, there

wasn’t found any correlation between CD11b and

CD3-CD16 + CD56 +, reflecting the absence of co-

expression of the adhesion molecule on NK cells.

Based on the obtained data, it could be concluded

that application of ECP leads tomodulation of co-

expression of the leukocyte integrin adhesion

molecule on the NK, which results in blockage of

transendothelial migration ofthese cells to the lesion.

After the course of ECP in PV patients, there was

also identified increased expression of the relative

quantity of Treg cells (from 4.8 + 0.8% to 13.3 +

2.3%, p <0.05), which indicated the restoring of the

Treg cells peripheral immunological tolerance

control over the autoreactive clone of the

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lymphocytes, escaped the negative selection in the

thymus.

Thus, in short, it could be assumed that

immunomodulatory effect of ECP in PV is based on

the re-establishment of the receptor-ligand relations

between immunocompetent cells, intercellular

adhesion molecules and target cells - keratinocytes.

An important role in this process is devoted to the

restoration of the suppressor function of Treg cells

in relation to the autoreactive clone of cytotoxic

effector cells.

T-cell reactivity to self-antigens, as well as T-

and B-cell interactions in the formation and

progression of PVarenot yet fully understood,

therefore giving reasons for a detailed study of this

problem. At the same time, the solution of cell-cell

interactions is impossible without understanding of

the role and significance of intercellular adhesion

molecules and their ligands. The study of the

function of the adhesive-ligand system in PV seems

to be really important and crucial, since it concerns

both the intercellular interactions of

immunocompetent blood cells and the mechanisms

of their transendothelial migration to the target cells

(keratinocytes). Currently, the literature contains a

great deal of new fundamental data relating the

issues of the function and the classification of

human adhesion molecules,however, their

significance in the occurrence and progression of

autoimmune diseases, in particular in PV, hasn’t

been sufficiently studied yet.

Therefore, our research indicates that the

immunotherapeutic method - ECP conducted with

anextracorporeal blood irradiator "KIT-A" (SJJ NPP

"Cyclone-Test", Russia) is a highly effective and

promising method of treatment PV, which requires

deeper study for enhancing its clinical application.

5 CONCLUSION

High doses of systemic corticosteroids in

combination with adjuvant therapy with cytostatics,

traditionally used in PV, are quite effective in most

cases, however, they are associated with the

appropriate development of severe side effects such

as myelosuppression, anemia, visceral cancer,

hepatotoxic reactions, hemorrhagic cystitis, impaired

renal function (Ahmed & Hombal, 1984; Bystryn &

Steinman,1996; Fairley et al.,1972; McDonald,1985)

We consider that use of methods of adjuvant

therapy, targeted at the main links of the

immunopathogenesis of the disease to be the most

promising direction for improvement of the

PVtherapy. Only single observations of the mainly

drug-resistant PV treatment with the use of ECP

were published to date and summarized in 2020 with

review of ECP use in 11 cases of a resistant PV

(Knobler, et al.,2020).

Notably, this review outlines good clinical

efficacy of therapy, with a minimal side effects, and

the main factor supposed to limit the widespread use

of current technique is the high cost of the

procedure. "KIT-A" (SJJ NPP "Cyclone-Test",

Russia), which is used in the described above ECP

technique makes it possible to greatly reduce the

cost of the procedure and thereby ensure the

availability of ECP in wide clinical practice

(including the treatment of uncomplicated PV

variants). As for the clinical efficacy of proposed

method, we obtained results, comparable to review

of R.Knobler et al., but our study was conducted in

patients with a typical course of the disease with the

use of one ECP course, which consisted of 4

procedures (in comparison with 2-6 courses for

resistant PV in R.Knobler, et al review) (Knobler, et

al.,2020).

REFERENCES

Stanley JR. Pemphigus. in: Freedberg IM Eisen AZ Wolff

K Fitzpatrick's Dermatology in General Medicine.

McGraw-Hill, New York, NY1999: 654-666

Veldman C., Stauber A., Wassmuth R., Uter W., Schuler

G., Hertl M.; Dichotomy of Autoreactive Th1 and Th2

Cell Responses to Desmoglein 3 in Patients with

Pemphigus Vulgaris (PV) and Healthy Carriers of PV-

Associated HLA Class II Alleles. Journal of

immunology. 2003; 170. 635-42.

10.4049/jimmunol.170.1.635

Hertl M., Riechers R.; Analysis of the T cells that are

potentially involved in autoantibody production in

pemphigus vulgaris. J Dermatol. 1999; 26:748–752

Lin M., Swartz S., Lopez A., Ding X., Fernandez‐Vina

M., Stastny P. et al.; Development, and

characterization of desmoglein 3‐specific T cells from

patients with pemphigus vulgaris. J Clin Invest 1997;

99:31–40

Edelson R.; Pemphigus — Decoding the Cellular

Language of Cutaneous Autoimmunity. The new

England journal of medicine. 2000; 343: 60-61

Edelson R., Berger C., Gasparro F., Jegasothy B., Heald

P., Wintroub B., Vonderheid E., Knobler R., Wolff K.,

Plewig G., et al.; Treatment of cutaneous T-cell

lymphoma by extracorporeal photochemotherapy.

Preliminary results. N Engl J Med. 1987;316(6):297–

303. doi: 10.1056/ NEJM198702053160603

Scarisbrick J., Taylor P., Holtick U., Makar Y., Douglas

K., Berlin G., Juvonen E., Marshall S.; Photopheresis

Expert Group. U.K. consensus statement on the use of

Clinical Efﬁcacy and Pathogenetic Substantiation of Adjuvant Extracorporeal Photochemotherapy in Pemphigus Vulgaris

221

extracorporeal photopheresis for treatment of

cutaneous T-cell lymphoma and chronic graft-versus-

host disease. Br J Dermatol. 2008;158(4):659–78. doi:

10.1111/j.1365-2133.2007.08415.x

Molochkov V.A., Kil'diushevskiĭ A.V., Molochkov A.V.,

Karzanov O.V., Iakubovskaia E.S., Fedulkina V.A.;

Clinical and immunological aspects of extracorporeal

photochemotherapy for psoriasis and psoriatic

arthritis. Terapevticheskii Arkhiv, 2012; 84 (10), pp.

69-74.

Molochkova Y.V., Molochkov V.A., Pimenova Y.A.;

Lichen planus pigmentosus: report of effectiveness of

extracorporeal photochemotherapy in recalcitrant case.

Hong Kong J. Dermatol. Venereol. (2019) 27, 75-78.

Molochkov V.A., Kil'dyushevskiy A.V., Karzanov O.V.;

Treatment of the tumor stage of mycosis fungoides

with extracorporeal photochemotherapy (a case

descript). Almanac of Clinical Medicine.

2016;44(1):103-106. (In Russ.) https://doi.org/

10.18786/2072-0505-2016-44-1-103-106

Kil’dyushevskiy A.V., Karzanov O.V., Aleksandrovа

N.M.; Extra-corporeal photochemotherapy in the

treatment of lymphomatoid papulosis and

folliculotropic mycosis fungoides: case reports.

Almanac of Clinical Medicine. 2014;(34):81-84. (In

Russ.) https://doi.org/10.18786/2072-0505-2014-34-

81-84

Berger C., Xu A., Hanlon D., Lee C., Schechner J., Glusac

E., Christensen I., Snyder E., Holloway V., Tigelaar

R., Edelson R.; Induction of human tumor-loaded

dendritic cells. Int J Cancer. 2001;91(4):438–47. doi:

10.1002/1097-0215(200002)9999:99993.0.CO;2-R.

Ahmed AR, Hombal SM. Cyclophosphamide (Cytoxan).

A review on relevant pharmacology and clinical uses.

J Am Acad Dermatol. 1984 Dec;11(6):1115-26. doi:

10.1016/s0190-9622(84)80193-0.

Bystryn JC, Steinman NM. The adjuvant therapy of

pemphigus. An update. Arch Dermatol. 1996

Feb;132(2):203-12.

Fairley KF, Barrie JU, Johnson W. Sterility and testicular

atrophy related to cyclophosphamide therapy. Lancet.

1972 Mar 11;1(7750):568-9. doi: 10.1016/s0140-

6736(72)90358-3.

McDonald CJ. Cytotoxic agents for use in dermatology. I.

J Am Acad Dermatol. 1985 May;12(5 Pt 1):753-75.

doi: 10.1016/s0190-9622(85)70097-7.

European dermatology forum: Updated guidelines on the

use of extracorporeal photopheresis 2020 - Part 2 R.

Knobler, P. Arenberger, A. Arun, C. Assaf, M. Bagot,

G. Berlin, A. Bohbot, P. Calzavara-Pinton, F. Child,

A. Cho, L.E. French, A.R. Gennery, R. Gniadecki,

H.P.M. Gollnick, E. Guenova, P. Jaksch, C.

Jantschitsch, C. Klemke, J. Ludvigsson, E. Papadavid,

J. Scarisbrick, T. Schwarz, R. Stadler, P. Wolf, J. Zic,

C. Zouboulis, A. Zuckermann, H. Greinix J Eur Acad

Dermatol Venereol. 2021 Jan; 35 (1): 27-49. Published

online 2020 Sep 22. doi: 10.1111 / jdv.16889

BIODEVICES 2022 - 15th International Conference on Biomedical Electronics and Devices

222